Movement Behaviour and Health Outcomes in Rural Children: A Systematic Review

Background: Studies with rural children are limited, and results are divergent regarding the information on movement behaviours. Purpose: to (i) describe the physical activity and sedentary behaviour in children; (ii) synthetize the year and place of publication, methodological quality, and instruments used to measure physical activity and sedentary behaviour; and (iii) to analyse the relationship between physical activity, sedentary behaviour, and health outcomes in these children. Methods: We use the databases PubMed, Web of Science, SPORTDiscus, Scopus, Virtual Health Library, and SciELO, considering papers published until October 2021. A total of 12,196 studies were identified, and after the exclusion of duplicate, title and abstract screening, and the full-text assessment, a total of 68 were included in the study. Results: A cross-sectional design was dominant among the studies, with sample sizes ranging from 23 to 44,631 children of both sexes. One-third of the studies were conducted in North America and Europe, and most of them used device-based measurements. Inequalities were observed regarding sex, age, economic level, race, and physical activity domains within and between the places of residence. Sociodemographic characteristics were also related to health outcomes for children living in rural and urban areas. Conclusion: It is necessary to increase the evidence on movement behaviours among children living in the countries of South America and Oceania, as well as to increase the level of evidence on the role of school for physical activity in children in rural areas, given the inconsistent findings.


Introduction
Children's movement behaviour is closely related to environmental aspects [1,2], which include not only the physical environment (e.g., urbanization, housing infrastructure, climate, and transport) [3], but also the social (e.g., family support, encouragement of friends and partners), cultural, and the political ones [2]. Considering the physical environment, previous studies showed differences in physical activity levels between children from urban and rural areas [4,5]. In general, a reduced number of structured spaces for physical activity practices, safety perception, motorized transport, and high availability of screen leisure activities are pointed out as factors related to a decrease in physical activity levels among children living in urban areas [6][7][8]. On the other hand, rural areas may have a more peaceful lifestyle, with more open-air areas, greater possibilities for active transport,

Quality Assessment
The studies included in this research were evaluated for their methodological quality by two independent researchers. The checklist used (Table 1) was adapted from a previous published study [23], which comprises 10 items, which evaluate: (1) the study aims; (2) sample characteristics; (3) sample size justification; (4) instruments for data collection; (5) statistical analysis; (6) description of the results; (7) conclusions; (8) practical implications; (9) limitations; and (10) directions for future research. Table 1. Checklist used to evaluate studies' quality.

Item
Question Score 1 Was the objective(s) of the study clearly defined(s)? 0-2 2 Were the characteristics of the participants presented in detail in the methods (number of subjects, sex, age, country/city)? 0-2 3 Was the sample size justified? 0-2 4 Were the instruments used clearly described in the methods section? 0-2 5 Were the statistical analyses clearly presented? 0-2 6 Were the results detailed (means and standard deviations and/or change/difference, effect size)? 0-2 7 Were the conclusions appropriate, giving the methods of study and the objectives? 0-2 8 Are there implications for practice given the results of the study? 0-2 9 Were the limitations of the study recognized and described by the authors? 0-2 10 Is there any future direction described by the authors? 0-2 Total 0-20 Note: Adapted from Abarghoueinejad et al. (2021) [23]. Scores: Not = 0; Maybe = 1; Yes = 2.
If divergences in the evaluation were found between the two researchers, a third researcher evaluation was considered. Selected articles were not excluded based on the results of this evaluation. Based on this evaluation, the studies were categorized into levels: high (>75%), intermediate (50-74%), and low (<50%). Figure 1 shows the study selection process flowchart. A total of 12,196 studies were identified. Duplicate records were deleted, using EndNote's specific tool, and then through a manual check, resulting in 6351 studies for title and abstract screening. After reading the title and abstract, ≈98.6% of the papers were excluded, and 90 were fully assessed, from which 68 were included in the study.  Figure 1 shows the study selection process flowchart. A total of 12,196 studies were identified. Duplicate records were deleted, using EndNote's specific tool, and then through a manual check, resulting in 6351 studies for title and abstract screening. After reading the title and abstract, ≈98.6% of the papers were excluded, and 90 were fully assessed, from which 68 were included in the study.   Table 3 (comparison between rural and urban) present data extraction from the selected papers. Information is related to the sample location (continent, country, and specific region, when informed), sample characteristics (size and age/school grade), instruments used (based-device or questionnaires), main results, and the evaluation of methodological quality.   Table 3 (comparison between rural and urban) present data extraction from the selected papers. Information is related to the sample location (continent, country, and specific region, when informed), sample characteristics (size and age/school grade), instruments used (based-device or questionnaires), main results, and the evaluation of methodological quality.    69

3-5 years
Accelerometer The group that received PA and feeding intervention was involved significantly more in MVPA; sedentary behaviour decreased after the intervention. 85   There were differences in physical activity levels between boys; the total score of physical activity among rural adolescents was higher and going to school by bike was more frequent among boys in rural schools compared to their urban peers. In the rural group, obesity among boys was 5.4%, while among girls it was 1.7%; the prevalence of children who used computer/watched TV for more than 3 h per day was 8.6% in the rural group, and 27.7% in the urban group; the prevalence of children who spent more than 3 h per day doing homework was 5.3% in the rural group and 21,2% in the urban group. During winter, urban children reached more average steps/day than rural children, and the opposite was observed during summer; urban children spent more time playing video games compared to rural children during winter; rural children spent more time outdoors than urban children in both winter and summer; parents of urban children reported transferring their children more often to places where they can be physically active (in winter and summer).  The prevalence of overweight and obesity was similar between rural and urban children; physical activity did not differ according to the place of residence (rural or urban). Suburban girls achieved significantly lower VPA Scores than urban boys and rural boys; 57% of all subjects practiced MVPA for three days for more than 60 min; boys from suburban districts scored higher in VPA; for MVPA, rural children scored more than suburban per day; both rural and suburban adolescents tend to be less active on Sunday. 85 Craggs et al., 2011 [73] United Kingdom (England) 1653 9-10 years Accelerometer The percentage of parents with higher education was greater among children from rural areas; mean level of physical activity differed between sex; no differences were found between environments; regardless of location, boys were more active than girls; overweight children were less active compared to normal-weight children; in addition to sex and overweight indexes, the preference for PA also showed associations with total PA. 18.0% of the children were overweight and 3.9% were obese; the prevalence of overweight and obesity was 17% and 5.1% among rural youth, and 20% and 1% among urban youth, respectively; rural boys spent more time in LPA during the week, while urban boys spent more time in MVPA at the weekend; urban girls spent more time in sedentary activities, less time in LPA and MVPA compared to rural girls; MVPA was positively correlated with cardiorespiratory fitness among rural and urban adolescents; adolescents with higher levels of cardiorespiratory fitness had a lower relative risk of being overweight and/or obese than young people classified as normal-weight. During primary education students were moderately active, both rural and urban; in secondary education, urban children were more moderately active; children from rural areas practiced more MVPA; girls were more inactive in both environments; in secondary education, boys from the rural area were the most inactive; students in urban areas were more moderately and very active. Among black girls, those from rural areas practiced more VPA than urban girls; among white girls, those from urban areas were more vigorously active than those from rural areas; physical activity, in general, did not differ between urban and rural areas. The prevalence of overweight was higher among rural children; rural children were 1.47 times more likely to be overweight than children from small towns; urban children were less active; boys were more active than girls; urban children also reported less activity after school and at night than children in rural areas. Rural children were more likely to be overweight; among physically active children, rural children were more likely to be overweight; urban children were more likely to be physically inactive than rural children; urban girls were more likely to be physically inactive than rural girls; rural children were 21% less likely to be physically inactive than urban children. Urban adolescents were less active than rural adolescents; urban youth reported lower MVPA; urban girls had lower MVPA than those from remote regions; daily steps were lower among boys and girls from major cities than those from peripheral regions; urban boys had more screen time per day than those from remote areas; TV time was shorter among boys from remote areas; among girls, total screen and TV time did not differ between categories. 36.7% of rural children practiced 60 min or more of PA/day and 18.8% spent more than 2 h on electronic devices, and both values were higher compared to their peers from urban areas; rural children were more likely to perform physical activity and comply with screen time recommendations than urban children; patterns of healthy lifestyle behaviours were significantly higher among rural children.

Methodological Quality Assessment
The methodological quality attributed to the studies were categorized based on the study of Abarghoueinejad et al. [23]. No research presented a low methodological evaluation. In general, most were evaluated as high methodological quality (62), and only seven were classified as intermediate. Among the studies that sampled only rural children, four of them were classified as intermediate, while 33 were classified as high (only one study [40] reached the highest score). Among the studies that compared urban vs. urban subjects, two of them obtained a grade that classified them as intermediate (one with 50% [68]), and 29 of them were classified as high (of which reached the highest score [4,62,73,74]).

Instruments Used
Among studies that sampled only children from rural settings, both questionnaires and device-based measurements were used to estimate physical activity and/or sedentary behaviour. Of these studies, 14 of them used device-based measurements, namely accelerometers [25,27,29,32,37,40,45,48,52,53] or pedometers [6,28,31,44], which were mostly conducted in North America or Europe, with sample sizes, in general, smaller than studies that used questionnaires (maximum with 406 subjects). In general, movement behaviours were estimated based on 7 days of device use (ranging from 3 to 7 days).
Regarding age, from the published studies, it was possible to notice that the intensity and/or time (minutes) of physical activity decreases with increasing age [27,43,45,57], but one study found the opposite-lower levels of physical activity among young children compared to their oldest peers [42].
About the domains of physical activity, two studies reported the role of domestic tasks in the amount of physical activity of youth from rural areas, especially among girls [26,27]. On the other hand, regarding the leisure domain, boys were more active than girls, due to more involvement in sports practice [26]. Moreover, results related to active transportation showed that children who walk to school presented a higher daily steps average than those who reported using some type of inactive transportation [28], and scholars who lived close to schools used more active commuting to go to/from school [39].
A trend related to differences in physical activity was not observed when comparing school days and weekend days. For example, among children, Fukushima et al. [36] reported that children were more active on days without classes, while Button et al. [56] found the opposite-children were less active on weekends, and Brazendale et al. [55] did not find differences in physical activity among children based on days of the week. Among adolescents, Williams et al. [32] reported that teenagers were more active during school days.
Only one study investigated the role of the weather in youth physical activity, showing a positive association between increasing temperature and an increase in time spent in MVPA [56] among Canadian children. Regarding the role of the time in children's physical activity, the longitudinal study conducted by Benefice et al. [25] analysed three cohorts of Senegalese children between 13 and 15 years old (1997, 13 years; 1998, 14 years; and 1999, 15 years). The results from the last cohort (1999) showed (compared to the other first two cohorts) a decrease in MPA levels and an increase in VPA, but no significant changes were observed for LPA [25].

Rural × Urban Samples-Comparison
Studies that compared children from rural × urban/suburban areas showed, in general, that rural children were more active than their urban/suburban peers [62,65,66,72,77,78,80,81,[85][86][87], with only one study showing the opposite-children from a rural area had a lower steps count compared to those from an urban area [64]. This pattern was also observed when stratified by sex, where rural girls were more active [74,81] and spent more time in MVPA than the urban ones [75,83,86]. Only one survey showed rural boys as being more active than urbans [75].
However, some studies did not observe differences in physical activity (time and/or level) according to sex [73] and place of residence [4,70,71,79]. In addition, regardless of the place of residence, some studies showed that boys were more active [80,89], and only one study found high activity levels among girls when compared to boys [77]. Regarding race, one study showed that, among rural children, black girls were more vigorously active, and when comparisons between rural vs. urban were made, white girls were less engaged in VPA [79].
Regarding active transportation, Andrade Neto et al. [88] and Itoi et al. [64] described that rural children tend to use less active commuting to/from school than urban children, while Kundapur et al. [67] reported, specifically about the use of bicycle to go to school, that rural children used more this commuting strategy compared to urban ones, and Christiana et al. [4] and Morais Macieira et al. [76] found that, considering active commuting as a whole, rural youth tend to be more active to go to/from places. Moreover, domestic activities, such as fetching water and herding animals, were more usual among rural samples, playing relevant roles in their total physical activity [61]. About sports practice, Bathrellou et al. [70] observed a lower involvement of rural children in sports, compared to urban ones.
Considering the period of the day, Kundapur et al. [67] and Joens-Matre et al. [80] found that rural children and adolescents engage more in physical activities at night than their urban peers. Moreover, the role of seasons was investigated in two studies, with divergent results: Loucaides et al. [69] showed that rural children take more steps in summer and fewer steps during winter, and spent more time outdoors in general than their urban peers [69]; while McCrorie et al. [78] reported that rural youth spent more time in MVPA in winter and lower levels in spring than urban youth.

Rural Sample
Studies with rural children observed some sex differences-boys spent less time in sedentary behaviour than girls [37,45,49,54]; but one study pointed out that boys spent more time on computer games [38]. Regarding age, two studies reported that older children and adolescents spent more time in sedentary behaviour [53,54,59].
Regarding sedentary behaviour on school days, Brazendale et al. [55] observed that children were less sedentary during school days and had more screen time during the week, while Pate et al. [42] stated that students who watched television or played video games for more than 3 h after school were more likely to be inactive [42].
Furthermore, two studies reported results regarding race and socioeconomic aspects. Newton et al. [48] showed that children with low socioeconomic status spent less time in sedentary behaviour, and Moore et al. [46] reported that black children spent more time watching TV during school days when compared to white children [46].

Rural × Urban Sample-Comparison
Studies that compared children living in rural and urban settings observed, in general, that rural children spent less time watching TV and/or using computer [4,62,65,66,68,78,84,85,90], notwithstanding Andrade Neto et al. [88] have pointed out that rural children spend more time watching TV, and Morais Macieira et al. [76] reported that among children who spent >2 h/day on screen, the majority of them were from a rural area. One study did not find differences in screen time between rural and urban youth [70].
When the compliance of screen time guidelines was investigated, rural children complied the most when compared to urbans [62,87]. Taking into account sex differences, results seem to be quite different, although Dollman et al. [86] have noticed that rural boys spent less daily screen time than urban ones. In addition, the two studies from Machado-Rodrigues et al. [74,75] revealed different results, due to the use of different instruments to collect information about the same variable. For example, using accelerometers, authors found that urban girls spent more time in sedentary behaviour than rural ones [74], while through the use of questionnaire, and focusing on screen-time, authors reported that rural girls had more screen-time sedentary behaviour [75]. Dollman et al. [86] did not find any difference in TV time between urban and rural girls [86].
Regarding the association between movement behaviours and health outcomes, several studies showed significant associations between physical activity and sedentary behaviour with BMI [6,25,41,53] (more time spent in sedentary behaviour was related to a higher BMI). In addition, the involvement in physical activity seems to differ accordingly to children's fat percentage or nutritional status, since girls with high fat percentage were more physically inactive than their peers with lower levels of body fat [45]. Shriver et al. [49] and Bin Saad et al. [34] showed that between 70% and 80% of overweight/obese children were inactive [34] or spent less time in moderate physical activity compared to normal-weight children [49].
Some studies investigated other health outcomes in addition to BMI. Moore et al. [46] reported that children with low levels of physical activity were three times more likely to have metabolic syndrome and twice more likely to be overweight than children with high physical activity levels. On the other hand, Santos et al. [30] pointed out that no significant associations were observed between levels of physical activity and cardiorespiratory fitness.

Rural × Urban Comparison
Different results were shown for children from both rural and urban areas. Almost all the studies analysed overweight as a health outcome, and results were different, showing (i) non-differences in nutritional status according to the place of residence [70,71,76], or (ii) higher prevalence of overweight/obesity among rural children [74,[80][81][82], or (iii) higher prevalence of overweight/obesity [63,89,90] and higher levels of subcutaneous adipose tissue [85] among urban children.
Regarding differences taking into account sex and the place of residence, one study reported a higher prevalence of overweight among rural boys [81], while another showed a higher prevalence of obesity among urban girls [89], and one study stated no differences between urban and rural girls for overweight prevalence [81]. Some studies investigated health outcomes according to physical activity and sedentary behaviour. Liu et al. [81] observed that among physically active children, those living in rural areas had higher levels of overweight. In addition, the study conducted by Xu et al. [63] showed that children who spent more time in sedentary behaviour (tv time >7 h/week), regardless of where they live, were more likely to be overweight.

Discussion
The purposes of this systematic review were (i) to describe physical activity and sedentary behaviour in children from rural settings; (ii) synthesize the year and place of publication, methodological quality, and instruments used to measure movement behaviours (physical activity and sedentary behaviour); and (iii) to analyse the relationship between physical activity, sedentary behaviour and health outcomes in children living in rural areas. Substantial and methodological findings are highlighted: (i) little evidence is available from longitudinal studies, (ii) studies are centred in North America and Europe, with few results from South America and Oceania; (iii) both device-measurement and questionnaire were used for data collection; (iv) inequalities regarding sex, age, economic level, race, and physical activity domains within and between the places of residence (i.e., rural and urban areas); (v) sociodemographic characteristics were also related to health outcomes for children living in rural and urban areas. Figure 2 highlights the seven main findings of this systematic review.
America and Europe, with few results from South America and Oceania; (iii) both devicemeasurement and questionnaire were used for data collection; (iv) inequalities regarding sex, age, economic level, race, and physical activity domains within and between the places of residence (i.e., rural and urban areas); (v) sociodemographic characteristics were also related to health outcomes for children living in rural and urban areas. Figure 2 highlights the seven main findings of this systematic review.

Physical Activity and Health-Related Outcomes in Rural Children
Inequalities in physical activity were found among children living in rural areas. The role of sex and age was established, since older children tend to present less time in physical activity. These results are in accordance with previous studies [91][92][93]. Inconsistent findings were found regarding sex differences, except for physical activity in the domestic activities domain, in which girls presented higher mean values comparatively to boys [26,27], and physical activity during leisure time, in which boys were more active [26]. Differences in physical activity between sexes are similar to previous findings [94]. In summary, these differences were related to social expectations and cultural stereotypes, that overvalued the role of girls in domestic activities [26]. The paradox of physical activity was previously tested among adults [95] and the results showed that resources and environmental factors are the main barriers to PA practice, while social influences are the main motivator for involvement and adherence to physical activity; however, future studies need to deeply understand the characteristics of the domestic activities performed by children living in rural areas, especially the healthrelated outcomes possibly associated with the involvement of these activities.

Physical Activity and Health-Related Outcomes in Rural Children
Inequalities in physical activity were found among children living in rural areas. The role of sex and age was established, since older children tend to present less time in physical activity. These results are in accordance with previous studies [91][92][93]. Inconsistent findings were found regarding sex differences, except for physical activity in the domestic activities domain, in which girls presented higher mean values comparatively to boys [26,27], and physical activity during leisure time, in which boys were more active [26]. Differences in physical activity between sexes are similar to previous findings [94]. In summary, these differences were related to social expectations and cultural stereotypes, that overvalued the role of girls in domestic activities [26]. The paradox of physical activity was previously tested among adults [95] and the results showed that resources and environmental factors are the main barriers to PA practice, while social influences are the main motivator for involvement and adherence to physical activity; however, future studies need to deeply understand the characteristics of the domestic activities performed by children living in rural areas, especially the health-related outcomes possibly associated with the involvement of these activities.
Obesity rates ranged from 16% to 38% among children living in rural areas, and similar results were observed among urban children (19% to 36%) [6,31,[38][39][40][41]47,[49][50][51]55,59,60], with inconsistent findings for sex [6,38,40,44,49,50,53]. Low physical activity levels and high sedentary behaviour were positively associated with BMI [6,25,41,53]. The direction of this relationship is well established in the literature [96]. The negative spiral of disengagement [97] refers to the risk of obesity when the relationship between physical activity and motor competence was not well developed during the first years of the children's life. These findings were supported by recent studies [10][11][12], and different health outcomes were investigated [96,98]. For the present review, among the revised studies, metabolic syndrome was also investigated among children living in rural areas [46], with no association be observed with physical fitness [30]. The association between BMI and physical activity needs to be investigated in longitudinal design studies sampling rural children, due to the relevance of the outcome derived from this relationship to people's health across the lifespan, and also since this relationship may change from childhood to adolescence. In addition, the mentioned relationship, and its outcomes, can be presented differently in children living in rural settings compared to results derived from children living in urban areas.
Moreover, differences in physical activity according to days of the week showed different results, with some studies showing that children were more active on days without classes [36], while Button et al. [56] found the opposite, i.e., children were more active during school days. These differences may be related to the environmental characteristics considered, as well as different methods used in the studies [36,56]. Therefore, living near the school was positively associated with active commuting [39]. Previous results showed that long distances to be covered during commuting and household income were negatively related to active transportation among children [99], while recreational facilities and the existence of walking or bike paths increase the use of active transportation [99]. Notwithstanding the relevance of active commuting and leisure physical activity for children's health, specific environmental conditions must be taken into account, since the natural and built environments can affect, both positively or negatively, the involvement in physical activity in its different domains. For example, as shown, in the Canadian context it was observed that higher temperatures were related to higher physical activity levels among children [56] (each 1 • C (1.8 • F) increase in temperature leads to increases in MVPA by about 1.2 min) due to opportunities to perform physical activities in outdoor spaces. However, this relationship must be better explored in countries with higher temperatures during most of the year, which could allow the understanding of the role of weather in active commuting and outdoor leisure physical activity.

Differences in Physical Activity and Health-Related Outcomes between Rural and Urban Children
The main findings showed that children from rural areas presented, in general, higher physical activity levels [62,65,66,72,77,78,80,81,[85][86][87] as well as were more active in the domestic domain [61], regardless the sex. Differences in physical activity, such as during leisure, are related to environmental features, such as security perception and the availability of outdoor spaces for physical activity [100], which seems to be friendly/available in rural areas. In addition, differences in physical activity in the domestic domain can be related to socioeconomic conditions, since rural children may be more involved in domestic activities to assist with household chores such as gardening, animal grazing, and fetching water [61]. In another way, children living in urban areas presented higher engagement in sports activities [70], which is also related to motor, physical and social development [101]. These disparities are explained by the higher possibilities to access to structured activities in urban areas, as well as the diversity of practices, sometimes available in extra school time [6][7][8]. Further, considering the physical structure of urban areas, the lack of available, free of taxes, and secure spaces for children usage increase the search for structured spaces [7]. These differences are also expressed when analysing the weekly physical activity time, in which children living in rural areas tend to present higher levels of physical activity during the evenings [67,80]. Factors such as the perception of security, availability of outdoor spaces for physical activity practice, and even parental availability to play with their children in the outdoor area may be related to these differences [67,80]. Inconsistent findings were shown for active transportation [64,67,88].
Obesity rates were similar among children living in rural and urban areas [70,71,76]. Since obesity is a complex phenotype, related to individual and environmental characteristics [96], a more holistic approach needs to be considered for a better explanation. Food consumption was previously related to obesity in children [102]; however, non-differences were provided regarding the place of residence, and the pattern of food consumption in these different places. Among inactive children, those living in rural areas presented higher levels of being overweight [81].

Differences in Sedentary Behaviour within and between Rural and Urban Areas
Among those living in rural areas, girls [37,45,49,54] and older children [53,54,59] spent more time in sedentary behaviour than their peers. Differences in movement behaviours according to sex were already expected. Historical, cultural, economic, and family factors affect the involvement and engagement in physical activities [88], being able to reinforce sexist patterns that more hectic tasks are for boys and calmer for girls. Given that, girls are more prone to perform activities in sedentary positions (such as sitting). Comparing urban and rural children, regardless of sex, urban children spent more time in sedentary behaviour [4,62,65,66,68,78,84,85,90] and were less prone to meet screen time recommendations [62,87]. Economic aspects, such as more access to TV, video games and smartphones, as well as less availability of outdoor spaces to play, can play a relevant role in these differences [65,66]. The WHO Physical Activity and Sedentary Behaviour Guidelines [13] emphasize the association of sitting time/screen with several negative health outcomes, so although it does not stipulate a daily screen time, it is recommended that "kids and teens should limit the amount of time they spend sedentary, particularly the amount of recreational screen time". A revised study on this subject reported that children who spent more time in sedentary behaviours were more likely to be overweight [63].
Two studies, sampling the same subjects but using different instruments for data collection, found distinct results regarding differences in sedentary behaviour between rural and urban girls-data derived from accelerometer showed that urban girls spent more time in sedentary behaviour [74], while data derived from self-reported questionnaire revealed that rural girls were more sedentary (screen time) [75]. This demonstrates the relevance of choosing the measurement method according to the study purpose, avoiding possible bias in the results. Although the use of device-based measurements (such as accelerometer or pedometer) presents a trend of greater reliability for the collected variable [103], they are more expensive and often less accessible in countries with less investment and support for researches, highlighting that the use of questionnaires seems to be a more viable alternative [103]. In addition, Tremblay et al. [104] noted, in their systematic review, that informed information is usually the most used to measure sedentary behaviour, "allowing" to classify subjects based on time spent in screen (the 2 h/day is the most used cut-off point), which can lead to a false conclusion that there is a screen time limit during the day to be, or not be, sedentary.
Regarding screen time, the findings indicate that rural children had more TV time [88]. This fact may be related to a possible difficulty of access to other types of screens (e.g., computer, smartphone, video game), perhaps due to economic factors or, often, difficulties with internet access, which ends up limiting the functionalities of these devices, made less attractive, especially for children [9,88]. Such aspects can also explain the results that showed that children with lower socioeconomic status spent less time in sedentary behaviour [48]. This lack of access to technologies can lead to greater involvement in active play and reduce the possibilities of sedentary leisure [88].

Limitations, Strengths, and Remarks
Limitations of the present study include the search strategy used which, although it was thought to cover most of the studies on the subject studied, may have excluded some pertinent articles from the results, especially those published in languages other than English, Portuguese, and Spanish. In addition, the different forms of measurement and cut-off points of physical activity and sedentary behaviour used, hinder the synthesis and generalization of the findings presented by the studies. In addition, the limited number of reviewed papers that used other health outcomes than BMI does not allow us to deeply understand the relationship between movement behaviour and health outcomes in rural children. Despite these limitations, to the author's knowledge, this is the first review that has set out to investigate differences in movement behaviours and health outcomes in rural children. In addition, the fact that we used three different languages (Portuguese, English, and Spanish) allowed us to access a larger number of articles for the analysis, which increased the accuracy of our screening process. Therefore, performing a meta-analysis with the information discussed here could increase the robustness of the synthesis of the results presented in the study.
Based on these findings, suggestions for future studies include: increasing the evidence about movement behaviours among children living in South America and Oceania countries, since differences regarding geographic, social, cultural, economic, and political factors are evident; increasing the level of evidence about the role of the school for physical activity in children from rural areas, given the inconsistent findings; provide information about natural (e.g., weather) and built environments (e.g., school structure, bike lanes) for physical activity and sedentary behaviour, especially considering the socioeconomic gradient.

Conclusions
Our findings showed that rural children were more physically active and spent less time in sedentary behaviour compared to their urban peers. Among the rural samples, boys were more active and had less screen time than girls and, overall, the rates of overweight were between 16% and 38% and did not differ according to the place of residence (rural and urban). As expected, we noted that low levels of physical activity and long periods of sedentary behaviour were associated with negative health outcomes, such as obesity. We observed a greater number of publications in the recent five years, and a greater concentration of research conducted by high-income countries, especially North Americans and Europeans, which were also the ones that used more device-based measurements, although most studies have been conducted using questionnaires. Finally, the methodological quality attributed to most of the studies was considered high.