Abstract

Background/objective

Physical literacy (PL) is 鈥�the motivation, confidence, physical competence, knowledge, and understanding to value and take responsibility for engagement in physical activities for life鈥�. Recent evidence has shown that PL was associated with mental wellbeing in different populations, yet a comprehensive review examining the association between PL and mental health among tertiary education students was lacking. The aims of this scoping review were to rapidly map relevant evidence on the relationships between perceived PL and mental health in higher education students and to determine the feasibility and value of conducting a full systematic review in this research area.

Methods

All primary studies (observational and experimental) examining the associations between PL and mental health in college/university/undergraduate students were included. Seven electronic databases, namely PubMed, Academic Search Premier, CINAHL, ERIC, PsycINFO, Medline, and SPORTDiscus, were searched from their inceptions through 30 September 2024. A narrative approach was adopted to synthesize results relevant to the study aims categorized based on mental health outcomes.

Results

Seven observational studies (n鈥�=鈥�34,824) were included. Results showed that PL was positively correlated with better mental wellbeing, including greater quality of life, better subjective wellbeing, higher levels of life satisfaction, improved resilience, and greater compliance with sleep guideline, and negatively associated with psychological distress (depression, anxiety, and stress) among university students. During the COVID-19 pandemic, PL was also shown to buffer university students鈥� psychological distress, declines in quality of life and life satisfaction, as well as impaired sleep in the population.

Conclusion

Despite emerging research efforts to decipher the relationships between perceived PL and mental health in tertiary institution settings, further high-quality experimental studies are imperatively needed to guarantee the relevance of rigorous systemic reviews in the realm of university students鈥� mental health.

Introduction

Physical literacy (PL) is defined as 鈥�the motivation, confidence, physical competence, knowledge, and understanding to value and take responsibility for engagement in physical activities for life鈥� [1]. According to the definition by International Physical Literacy Association, PL consists of four essential, interrelated elements, namely (1) physical domain which is about an individual鈥檚 movement proficiency to participate in a variety of physical activities (PAs) (i.e., physical competence), (2) affective domain emphasizing positive attitude towards PA and perceptions of competence (i.e., motivation and confidence), (3) cognitive domain which refers to an individual鈥檚 understanding of the health benefits of an active lifestyle as well as his/her knowledge on how to react to the surrounding environments (i.e., knowledge and understanding), and (4) behavioural domain focusing on encouraging an individual to be fully responsible for taking part in habitual PAs (i.e., sustainable PA engagement for life). Emerging evidence showed that PL was an important antecedent of increased PA, reduced sedentary behaviour (SB), and/or better physical wellbeing in children [2], adolescents/young adults [3,4,5,6], and older people [7, 8]. Given that childhood and adolescence are critical periods of habit, lifestyle, and health risk factor formation that can be considerably tracked into adulthood [9, 10], fostering younger populations to become physically literate serves as a milestone to alleviate the increasing worldwide trend of inadequate PA, where almost one-third of the global population were having insufficient PA [11]. To meet the 2030 target of reducing the global prevalence of physical inactivity by 15% in adults and adolescents, the World Health Organization recommends to 鈥渃reate active people鈥� by reinforcing lifelong health and PL in educational settings, including tertiary institutions [12].

Studies demonstrated that tertiary education students who were more physically literate were more likely to have favourable movement patterns and good mental health. For instance, university students who were more physically literate were more likely to meet the 24-h movement guidelines (PA, SB, sleep) [3]. Perceived PL was shown to be a positive predictor for PA levels, especially moderate-to-vigorous PA, among tertiary education students likely through reduced SB and increased light PA [4, 6, 13]. In college students, Wang et al. (2020) was the first research group to address the inseparability of PL and mind factors [14]. Latest findings showed that PL was favourably associated with overall mental wellbeing (emotional, psychological, and social) [15], psychological distress (depression, anxiety, and stress) [16], life satisfaction [16], health-related quality of life [17, 18], and sleep duration [3] among university students. During the COVID-19 pandemic which entailed an increment of 25% in the global prevalence of depression and anxiety [19], PL was also shown to play a mediating role in the relationships of psychological distress with life satisfaction [20] and quality of life [21] in higher education students. Kan et al. (2024) further showed that the affective and cognitive domains of PL in college students were negatively associated with psychological distress in respect of stress, depression, and anxiety, suggesting that people with positive attitudes and sound knowledge and understanding of the value of PL are more likely to have better mental health [16]. Thus, school-based PL promotion could be an effective strategy to reduce physical inactivity and mental distress burdens in higher education settings, where nearly half of the students did not have sufficient PA and 63.5% of them failed to meet al.l the 24-h movement guidelines [3].

Different from high schools, commencing tertiary education represents a significant transition into adulthood accompanied by higher expectations from others in terms of academic and behavioural performances. During this critical transition point, factors that might bring about significant decrements in mental health include learning to live independently from their parents, adjusting to a new way of learning, developing new social networks, and coping with greater financial burdens arising from higher tuition fees and cost of living (i.e., possible debts in the future) [22]. Some studies further showed that tertiary education students in certain academic disciplines (e.g., nursing) might face even more stress than other discipline students and the general population largely due to their clinical working environments, higher expectations for their clinical performances with increasing years of study, and a perceived lack of time for regular exercise participation [23,24,25,26]. Given that the primary aim of higher education is to prepare students for careers where students will have numerous client encounters, the influence of promoting PL in higher education students on population health could be tremendous. For instance, health professional students will be the major pillars (key messengers, advocates, and facilitators of health) of the healthcare system. Cultivating PL champions in pre-vocational healthcare settings could surely relieve global physical inactivity prevalence and the associated disease burdens (e.g., diabetes and cardiovascular diseases) that are usually modifiable, preventable, and treatable by lifestyle modification.

Although recent systematic reviews supported the associations of PL with levels of PA and physical health/fitness across the life span [27, 28], our literature search of seven electronic databases (PubMed, Academic Search Premier, CINAHL, ERIC, PsycINFO, Medline, and SPORTDiscus) (n鈥�=鈥�282 after removal of duplicates) showed that there were no comprehensive reviews (e.g., systematic or scoping reviews) examining the relationships between perceived PL and mental health in university students. Since tertiary education students usually face unique challenges (e.g., academic stress, romantic and peer relationships, future uncertainty, and financial pressure) during their transition through adulthood and current research has revealed the alarmingly increasing rate of mental disorders (e.g., depression and anxiety) in this population [29], provision of empirical support to potentially beneficial interventions, especially targeting PL, may facilitate development of quality PE in tertiary education settings that could effectively alleviate their psychological distress often faced in their everyday university life and eventually promote their mental wellbeing.

According to the World Health Organization, mental health is more than just the absence of mental disorders, but also a state of mental well-being where people realize their own capabilities to cope with normal stresses of life, learn and work effectively and productively, and contribute their own community [30]. To guarantee breadth of coverage and reduce the risk of missing relevant records in this field of enquiry [31], a wide definition of mental health, spanning from mental wellbeing to clinically-relevant mental health symptoms, was adopted. In this study, we attempted to employ a scoping review strategy to systematically map relevant evidence, and hence determine if there were any research gaps in this specific research area [31, 32]. Also, this scoping review serves as a milestone to determine the feasibility and value of conducting a full systematic review in this specific area of inquiry [31,32,33]. Specifically, this scoping review aimed at improving our understanding of PL by answering the following research questions:

• 1. How did existing literature conceptualize and operationalize PL within the context of tertiary education students鈥� mental health?

• 2. Did current evidence reveal the relationship(s) of perceived PL with mental health outcomes (e.g., psychological distress, life satisfaction, sleep quality/insomnia, etc.) in higher education students? If yes, what were the key findings?

Methods

The construction of this scoping review study protocol was primarily based on and extended from the Arksey and O鈥橫alley鈥檚 framework [31]. The findings of the study were reported in line with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) Extension for Scoping Reviews (PRISMA-ScR) [32]. Since this scoping review was undertaken to have preliminary mapping of the existing relevant literature and hence to determine whether a full systematic review can be feasibly conducted [31], no prior PROSPERO registration of the review protocol was required [33].

Eligibility criteria

The PCC (population, concept, context) framework was employed to guide the screening and selection of eligible studies for review. Regardless of study design, all primary studies (observational and experimental) examining the associations between perceived PL and mental health in tertiary education students were considered eligible for inclusion. Both healthy tertiary education students and students who were at risk of or having mental health conditions (e.g., depression and anxiety) were considered. In the present scoping review, we only focused on the perception of their own PL in respect of motivation, confidence, physical competence, knowledge, understanding, and PA behaviour, but not the traditional skill-oriented assessment of PL that has primarily emphasized revealing fundamental movement skills and is too narrow to address the complexity of the concept [34]. For practical reasons (e.g., substantial cost and time in translating materials) according to the Arksey and O鈥橫alley鈥檚 framework [31], only studies published in English were included. Retracted articles or studies other than primary research, including reviews, meta-analyses, books/book chapters, erratum/correction, study protocols, editorials, and commentaries, were excluded.

Information sources and search

Seven electronic databases (PubMed, Academic Search Premier, CINAHL, ERIC, PsycINFO, Medline, and SPORTDiscus) were searched from their inceptions through 30 September 2024. The text word terms used for the database search were piloted twice and refined before implementation. The text word terms used in the search were 鈥減hysical literacy鈥� (but not 鈥減hysical鈥� or 鈥渓iteracy鈥�) for perceived PL, (student* OR college* OR universit* OR undergraduate*) for tertiary education students, and (mental OR psychological OR depress* OR anxiety OR stress OR distress OR mood OR emotion* OR affect* OR sleep OR insomnia OR resilience OR 鈥渜uality of life鈥� OR satisfaction) for mental health. The search strategies for every electronic database were shown in Appendix 1.

Selection of sources of evidence

The searched records were screened using a two-stage approach by firstly reviewing their titles and abstracts, followed by their full texts. The initial screening and full-text assessment followed a stepwise procedure [35]. For instance, once the searched study was a primary yet unrelated study, the study would be immediately excluded with no other exclusion/inclusion criteria considered. When the key information was missing in the titles and abstracts and the records were highly suspected to be eligible studies, full-text assessments of the records along with other potentially eligible studies were conducted. For example, a study conducted in young adults aged 18鈥�25 years (i.e., likely conducted in college/university settings) without emphasizing the research context in its title and abstract was included for full-text assessment. To avoid missing any eligible studies, the reference lists and the included/excluded study lists of our searched relevant systematic reviews and scoping reviews were screened [36,37,38,39]. All duplicate records were manually removed using an excel spreadsheet. Multiple reports or doubling counting of results were also examined based on publication details (e.g., authors鈥� names and locations), participants鈥� baseline characteristics (e.g., age, sample sizes, and medical conditions), interventions and controls, recruitment and completion rates, length of follow-up, etc. The initial screening and full-text assessment were conducted by the first author (Leung WK) and hence verified by two independent authors (Sum RKW and Lam SC), who had more than 20-year working experience in tertiary education (physical education and nursing education, respectively).

Data charting process

Prior to data extraction/charting, a data extraction form was developed and piloted based on two included studies by the first author (Leung WK). To ensure a precise and consistent extraction of relevant data, the piloted table was calibrated by two independent investigators (Sum RKW and Lam SC). Data items, including publication details (e.g., authors, year of publication, countries/region, and study design), participants, outcome measures (e.g., PL, PA, SB, and mental health), and main findings, were charted and presented in the calibrated forms chronologically. Since perceived physical literacy instruments (PPLIs) with varying numbers of items (e.g., 8-item, 9-item, and 18-item) were used across studies, the PL scores were standardized as mean values per item to guarantee comparability of results. In line with the Canadian 24-Hour Movement Guidelines for Adults aged 18鈥�64 years [40], the PA, SB, and sleep durations were also transformed into average minutes per week, average hours per day, and average hours per day, respectively. The data extraction was conducted by the first author (Leung WK) and independently verified by two investigators (Sum RKW and Lam SC). Disagreements among the investigators were resolved by discussion.

Critical appraisal of individual sources of evidence

Appraisal of risk of bias or certainty of evidence of the included studies was not required because the primary aim of conducting scoping reviews was to map the existing literature rather than to critically appraise and synthesize results to answer a specific research question [33].

Synthesis of results

A narrative synthesis of the charted results relevant to the study aims categorized based on mental health outcomes was adopted. All authors in this scoping review independently verified and edited every entry to guarantee data accuracy and consistency.

Results

Study selection

Our electronic database search yielded a total of 656 records. After removal of 374 duplicates, 282 records were initially screened for their titles and abstracts, and 12 records were therefore retrieved for full-text assessment. Finally, seven studies that met the eligibility criteria were included for review. For the included studies, there were no concerns about multiple reports or double counting results because all the studies were completely different from one another in terms of publication details (e.g., authors and locations), study objectives, participants鈥� characteristics, mental health outcomes, and key findings. The study selection process was presented in Fig.听1.

Fig. 1

Study Selection Flow

Characteristics of included studies

The seven included studies were published during 2021 and 2024 and conducted in China [3, 15,16,17, 20, 21] and Taiwan [18]. Their study designs were cross-sectional (85.7%) [3, 15,16,17, 20, 21] and prospective cohort (14.3%) [18] (i.e., observational in nature). Their sample sizes ranged from 388鈥夆垝鈥�24,236, with a total of 34,824 study participants (i.e., college/university students). The proportion of male sex varied from 42.1 to 82.5%. The average PPLI scores were 3.8-4.0 per item. For movement behaviour, moderate, vigorous, and moderate-to-vigorous PAs were 52.4鈥�145.6听min/week, 37.0鈥�116.8听min/week, and 89.4鈥�262.3听min/week, respectively, whereas daily sedentary time was 5.4听h. Mental health outcomes included quality of life (42.9%) [17, 18, 21], life satisfaction (28.6%) [16, 20], and others [e.g., overall mental wellbeing (emotional, psychological, and social) [15], subjective wellbeing [17], resilience [15], and sleep quality [3]] (42.9%). Characteristics and main findings of the seven individual studies were summarized in Tables听1 and 2, respectively.

Table 1 Characteristics of included studies (n鈥�=鈥�7)

Table 2 Characteristics and main findings of individual studies conducted in tertiary education students (n鈥�=鈥�7)

Synthesis of results

Quality of life

Perceived PL was shown to be independently associated with health-related quality of life in university students directly or indirectly through either PA increments or improved subjective wellbeing [17, 21]. In particular, the motivation and environment interaction domains of PL positively predicted overall quality of life, while the confidence and physical competence domains were shown to have an indirect impact on the relationships of perceived PL with the quality of life among university students [21].

Wang et al. (2024) also showed that baseline PL was positively associated with intrinsic motivation for participating in PE, PE satisfaction, and quality of life satisfaction among university students [18]. Meanwhile, PE satisfaction positively mediated the relationship between PL and quality of life. The authors explained that the experience of gaining satisfaction during PE lessons can nurture students鈥� PL development and eventually lead to their life fulfilment. This observation embodied the translation of psychological health from improved PL via a satisfying PE program.

Life satisfaction

Perceived PL was shown to be associated positively with levels of life satisfaction and PA, negatively with psychological distress (stress, depression, and anxiety), and partially mediate the relationship between psychological distress and life satisfaction among higher education students [16, 20]. In the independent relationship between psychological distress and life satisfaction, PL and PA were consistently found to be the significant mediators [20].

Others

Ma et al. (2021) showed that PL positively influenced mental health (overall, social, psychological, and emotional wellbeing) among university students [15]. Specifically, the relationships of PL with social and psychological wellbeing were partially mediated by resilience, whereas the relationship between PL and emotional wellbeing was fully mediated by resilience.

Liu et al. (2024) also demonstrated that 36.5% of university students met al.l three 24-h movement guidelines (PA, SB, and sleep), whereas 72.8% of them met the guideline for sleep (i.e., 7鈥�9听h of sleep daily) [3]. There were no significant differences in overall PL levels for compliance with sleep guideline. However, a higher score for the environment interaction domain of PL for adherence to sleep guideline was observed.

PL and COVID-19

Dong et al. (2020) and Gao et al. (2024) suggested that PL interventions could be a potentially beneficial modality to buffer university students鈥� psychological distress as well as declines in quality of life and levels of life satisfaction during the COVID-19 pandemic [21]. Given the strongest magnitude of relationship between environment interaction (versus overall PL and other subdomains) and quality of life, Gao et al. (2024) also mentioned that fostering environment adaptability was the key to sustain an active lifestyle during adverse circumstances (e.g., home confinement during COVID-19). Liu et al. (2024) also reported that university students having higher scores for environment interaction were more likely to comply with the sleep guidelines amidst the COVID-19 pandemic (i.e., data collection during November and December of 2020) [3].

Discussion

To the best of our knowledge, this study is the first scoping review to systematically examine the relationship between perceived PL and mental health in tertiary education students. Our results of seven included studies (n鈥�=鈥�34,824) showed that PL was positively correlated with better mental welling (e.g., greater quality of life [17, 18, 21], better subjective wellbeing [17], higher levels of life satisfaction [16, 20], improved resilience [15], and greater compliance with sleep guideline [3]), and negatively associated with psychological distress (depression, anxiety, and stress) [16, 20]. Given that the first relevant paper on this subject matter was published in 2021 [15] and 71.4% (5/7) of our included studies were published in 2024 [3, 16,17,18, 21], this addressed that the emerging research area on PL pertaining to mental health in higher education students became increasingly important and echoed the need of more research efforts appealed by the World Health Organization in exploring the relationships between PA, where PL is an important antecedent, and mental health outcomes across populations to inform critical decision-making [41].

The present scoping review aimed at determining the feasibility of conducting a full systematic review in this specific area of inquiry [31, 33]. Our findings showed that all included studies were observational studies, of which six (>鈥�85%) were cross-sectional in nature. This implied that the relationships between PL with mental health outcomes in tertiary education students could be bidirectional. No experimental studies in this research area greatly jeopardized the relevance of rigorous systematic reviews, especially conducted on randomized controlled trials. Further high-quality experimental studies are imperatively warranted to verify the observed causal inferences of PL with mental health among tertiary education students.

Kan et al. (2024) suggested that the affective and cognitive domains of PL mediated the relationship between psychological stress and life satisfaction in college students [16]. They proposed that fostering motivation and confidence as well as improving knowledge and understanding of an active lifestyle could help students promote positive attitudes and overcome psychological hurdles to become physically active. Gao et al. (2024) further underscored the importance of environment interaction (besides motivation), which had the strongest magnitude of relationship with quality of life, in alleviating psychological challenges of maintaining a healthy lifestyle during the COVID-19 pandemic [21]. They explained that college students who were more passionate about PA (i.e., higher PL) would be more likely to seek opportunities to enhance their quality of life by participating in more PA during challenging conditions (e.g., home confinement). This finding was in line with the emerging worldwide fitness trends of online training (1st in 2021), home exercises (2nd in 2022), virtual training (6th in 2021), and online live and on-demand exercise classes (9th in 2022) since the outbreak of COVID-19 [42, 43] to cater for the needs of environmental adaptability to be physically active in face of COVID-19 adversity.

Most included studies failed to address unique mental health needs among higher education students of various academic disciplines. For instance, nursing students experienced more stress than other health discipline students and the general population [24]. Their stress levels varied across their working environments categorized by the branches of adult, child, and mental health nursing [26] and years of study (e.g., academic courses for first-year students and clinical performance expectations for second-year students) [44], and became more intense with increasing levels of training [25]. Cornish et al. (2020) also mentioned that the area of PL with health care providers was understudied as evidenced by no existing literature found in this area [45]. Therefore, nurturing PL among health discipline undergraduate students, especially nursing students who will be the major pillars (key messengers, advocates, and facilitators of health) in the healthcare system and have a multitude of daily patient encounters, could adequately or synergistically reduce the global physical inactivity prevalence in the general and diseased populations. This research initiative echoed the 鈥淓xercise is Medicine鈥� global health initiative, where exercise can be prescribed for patients by healthcare providers who should be brought back into mainstream PE focusing more on disease prevention, health promotion, psychological wellbeing, and longevity [46].

There were several study limitations in this review. First, only studies published in the Asian context (e.g., China and Taiwan) were included. It was because mandatory PE curricula at higher education settings were only offered in certain Asian regions (e.g., China, Taiwan, and Hong Kong) [13, 18]. More research involving diverse ethnic populations could offer culturally sensitive solutions to tackle the worldwide issue of college students who were usually reported to have inadequate PA. Second, there was marked heterogeneity across studies in respect of PPLI measurements and mental health outcomes. This would lower the comparability of results across studies by precluding comprehensive meta-analysis to systematically evaluate the PL effectiveness on tertiary education students鈥� mental wellbeing. Third, many included studies (>鈥�85%) were cross-sectional in nature. Additional experimental studies (e.g., randomized controlled trials) were deserved to verify the observed potentially causal inferences of PL and mental health. Fourth, there was language bias because only English articles were included. Given that authors from non-English speaking countries were more likely to submit their negative/null findings to local journals not published in English, inclusion of journal articles merely in English may lead to an increased risk of publication bias [47].

Conclusion

This review advances our understanding of PL in the context of higher education students鈥� mental health. Despite emerging research efforts to decipher the associations between PL and mental health, further high-quality randomized controlled trials are imperatively needed to guarantee the relevance of rigorous systemic reviews in this research area. Given that adherence to nonmovement behaviour guidelines (e.g., SB and sleep) was usually associated with higher PL scores [3], more research efforts are also required to elucidate the mediating roles of these nonmovement behaviours, where SB was recently shown to correlate with greater likelihoods of anxiety and depressive symptoms in university students [48], in the relationship between PL and mental health.