Association between migration and physical activity among medical students from a university located in Lima, Peru
Association between migration and physical activity among medical students from a university located in Lima, Peru
Alejandro Zevallos-MoralesID 0 1
Leslie Luna-Porta 0 1
Henry Medina-Salazar 0 1
Mar??a Yauri 0 1
Alvaro Taype-RondanID 1
0 Universidad de San Mart ??n de Porres, Facultad de Medicina Humana, Lima, Peru, 2 Universidad San Ignacio de Loyola, Unidad de Investigacio ? n para la Generaci o ?n y S ??ntesis de Evidencias en Salud , Lima , Peru
1 Editor: Wisit Cheungpasitporn, University of Mississippi Medical Center , UNITED STATES
To evaluate the association between migration and physical activity among medical students from a university located in Lima, Peru. A cross-sectional study was conducted among second-year medical students from a Peruvian university. Data on moderate- to vigorous-intensity physical activity (MVPA) and migration features were obtained through a self-report questionnaire. To assess the associations of interest, prevalence ratios (PR) along with their 95% confidence intervals (95% CI) were calculated using Poisson regression with robust variances. We analyzed data from 312 students (54.5% were women, mean age: 19.0 years, standard deviation: 1.4 years), 90 (28.9%) students performed MVPA for 150 minutes/week, 118 (37.8%) performed MVPA for 30 minutes/week, and 114 (36.7%) were migrants. Being a migrant was not associated with performing MVPA for 30 nor 150 minutes/week. However, adjusted analysis showed that the frequency of performing MVPA for 30 minutes/ week was greater among those who migrated less than five years ago (PR: 1.43; 95% CI: 1.05-1.93) and among those who migrated to continue their studies (PR: 1.44; 95% CI: 1.06-1.94), compared to non-migrants.
Data Availability Statement: All relevant data are
within the manuscript and its Supporting
Funding: The authors received no specific funding
for this work.
Competing interests: The authors have declared
that no competing interests exist.
In our population, being a migrant was not associated with physical activity. However, low
physical activity was more prevalent among recent migrants and among those who had
migrated to study, compared to non-migrants.
Physical inactivity is associated with an increased risk of developing chronic diseases such as
type 2 diabetes mellitus, hypertension, and some types of cancer.  Also, physical inactivity is
considered as the fourth leading risk factor for mortality worldwide, being responsible for 5.3
million premature deaths in 2008. [
] Nonetheless, it is estimated that 31.1% of adults
worldwide are physically inactive (defined as not engaging in 30 minutes of moderate-intensity
physical activity on at least 5 days every week, not engaging in 20 min of vigorous-intensity
physical activity on at least 3 days every week, and not achieving a total of 600 metabolic
equivalent-min per week). [
Physical activity can be measured using different strategies: Self-report measures are the
most widely used, and much of worldwide data on physical activity are obtained through
these measures. On the other hand, direct measures (including accelerometers, pedometers,
heart-rate monitors, and multiple-sensor devices) are being used in a growing number of
Previous studies have found lower rates of physical activity in more urbanized areas
compared to less urbanized areas, [
] and that those who migrate from less urbanized towards
more urbanized locations tend to decrease their physical activity. [
] Considering that
migration usually occurs towards more urbanized areas and that around 3 million people
migrate to urban cities weekly worldwide,  the association between migration and physical
activity constitutes a public health issue.
In Latin America, many of the migrants are young, and they choose or are forced to migrate
seeking better economic, academic or job opportunities. [
] Since it has been observed
that physical activity patterns in youth are an important predictor of physical activity in
adulthood,  the potential decrease of physical activity in young migrants might have a great
impact on this population health.
Currently, there is a paucity of information regarding the association between migration
and physical activity in young people, making it difficult to develop and implement adequate
preventive interventions. Moreover, young people who migrate to pursue time-consuming
careers such as medicine may have less leisure time and, therefore, perform less physical
activity. Thus, the objective of this study was to evaluate the association between migration and
physical activity among medical students from a university located in Lima, Peru.
A cross-sectional study was conducted during May 2016 among second-year medical students
from Universidad de San Mart??n de Porres (USMP) located in Lima, the capital city of Peru.
At USMP, undergraduate medical education lasts 7 years, which are divided into 3 groups:
basic studies (first, second, and third years), clinical studies (fourth, fifth, and sixth years) and
internship (seventh year).
Lima, the capital city of Peru, has over 9 million inhabitants as of 2018.[
migration in Peru is fairly common and Lima is the primary destination. Between 2002 and 2007,
approximately 1.5 million people migrated to another location within Peru, of which 42.8%
migrated to Lima. [
Participants and procedures
The population consisted of second-year medical students enrolled in the Biostatistics course
(one of the obligatory courses of the second-year of the career). Four hundred and sixteen
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students were enrolled in this course during the first semester of 2016. We included all
students who accepted to participate in this study and excluded those who were less than 18 years
old and those who did not complete the variables of interest.
Biostatistics students were distributed among 30 classes. The distribution of students
per class was granted by the Department of Basic Studies of USMP. Subsequently, four
previously trained interviewers attended these classes to coordinate with the professors, perform
informed consent to the students, and administer the questionnaires to all those who accepted
to participate. This was conducted at the beginning or at the end of the class, according to
availability. Students were given enough time to complete the questionnaires. Later, two
authors entered the data from questionnaires in parallel into a Microsoft Excel database, and a
third author reviewed for inconsistencies.
Outcome: Physical activity
To assess self-reported physical activity, we asked participants: ?Please, calculate the number
of minutes per week you engage in moderate- to vigorous- intensity physical activity (MVPA)
during a regular week of classes.? In this case, MVPA was defined as any activity that involves
physical wear and heart rate increase, such as brisk walking, jogging, bike riding, swimming,
practicing a sport, among others, following the definition proposed by the Canadian Society
for Exercise Physiology (CSEP). [
The CSEP recommends that adults aged 18?64 years should engage in at least 150 minutes
of MVPA weekly. [
] Accordingly, we defined adequate physical activity as performing
MVPA for 150 minutes/week. In addition, we defined low physical activity as being in the
lowest tertile of MVPA ( 30 minutes/week).
Exposure: Migration and characteristics
The exposures of interest were migration features (migration status, degree of urbanization of
the place of origin, years lived in Lima, and reason for migration). Other variables evaluated
were age and sex.
To define migration status, we used the question: ?Have you lived anywhere other than
Lima?? Those who answered yes were considered migrants, and those who answered no were
To evaluate the degree of urbanization of the place of origin of the participants, we asked
where they were born and where they lived before moving to Lima. Then, we divided migrants
into two groups: those who came from a big city (if they were born in a big city or had lived in
a big city before migrating to Lima), and those who came from a small city (if they were born
in a small city and had lived in a small city before migrating to Lima). We used the median of
the population of the places of origin of our migrants (500,000 people) as the cutoff point to
categorize cities in big and small. The population number was estimated using national and
international population data accordingly.
To know the number of years lived in Lima, we used the question: ?How many years have
you been living in Lima?? Then, we divided migrants into two groups: late migrants (if they
had migrated five or more years ago), and recent migrants (if they had migrated less than five
years ago). This was an arbitrary cut-off point decided by the authors.
To know the reason for migration, we used the question: ?Why did you move to Lima??
Then, we divided migrants into two groups: migrated to continue their studies and migrated
for other reasons (such as work, health, or because his/her family migrated).
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Ethical approval was obtained from the Institutional Review Board at Hospital Nacional
Docente Madre-ni?o "San Bartolome?" (RCEI-40). In addition, we obtained the signed consent
from the participants before applying the questionnaires.
We used STATA v.14 for the analysis. We did a descriptive analysis of the population using
absolute and relative frequencies as well as mean ? standard deviations. Then, we assessed the
factors associated with the two outcomes (performing MVPA for 150 minutes/week and for
30 minutes/week) by calculating crude and adjusted prevalence ratios (PR) and their 95%
confidence intervals (95% CI) using Poisson regression with robust variants, as proposed by
Coutinho et al. [
] Regressions were adjusted by age and sex. Lastly, we assessed the
association between the years lived in Lima and the reasons for migrating using the chi-2 test.
A total of 416 second-year medical students were enrolled in the Biostatistics course, of which
356 completed the questionnaire. We excluded 44 participants (19 male and 25 female): 39 for
being less than 18 years old, and 5 for not answering the physical activity question. Thus, we
analyzed data from 312 students (75.0% of the total number of students).
Among those, 170 (54.5%) were women and the mean age was 19.0 ? 1.4 years. Regarding
physical activity, 118 (37.8%) performed MVPA for 30 minutes/week and 90 (28.9%)
performed MVPA for 150 minutes/week. With respect to migration features, 114 (36.5%) were
migrants; 57 (50.0%) of them came from big cities before migrating to Lima, 67 (46.5%) had
migrated less than five years ago, and 77 (53.5%) had migrated to continue their studies
In the analysis adjusted by age and sex, we did not find any factor associated with
performing MVPA for 150 minutes/week. However, students who migrated less than five years ago
had a 43% higher prevalence of performing MVPA for 30 minutes/week compared to
nonmigrants, and those who migrated in order to continue their studies had a 44% higher
prevalence of performing MVPA for 30 minutes/week compared to non-migrants. (Table 2).
Lastly, we evaluated the association between years lived in Lima and the reasons for
migrating to Lima and found that 88.1% of recent migrants and 38.3% of late migrants had migrated
to continue their studies (chi-2 p-value <0.001).
We analyzed self-reported information from 312 medical students, finding that a little less
than a third performed MVPA for 150 minutes/week and a little more than a third
performed MVPA for 30 minutes/week. Migration status was not associated with physical
activity. Also, we did not find any association between migration features and performing MVPA
for 150 minutes/week. However, recent migrants and those who migrated to continue their
studies had a higher prevalence of performing MVPA for 30 minutes/week compared to
Despite the CSEP recommendation for adults to accumulate at least 150 minutes/week of
MVPA, only 28.9% of students met this recommendation. This rate seems to be lower than
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19.0 ? 1.4
previous physical activity reports among medical students. In a Canadian university, 64% of
fourth-year medical students met the CSEP recommendation. [
] In addition, 61% of
students from a university in the United States and 32.3% of students from a university in India
met the Center for Disease Control and Prevention (CDC) recommendation of 150 minutes of
moderate physical activity or 60 minutes of vigorous physical activity weekly. [
Previous studies have reported barriers to perform physical activity among university
students, which might also be present in our population. These include high stress levels, high
academic demand [
], lack of time [
], lack of knowledge of international
recommendations about physical activity [
], lack of personal or family motivation [
lack of opportunities or facilities at universities.  Thus, the implementation of certain
university-based interventions could modify these barriers, such as promoting cycling or walking
as a means of transportation, creating environments that encourage physical activity during
leisure time, or offering free workshops that can work around students? schedules, could help
overcome these barriers. [
Physical activity and migration
We did not find any association between migration status and physical activity. To our
knowledge, this was the first study to evaluate this association among university students,
although previous studies in the general population found that adult migrants tend to decrease
their physical activity. [
] The lack of association in our study is probably due to the
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undifferentiated inclusion of migrants who came from places with a different degree of
urbanization and had different length of migration.
We did not find any factor associated with performing MVPA for 150 minutes/week.
However, the number of years lived in Lima and the reason for migrating was associated with
performing MVPA for 30 minutes/week. This could mean that the cut-off point of 150
minutes may not be ideal for identifying the effects of migration features on physical activity. In
consequence, further studies should consider the use of more than one cut-off point to
evaluate factors associated with physical activity.
Compared to non-migrants, recent migrants performed less physical activity.
Concomitantly, other studies in the general population have also found that recent migrants perform
less physical activity. A study conducted in Canada assessed over 170,000 individuals from
2000 to 2003. They found that recent migrants and immigrants performed less physical activity
compared to non-migrants. In this study, they defined recent migrant as being a resident for
less than 10 years. [
] Another study conducted in Australia found that migrants performed
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less physical activity compared to non-migrants. This was higher in older populations, females
and those who came from non-English speaking countries. [
These results may indicate that recent migrants are not yet well suited to the new
environment (they are not sufficiently acculturated), [
] having higher levels of stress and just a few
friends, which could be preventing them from doing physical activity. [
] Accordingly, a
systematic review indicates that promoting the process of acculturation among migrants would
be beneficial for physical activity interventions in prevention programs. [
] Thus, the
implementation of activities targeted to individuals with low acculturation levels should be explored
at universities. In addition, it cannot be guaranteed that recent migrants will be able to
establish an exercise routine in the future, then longitudinal studies would be needed.
Those who migrated to continue their studies performed fewer physical activities compared
to non-migrants. We have not found other studies that have assessed this association. The
reason for this association is uncertain, possible explanations are that those who migrated to
continue their studies spend more time studying or have migrated without their family, having to
household tasks themselves; which decreases their time to do physical activity. Also, these
migrants could not have the economic resources aimed at activities unrelated to their studies,
thus leaving aside physical activity. Another explanation is that this is a fictitious association
confounded by the length of migration since most of those who migrated to continue their
studies are also recent migrants.
Limitations and strengths
Our study assessed self-reported physical activity, which is a widely used method to evaluate
physical activity patterns. [
20, 34, 40, 43, 45
] However, it should be taken into account that
assessing self-reported physical activity may lead to over-or underestimations of the real physical
] Furthermore, the use of a tool that was not previously validated may affect the study
reproducibility, but as we mentioned earlier, we wanted to explore directly measured MVPA.
In addition, it is important to note that our participants were medical students from a single
university, thus, generalization to other universities and careers would not be adequate,
especially because USMP is a private university, which could have a population with higher
socioeconomic status than that of public Peruvian universities. Lastly, we used the number of
inhabitants in the cities as a proxy to measure the degree of urbanization. This evaluation may
not be sufficiently accurate, we are not considering certain aspects of the place of origin, such
as the type of terrain or elevation.
However, this is to our knowledge the first study to assess the association between
migration/migration features and physical activity in young people, which are a large group of
migrants worldwide. This evaluation provides a relevant understanding of this subject and
opens new research subjects in this field.
We assessed second-year medical students from a Peruvian university and found no
association between migration status and physical activity. However, low physical activity was more
prevalent in those who were recent migrants, and in those who had migrated to continue their
studies, compared to non-migrants.
S1 File. Minimal data set: Database plos.dta.
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Conceptualization: Alejandro Zevallos-Morales, Alvaro Taype-Rondan.
Data curation: Alejandro Zevallos-Morales.
Formal analysis: Alejandro Zevallos-Morales, Alvaro Taype-Rondan.
Investigation: Alejandro Zevallos-Morales.
Methodology: Alejandro Zevallos-Morales.
Supervision: Alvaro Taype-Rondan.
Writing ? original draft: Alejandro Zevallos-Morales, Leslie Luna-Porta, Henry
Medina-Salazar, Mar??a Yauri, Alvaro Taype-Rondan.
Writing ? review & editing: Alejandro Zevallos-Morales, Leslie Luna-Porta, Henry
Salazar, Mar??a Yauri, Alvaro Taype-Rondan.
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Warburton DE , Charlesworth S , Ivey A , Nettlefold L , Bredin SS . A systematic review of the evidence for Canada's Physical Activity Guidelines for Adults . International Journal of Behavioral Nutrition and Physical Activity . 2010 ; 7 ( 1 ): 39 .
2. Lee I-M , Shiroma EJ , Lobelo F , Puska P , Blair SN , Katzmarzyk PT , et al. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy . The lancet . 2012 ; 380 ( 9838 ): 219 - 29 .
World Health O. Global Health Risks-Mortality and burden of disease attributable to selected major risks . Cancer . 2017 .
4. Hallal PC , Andersen LB , Bull FC , Guthold R , Haskell W , Ekelund U , et al. Global physical activity levels: surveillance progress, pitfalls, and prospects . The lancet . 2012 ; 380 ( 9838 ): 247 - 57 .
5. Ainsworth B , Cahalin L , Buman M , Ross R. The current state of physical activity assessment tools . Progress in cardiovascular diseases . 2015 ; 57 ( 4 ): 387 - 95 . https://doi.org/10.1016/j.pcad. 2014 . 10 .005 PMID: 25446555
6. Patel RB , Burke TF . Urbanization-an emerging humanitarian disaster . New England Journal of Medicine . 2009 ; 361 ( 8 ): 741 - 3 . https://doi.org/10.1056/NEJMp0810878 PMID: 19692687
7. Creber RMM , Smeeth L , Gilman RH , Miranda JJ . Physical activity and cardiovascular risk factors among rural and urban groups and rural-to-urban migrants in Peru: a cross-sectional study . Revista Panamericana de Salud Pu?blica. 2010 ; 28 ( 1 ): 1 - 8 . PMID: 20857014
8. Ebrahim S , Kinra S , Bowen L , Andersen E , Ben-Shlomo Y , Lyngdoh T , et al. The effect of rural-to-urban migration on obesity and diabetes in India: a cross-sectional study . PLoS Med . 2010 ; 7 ( 4 ):e1000268. https://doi.org/10.1371/journal.pmed. 1000268 PMID: 20436961
9. Oyebode O , Pape UJ , Laverty AA , Lee JT , Bhan N , Millett C . Rural, urban and migrant differences in non-communicable disease risk-factors in middle income countries: a cross-sectional study of WHOSAGE data . PloS one . 2015 ; 10 ( 4 ):e0122747. https://doi.org/10.1371/journal.pone. 0122747 PMID: 25849356
10. Lyngdoh T , Kinra S , Shlomo YB , Reddy S , Prabhakaran D , Smith GD , et al. Sib-recruitment for studying migration and its impact on obesity and diabetes . Emerging Themes in Epidemiology . 2006 ; 3 ( 1 ): 2 .
11. Desa U. World urbanization prospects, the 2011 revision. United Nations . 2011 ; 505 .
12. Migration IOf. World Migration Report 2015: Migrants and Cities: New Partnerships to Manage Mobilit. 2015 .
13. Rodr ??guez Vignoli J. Migracio?n interna en Ame?rica Latina y el Caribe: estudio regional del per??odo 1980- 2000 . 2004 .
14. Thomas RN , editor Internal Migration in Latin America; An Analysis of Recent Literature. Publication Series (Conference of Latin Americanist Geographers) ; 1971 : JSTOR.
15. Bauman AE , Reis RS , Sallis JF , Wells JC , Loos RJ , Martin BW , et al. Correlates of physical activity: why are some people physically active and others not? The lancet . 2012 ; 380 ( 9838 ): 258 - 71 .
16. Informatica INdEe. Lima alberga 9 millones 320 mil habitantes al 2018 Lima2018 [ 31 - 3 -2018]. https:// www.inei.gob.pe/prensa/noticias/lima-alberga-9 - millones-320 - mil-habitantes-al-2018 -10521/.
17. Salinas EM . Peru, migraciones internas 1993 -2007 . Lima, Peru: INEI, Direccion Tecnica de Demografia e Indicadores Sociales. 2009 .
18. Tremblay MS , Warburton DE , Janssen I , Paterson DH , Latimer AE , Rhodes RE , et al. New Canadian physical activity guidelines . Applied Physiology , Nutrition, and Metabolism . 2011 ; 36 ( 1 ): 36 - 46 . https:// doi.org/10.1139/H11-009 PMID: 21326376
19. Coutinho L , Scazufca M , Menezes PR . Methods for estimating prevalence ratios in cross-sectional studies . Revista de saude publica. 2008 ; 42 ( 6 ): 992 - 8 . PMID: 19009156
20. Holtz KA , Kokotilo KJ , Fitzgerald BE , Frank E. Exercise behaviour and attitudes among fourth-year medical students at the University of British Columbia . Canadian Family Physician . 2013 ; 59 ( 1 ): e26 - e32 . PMID: 23341676
21. Anand T , Tanwar S , Kumar R , Meena GS , Ingle GK . Knowledge, attitude, and level of physical activity among medical undergraduate students in Delhi. 2011 .
22. Frank E , Tong E , Lobelo F , Carrera J , Duperly J . Physical activity levels and counseling practices of US medical students . Medicine and science in sports and exercise . 2008 ; 40 ( 3 ): 413 - 21 . https://doi.org/10. 1249/MSS.0b013e31815ff399 PMID: 18379201
23. Aslam F , Mahmud H , Waheed A . Cardiovascular health-behaviour of medical students in Karachi . JPMA The Journal of the Pakistan Medical Association . 2004 ; 54 ( 9 ): 492 - 5 . PMID: 15518377
24. Ram??rez-Ve?lez R , Tordecilla-Sanders A , Laverde D , Herna? ndez-Novoa JG , R??os M, Rubio F , et al. Prevalencia de barreras para la pra? ctica de actividad f??sica en estudiantes universitarios Nutricion Hospitalaria . 2014 ; 31 ( n02 ): 858 - 65 .
25. Rodr??guez R , Palma L , Romo B , Escobar B , Aragu ? G, Espinoza O , et al. Ha?bitos alimentarios, actividad f??sica y nivel socioecono?mico en estudiantes universitarios de Chile . Nutricio?n hospitalaria . 2013 ; 28 ( 2 ): 447 - 55 .
26. Go ?mez- Lo?pez M , Gallegos AG , Extremera AB . Perceived barriers by university students in the practice of physical activities . Journal of Sports Science and Medicine . 2010 ; 9 ( 3 ): 374 - 81 . PMID: 24149629
27. Lovell GP , El Ansari W , Parker JK . Perceived exercise benefits and barriers of non-exercising female university students in the United Kingdom . International Journal of Environmental Research and Public Health . 2010 ; 7 ( 3 ): 784 - 98 . https://doi.org/10.3390/ijerph7030784 PMID: 20617003
28. Steptoe A , Wardle J , Cui W , Bellisle F , Zotti A-M , Baranyai R , et al. Trends in smoking, diet, physical exercise, and attitudes toward health in European university students from 13 countries, 1990 - 2000 . Preventive medicine. 2002 ; 35 ( 2 ): 97 - 104 . PMID: 12200093
Wolf TM , Kissling GE . Changes in life-style characteristics, health, and mood of freshman medical students . Academic Medicine . 1984 ; 59 ( 10 ): 806 - 14 .
30. Hui SS-C, Hui GP-S, Xie YJ . Association between physical activity knowledge and levels of physical activity in Chinese adults with type 2 diabetes . PloS one . 2014 ; 9 ( 12 ):e115098. https://doi.org/10.1371/ journal.pone. 0115098 PMID: 25493559
31. Brown SA . Measuring perceived benefits and perceived barriers for physical activity . American journal of health behavior . 2005 ; 29 ( 2 ): 107 - 16 . PMID: 15698978
32. Chinn DJ , White M , Harland J , Drinkwater C , Raybould S . Barriers to physical activity and socioeconomic position: implications for health promotion . Journal of Epidemiology and Community Health . 1999 ; 53 ( 3 ): 191 . PMID: 10396499
33. Gyurcsik NC , Spink KS , Bray SR , Chad K , Kwan M. An ecologically based examination of barriers to physical activity in students from grade seven through first-year university . Journal of Adolescent Health . 2006 ; 38 ( 6 ): 704 - 11 . https://doi.org/10.1016/j.jadohealth. 2005 . 06 .007 PMID: 16730599
34. Al-Drees A , Abdulghani H , Irshad M , Baqays AA , Al-Zhrani AA , Alshammari SA , et al. Physical activity and academic achievement among the medical students: A cross-sectional study . Medical teacher . 2016 ; 38 ( sup1 ): S66 - S72 .
35. El Ansari W , Stock C. Relationship between attainment of recommended physical activity guidelines and academic achievement: undergraduate students in Egypt . Global journal of health science . 2014 ; 6 ( 5 ): 274 . https://doi.org/10.5539/gjhs.v6n5p274 PMID: 25169005
Wald A , Muennig PA , O'Connell KA , Garber CE . Associations between healthy lifestyle behaviors and academic performance in US undergraduates: a secondary analysis of the American College Health Association's National College Health Assessment II . American Journal of Health Promotion . 2014 ; 28 ( 5 ): 298 - 305 . https://doi.org/10.4278/ajhp.120518-QUAN-265 PMID: 23941106
37. Dogra S , Meisner BA , Ardern CI . Variation in mode of physical activity by ethnicity and time since immigration: a cross-sectional analysis . International journal of behavioral nutrition and physical activity . 2010 ; 7 ( 1 ): 75 .
38. Kagotho N. A Longitudinal analysis of physical activity among foreign-born individuals . Journal of Human Behavior in the Social Environment . 2011 ; 21 ( 5 ): 540 - 54 .
39. Koya DL , Egede LE . Association between length of residence and cardiovascular disease risk factors among an ethnically diverse group of United States immigrants . Journal of general internal medicine . 2007 ; 22 ( 6 ): 841 - 6 . https://doi.org/10.1007/s11606-007-0163-y PMID: 17503110
40. Tremblay MS , Bryan SN , Pe?rez CE , Ardern CI , Katzmarzyk PT . Physical activity and immigrant status: evidence from the Canadian Community Health Survey . Canadian Journal of Public Health/Revue Canadienne de Sante'e Publique . 2006 : 277 - 82 .
41. Statistics ABo. Migrants and participation in sport and physical activity . Commonwealth of Australia . 2006 .
42. Schwartz SJ , Unger JB , Zamboanga BL , Szapocznik J . Rethinking the concept of acculturation: implications for theory and research . American Psychologist . 2010 ; 65 ( 4 ): 237 . https://doi.org/10.1037/ a0019330 PMID: 20455618
43. Perez LG , Chavez A , Marquez DX , Soto SC , Haughton J , Arredondo EM . Associations of acculturation with self-report and objective physical activity and sedentary behaviors among Latinas . Health Education & Behavior . 2016 : 1090198116669802 .
44. Gerber M , Barker D , Pu?hse U. Acculturation and physical activity among immigrants: A systematic review . Journal of Public Health . 2012 ; 20 ( 3 ): 313 - 41 .
45. Nacar M , Cetinkaya F , Baykan Z , Yilmazel G , Elmali F . Hazardous health behaviour among medical students: a study from Turkey . Asian Pac J Cancer Prev . 2015 ; 16 : 7675 - 81 . PMID: 26625780
46. Prince SA , Adamo KB , Hamel ME , Hardt J , Gorber SC , Tremblay M. A comparison of direct versus selfreport measures for assessing physical activity in adults: a systematic review . International Journal of Behavioral Nutrition and Physical Activity . 2008 ; 5 ( 1 ): 56 .
47. Sallis JF , Saelens BE . Assessment of physical activity by self-report: status, limitations, and future directions. Research quarterly for exercise and sport . 2000 ; 71 ( sup2 ): 1 - 14 .