State laws governing school physical education in relation to attendance and physical activity among students in the USA: A systematic review and meta-analysis

Background: This study systematically synthesized and quantified the relationship linking state laws governing school physical education (PE) to PE attendance and physical activity (PA) in class and throughout the day and week among students in the USA. Methods: A keyword search was performed in PubMed, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Academic Search Complete, and EconLit. Meta-analyses were performed to estimate the effects of state PE laws. Results: A total of 17 studies were included in the review, and five contributed to the meta-analyses. A total of 8 studies used nationally representative school- or student-level data, three focused on multiple states, and the remaining six examined the PE laws of a single state. The presence and strength of state PE laws were positively associated with PE attendance and the frequency and duration of PA during PE classes and throughout the school day. Compared to those residing in states with weak or no PE laws, students in states with strong PE laws had an additional 0.2 days (95% confidence interval (95%CI): 0.1-0.4) of PE attendance per week and spent an additional 33.9 min (95%CI: 22.7-45.0) participating PE classes per week. State PE laws affected girls' PA more than boys'. Different aspects of state PE laws tended to affect students' PE attendance differently. Disparities in the implementation of state PE laws existed across schools. Conclusion: Future studies should adopt objective measures on PE and PA participation and examine the roles schools and districts play in mediating the effect of state PE laws on students' PE attendance and PA.