Physiological and Functional Health Outcomes of Dance-Based Physical Activity in Midlife Adults

doi:10.21203/rs.3.rs-8491633/v1

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Systematic Review

Physiological and Functional Health Outcomes of Dance-Based Physical Activity in Midlife Adults

https://doi.org/10.21203/rs.3.rs-8491633/v1

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Background

Sedentary behavior is strongly associated with increased cardiometabolic risk in adults. Dance-based physical activity represents a potentially engaging form of moderate-to-vigorous exercise; however, its physiological and functional health effects in midlife adults remain insufficiently synthesized.

Objective

To systematically synthesize evidence on the effects of dance-based physical activity on objectively measured physiological and functional health outcomes in adults aged 30–60 years.

Methods

This systematic review was conducted in accordance with PRISMA 2020 guidelines. Scopus, Web of Science, PubMed, and ScienceDirect were searched for studies published between 2020 and 2025. Eligible studies included adults aged 30–60 years, employed quantitative or mixed-methods designs, and reported objectively measured physical health outcomes. Risk of bias was assessed using the Cochrane RoB 2 tool and the Newcastle Ottawa Scale. Due to heterogeneity in intervention characteristics and outcome measures, a narrative synthesis was performed.

Results

From 1,148 records identified, 31 studies involving 2,432 participants across 16 countries met the inclusion criteria. Dance-based interventions were associated with improvements in cardiorespiratory fitness (VO₂max increases of approximately 7–22%), reductions in systolic blood pressure (3–12 mmHg), favorable changes in body composition (body fat reductions of 1.5–6.4%), gains in muscle strength (5–18%), enhanced flexibility (7–19%), and improved balance outcomes (postural sway reductions of 10–27%). Interventions lasting at least 12 weeks generally demonstrated greater effect magnitudes.

Conclusions

Dance-based physical activity appears to elicit meaningful physiological and functional health adaptations in midlife adults, supporting its potential role as an alternative exercise modality for cardiometabolic health promotion and disease prevention during midlife.

dance-based physical activity

exercise physiology

functional performance

cardiometabolic health

midlife adults

Physical activity is fundamental to non communicable disease prevention and cardiometabolic health across the adult lifespan. Longitudinal evidence demonstrates that lifestyle patterns established during ages 30–60 years substantially influence subsequent disease trajectories, making this period a critical epidemiological window for preventive intervention (Dube, 2025; Sommer et al., 2024). Physical inactivity accounts for significant global disease burden, with middle-aged adults experiencing notable declines in habitual physical activity due to occupational demands, time constraints, and competing responsibilities (Liao, 2025; (X. Lu, 2024).

Adults aged 30–60 years occupy a distinct physiological life stage. This period involves metabolic transition characterized by progressive changes in body composition, muscle mass, bone mineral density, and insulin sensitivity changes that remain substantially reversible through lifestyle intervention (Y. Liu et al., 2021).This age group therefore represents an optimal primary prevention window, contrasting with older adults who frequently present established pathology with limited reversibility and younger cohorts with greater metabolic plasticity (J. Lu, 2024).Targeted intervention during ages 30–60 years offers distinct strategic opportunity for disease prevention and reversal of metabolic decline.

Dance based interventions represent a form of physical activity demonstrating both physiological efficacy and practical adherence advantages. Evidence indicates that conventional exercise prescriptions encounter persistent adherence limitations at the population level, with many interventions demonstrating adherence rates below 50% at 12 month follow up (Y. Liu et al., 2021). In contrast, dance-based interventions demonstrate notably superior adherence, with documented rates ranging from 76.5% to 100% across diverse populations (Yoong, 2024; X. Lu, 2024). Recent systematic reviews confirm that structured dance interventions produce measurable improvements in cardiovascular fitness, body composition, and functional capacity (Dwarika, 2024; Schäfer, 2024; Sánchez-Alcalá, 2025).

Existing systematic reviews on dance and health have primarily focused on older adults (> 60 years), clinical populations such as those with Parkinson's disease or post stroke conditions, or isolated outcome domains including balance and fall prevention. The role of dance as a comprehensive physical health intervention during mid-adulthood remains insufficiently synthesized. Adults aged 30–60 years, despite their strategic importance for primary prevention, have received limited integrated attention in prior dance and physical health reviews. Previous evidence demonstrates that dance interventions in middle-aged and older adults show superior adherence compared to conventional exercise modalities, yet comprehensive understanding of dance's benefits in the critical prevention window of ages 30–60 years remains limited (J. Lu, 2024; Fonseca et al., 2025; Yoong, 2024).

The present systematic review addresses this evidence gap by providing a comprehensive synthesis of dance-based interventions targeting objectively measured physical health outcomes specifically among community-dwelling adults aged 30–60 years. This review examines cardiovascular, metabolic, neuromuscular, and functional outcome domains within a unified framework, positioning dance as a pragmatic, sustainable intervention strategy for non communicable disease prevention with quantifiable impact on modifiable cardiometabolic risk factors during a critical prevention window.

Study Design And Protocol Registration

This systematic review adheres to the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) 2020 statement (Page et al., 2021)). The review protocol was developed a priori using the PICOS (Population Intervention Comparison Outcome Study Design) framework, ensuring transparent, reproducible, and pre-specified methodology.

Table 1

PICOS Framework and Scientific Justification
PICOS Component	Eligibility Specification	Scientific Justification	PRISMA Alignment
Population (P)	Community dwelling adults aged 30–60 years; no age-based stratification; inclusive of healthy adults and those with metabolic risk factors; exclusion of institutionalized or clinical populations.	The age range represents midlife adulthood, a critical period for the emergence of cardiometabolic decline while retaining sufficient physiological plasticity for exercise adaptation. Inclusion of heterogeneous baseline health status enhances external validity and mirrors real world community populations targeted by dance based interventions.	Defines Population eligibility at the screening and full-text eligibility stages of the PRISMA flow diagram.
Intervention (I)	Dance-based physical activity as the primary intervention; duration ≥ 4 weeks; frequency ≥ 1 session/week; inclusion of all structured dance forms (aerobic, contemporary, traditional, ballroom, cultural).	A minimum of 4 weeks is required to elicit measurable physiological adaptations in cardiovascular and musculoskeletal systems. Dance is conceptualized as a multicomponent physical activity combining aerobic, neuromotor, and musculoskeletal demands, justifying inclusion of diverse dance styles to capture modality-specific effects.	Guides inclusion criteria for intervention classification during full text assessment.
Comparison (C)	Waitlist control, no intervention control, conventional exercise programs, or attention control.	Inclusion of multiple comparator types allows differentiation between absolute intervention effects, exercise specific effects, and contextual/attention effects, strengthening internal validity and interpretability of effect estimates.	Applied during study selection and documented as reasons for exclusion in the PRISMA diagram.
Outcomes (O)	Primary physical health outcomes: cardiorespiratory fitness (VO₂max or submaximal tests); blood pressure; body composition; muscle strength/power; flexibility; balance/postural control; functional mobility.	Outcomes were selected based on established exercise physiology and public health frameworks, representing clinically and functionally meaningful indicators of physical health. Prioritizing objective, quantifiable outcomes minimizes measurement bias and enables meta analytic synthesis.	Corresponds to outcome eligibility at the data extraction and synthesis phases of PRISMA.
Study Design (S)	RCTs prioritized; quasi experimental (non randomized controlled, pre post); longitudinal cohort studies; quantitative or mixed methods with quantitative outcomes.	RCTs provide the highest level of causal inference, while inclusion of quasi-experimental and longitudinal designs increases evidence breadth in emerging or under researched intervention contexts such as dance based physical activity.	Justifies study design inclusion/exclusion reported in the PRISMA flow diagram.

Information Sources and Comprehensive Search Strategy

Table 2

Information Sources and Comprehensive Search Strategy
Domain	Specification
Databases Searched	Scopus (SciVerse platform); Web of Science (Core Collection); PubMed (Medline); ScienceDirect.
Search Period	2020–2025.
Justification of Time Frame	The selected period captures contemporary evidence reflecting recent methodological rigor, standardized outcome measurements, and modern intervention designs in dance based physical activity research.
Search Strategy Framework	Comprehensive electronic search using controlled vocabulary (where applicable) and Boolean logic, adapted to the syntax of each database to balance sensitivity and specificity.
Core Concept Blocks	(1) Dance-based intervention; (2) Adult population; (3) Physical health outcomes.
Primary Boolean Search String (Main Manuscript)	(“dance” OR “dancing” OR “dance intervention” OR “aerobic dance” OR “Zumba” OR “Latin dance” OR “contemporary dance” OR “square dance” OR “ballroom dance” OR “folk dance” OR “hip-hop dance” OR “dance therapy”) AND (“adult” OR “middle-aged” OR “30 year” OR “40 year” OR “50 year” OR “30–60” OR “middle age” OR “productive age”) AND (“physical health” OR “physical fitness” OR “cardiometabolic” OR “cardiovascular” OR “cardiorespiratory” OR “VO₂max” OR “aerobic fitness” OR “muscle strength” OR “body composition” OR “balance” OR “flexibility” OR “functional fitness” OR “postural control”).
Simplified Boolean Search String (Supplementary File)	(dance OR dancing OR “dance intervention” OR “aerobic dance” OR Zumba OR “ballroom dance” OR “traditional dance” OR “contemporary dance”) AND (adult* OR “middle-aged” OR “middle age” OR “productive age”) AND (“physical health” OR “physical fitness” OR cardiorespiratory OR cardiovascular OR VO2max OR “aerobic fitness” OR “muscle strength” OR “body composition” OR balance OR flexibility OR “functional fitness”).
Search Fields	Title, abstract, and keywords across all databases.
Language Restrictions	English
Supplementary Identification Methods	(1) Manual screening of reference lists from all included studies and relevant reviews; (2) Forward citation tracking using Scopus and Web of Science; (3) Direct contact with corresponding authors to obtain unpublished or in-press data; (4) Gray literature searches of conference abstracts from the American College of Sports Medicine (ACSM), European Academy of Sports Sciences (EASS), and European Gerontological Society (EGS).

Study Selection Criteria: Detailed Inclusion and Exclusion

Table 3

Study Selection Criteria: Detailed Inclusion and Exclusion
Domain	Inclusion Criteria	Exclusion Criteria
Study Population	Community dwelling adults with a mean age or inclusive age range between 30–60 years; non-institutionalized; no restrictions based on sex, ethnicity, or socioeconomic status.	Mean age outside the 30–60 year range; samples primarily drawn from institutionalized settings or populations defined by specific clinical diagnoses (e.g., neurological or psychiatric disorders as the primary study focus).
Intervention Characteristics	Dance based physical activity as the primary intervention modality; structured and predefined protocol; minimum intervention duration ≥ 4 weeks; frequency ≥ 1 session/week; inclusion of all dance modalities (aerobic, contemporary, traditional, ballroom, cultural, competitive, or recreational) provided they are delivered as structured interventions.	Dance implemented as a secondary or adjunctive component within multicomponent programs where independent effects cannot be isolated; unstructured recreational or competitive dance without a defined intervention protocol; dance therapy interventions focusing exclusively on psychological outcomes without physical health assessment.
Outcome Measures	At least one quantitatively assessed physical health outcome, including cardiorespiratory fitness (VO₂max or validated submaximal proxies), blood pressure, anthropometric measures (BMI, body fat percentage, waist circumference), muscle strength and/or power, flexibility, balance or postural stability, composite functional fitness indices, or functional mobility measures.	Studies reporting psychological outcomes only (e.g., depression, anxiety, mental well being) without corresponding physical health endpoints; quality of life measures lacking objective physical health data; insufficient quantitative outcome reporting or absence of data enabling effect size estimation.
Study Design	Randomized controlled trials (RCTs); quasi-experimental designs (non randomized controlled trials, pre post designs with control groups); longitudinal cohort studies; mixed-methods studies incorporating quantitative physical health outcome measurement.	Qualitative-only studies; case reports or case series; opinion pieces, editorials, commentaries; narrative or scoping reviews without primary data extraction; conference abstracts lacking full-text peer-reviewed publication.
Publication Characteristics	Peer reviewed journal articles published January 2020 onward; publications in English or Indonesian; sufficient reporting of sample characteristics, intervention protocols, and outcome measures.	Non peer reviewed sources; duplicate publications (most comprehensive and recent version retained); articles with insufficient methodological or outcome detail preventing data extraction or synthesis.
Reporting Adequacy	Clear description of participant characteristics, intervention dosage, outcome measurement instruments, and statistical reporting adequate for synthesis or meta-analysis.	Incomplete reporting of intervention exposure or outcome metrics; missing variance data or unclear analytic methods precluding effect size calculation.

Study Selection Process: Dual Independent Screening with Quality Assurance

Phase 1 Title and Abstract Systematic Screening:

Two independent researchers (blinded to publication author names, institutions, and journal information to minimize selection bias) screened all identified titles and abstracts against predefined eligibility criteria using DistillerSR systematic review platform. Screening decisions were documented with dichotomous (include/exclude) coding. Disagreements regarding eligibility were documented with specific rationale and resolved through consensus discussion with reference to original PICOS criteria; cases where consensus could not be achieved were escalated to a third independent reviewer for arbitration. Inter rater reliability (Cohen's κ) was calculated; κ > 0.70 indicated acceptable agreement (Landis and Koch interpretation: κ 0.61–0.80 = substantial agreement; κ 0.81-1.00 = almost perfect agreement).

Phase 2 Full Text Systematic Review:

All articles advancing from Phase 1 screening underwent complete full text evaluation against detailed, pre-specified eligibility criteria. Reasons for exclusion were systematically documented with specific category notation (e.g., "wrong age group," "no physical health outcomes," "qualitative only design," "insufficient data for extraction") to enable transparent reporting. Final inclusion determination was made by consensus; disagreements regarding study eligibility were resolved through discussion with explicit reference to the original publication and eligible criteria, escalating to third-reviewer arbitration if consensus could not be achieved.

Flow Documentation:

Complete adherence to PRISMA flow diagram standards, with detailed reporting of article numbers and exclusion reasons at each stage, ensuring transparency, reproducibility, and audit trail documentation.

Data Extraction and Quality Assurance Procedures

Data extraction form (standardized, pilot tested across 5 randomly selected studies prior to full implementation to ensure consistency and completeness).

Table 4

Data Extraction Framework and Completeness Criteria
Data Category	Specification	Completeness Check
Bibliometric Information	Author surname (first author), publication year, country of study conduct, journal name/volume/issue/pages, DOI, URL	All fields required
Study Population	Total sample size (N), mean age ± SD, age range, sex distribution (M/F count or %), setting classification (urban/rural/community center/university), baseline health status classification	Sample ≥ 20 participants
Intervention Characteristics	Primary dance modality type(s), intervention frequency (sessions/week), duration per session (minutes), total intervention length (weeks), intensity specification (if reported: %HRmax, RPE scale, or qualitative), delivery format (in-person studio, home-based video, hybrid)	All intervention parameters
Comparison Group	Waitlist control characteristics, no intervention control, conventional exercise control specifications, attention control description	Clearly specified
Outcome Measures	Primary and secondary outcomes measured, assessment instruments/measurement tools, timing of measurement (baseline, post-intervention, follow-up timing), unit of measurement	Standardized instruments
Results Reporting	Means and standard deviations (baseline, post-intervention, change values), effect sizes (Cohen's d, partial eta-squared, odds ratios), p-values, 95% confidence intervals, statistical significance notation	Complete data or extractable
Quality Indicators	Study quality/bias assessment markers, participant attrition/dropout rates and specified reasons, intervention adherence rates (% sessions attended), intention to treat analysis conduct, loss to follow up patterns	Documented

Data extraction process:

Data extraction was performed independently by two researchers using the standardized form. Disagreements in data transcription or interpretation were resolved by consensus through discussion and reference to original publication tables/text/supplementary material. A third reviewer performed spot checking of 10% of extractions (n = 3 randomly selected studies) for accuracy and completeness. Extraction data were entered into standardized spreadsheet format (Excel) with automated validation checks for consistency.

Risk of Bias and Quality Assessment

Risk of bias and methodological quality of included studies were independently assessed by two reviewers using standardized and validated tools according to study design. Discrepancies in judgments were resolved through consensus discussion, and when necessary, a third senior reviewer was consulted to achieve agreement.

For randomized controlled trials (RCTs), the Cochrane Risk of Bias 2 (RoB 2) tool was applied, evaluating five bias domains: (1) bias arising from the randomization process (sequence generation, allocation concealment, baseline imbalances); (2) bias due to deviations from intended interventions (protocol adherence, intervention fidelity, contamination); (3) bias due to missing outcome data (extent, reasons, and handling); (4) bias in outcome measurement (blinding of outcome assessors, validity of outcome measures); and (5) bias in selection of reported results (selective outcome reporting, consistency with prespecified analysis plans).

For non-randomized studies, including quasi-experimental and cohort designs, methodological quality was assessed using the Newcastle-Ottawa Scale (NOS). The NOS evaluates studies across three domains: (1) Selection (representativeness of the exposed cohort, ascertainment of exposure); (2) Comparability (adjustment for key confounding variables such as age, sex, and baseline fitness); and (3) Outcome (validity of outcome assessment, adequacy of followup).

Each study was categorized as low risk, some concerns/moderate risk, or high risk of bias based on domain-level judgments. The overall certainty of evidence for each outcome was subsequently evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework, considering risk of bias, consistency of results, directness of evidence, precision of estimates, and potential publication bi

Data Synthesis Approach and Heterogeneity Assessment

Meta Analysis Feasibility Assessment

Given substantial heterogeneity evident across multiple dimensions intervention protocols (dance modalities: Zumba vs. contemporary vs. traditional folk styles), intervention parameters (duration: 4–16 weeks; frequency: 1–5 sessions/week; intensity: unmeasured or unreported in 13 studies), outcome measurement instruments (cardiorespiratory fitness assessed via maximal VO₂ testing vs. submaximal 6-minute walk test vs. shuttle walk; balance measured via multiple instruments: Berg Balance Scale vs. postural sway assessment vs. tandem stance), and population characteristics (baseline health status spectrum, geographic regions, study quality distribution) formal quantitative meta analysis with statistical pooling was deemed inappropriate. Statistical pooling would substantially obscure between study heterogeneity sources and violate underlying homogeneity assumptions, potentially producing misleading summary estimates.

Structured Narrative Synthesis Approach

A narrative synthesis was conducted, organized systematically by: (1) outcome domain classification (cardiovascular/cardiorespiratory, metabolic/body composition, neuromuscular [strength, flexibility, balance], functional/mobility/composite measures); (2) effect direction consistency analysis (did improvements occur consistently across studies within specific outcome domains?); (3) effect magnitude characterization (range of effect sizes, central tendency, clustering patterns within domains); (4) heterogeneity source analysis (which study characteristics design quality tier, intervention parameters, population characteristics accounted for outcome variation patterns?); and (5) subgroup pattern identification (differential effects stratified by dance modality, intervention duration quartiles, study quality tier, sex distribution).

Summary evidence tables presented key study characteristics, effect sizes with 95% confidence intervals, and quality indicators, enabling visual pattern recognition and comparative assessment of evidence strength across outcome domains.

Table 5

Detailed Study Characteristics and Physical Health Outcomes
No	Author & Year	Country / Scope	Title	Study Design	Dance Intervention Type	Duration & Frequency	Physical Health Outcomes	Key Physical Health Findings	Effect Magnitude	DOI / Link
1	Dwarika MS et al. (2024)	Germany	Characteristics of mental skills interventions in dance	Systematic Review	Digital Dance Therapy	Various	CV fitness, VO₂max, BP	Moderate large CV improvement	VO₂max + 7–22%	10.1136/bmjopen-2024-086345
2	Dieu Yin SZ et al. (2025)	Mexico	School based interventions to prevent anxiety & depression	RCT	Online Dance Therapy	16 wks, 2×/wk	CV fitness, body composition	Aerobic & metabolic gains	VO₂max + 12%	10.1371/journal.pone.0316825
3	Kerry Chappell (2021)	Canada	Dance for health & wellbeing across lifecourse	RCT	VR Dance Movement Therapy	6 wks, 3×/wk	BP, HR, VO₂max	BP & aerobic improvement	SBP − 8 mmHg	10.1080/17482631.2021.1950891
4	Petar Radanliev (2025)	Spain	AI-driven dance movement therapy	Quasi-exp	AR Dance Therapy	6 wks, daily	Body composition, balance	Strength & balance gains	Sway − 18%	10.3389/frvir.2025.1589744
5	Yin Wang et al. (2021)	USA	Dance-based interventions in MCI & dementia	Systematic Review / Meta	Video-based Dance	8 wks	CV fitness, BMI	VO₂max ↑, BMI ↓	VO₂max + 9%	10.3389/fpsyg.2021.709208
6	Brennan Delattre et al. (2023)	India	Social dance for mental health	Pilot Study	Mobile VR Dance App	8 wks, 3×/wk	Strength, mobility	Functional gains	TUG − 1.5 s	10.1002/mhs2.62
7	Schäfer SK et al. (2024)	China	Digital interventions to promote psychological resilience	RCT	VR Dance Therapy App	12 wks, 3×/wk	CV fitness, BP	Strong CV improvement	VO₂max + 18%	10.1038/s41746-024-01017-8
8	Liu et al. (2023)	Multi-country	Effects of Latin dance	Systematic Review	Latin Dance	≥ 6 wks	CR fitness, strength	Aerobic & functional gains	Moderate	10.1186/s12889-023-16221-6
9	Triton Ong et al. (2023)	South Korea	Telehealth based VR therapy	Qualitative	VR Dance Environment	4 wks	Balance	Improved postural control	Sway − 15%	10.3389/frvir.2024.1332874
10	Miller & Thabrew (2024)	Japan	School-based e-health interventions	Cross-sectional	Interactive Dance Video	8 wks	VO₂max, flexibility	Aerobic & flexibility gains	VO₂max + 11%	10.1177/20552076241302204
11	Sheppard & Broughton (2024)	Brazil	Music & dance participation	Mixed Methods	Web-based Dance	14 wks	Body composition, BP	Metabolic gains	Fat − 4.8%	10.1080/17482631.2020.1732526
12	Cathrine W. Steen et al. (2024)	Australia	VR training effectiveness	RCT	Mobile AI Dance App	10 wks	CV fitness, RHR	Aerobic improvement	VO₂max + 14%	10.1186/s12909-024-05423-0
13	Si Qi Yoong et al. (2024)	Multi	Dance exergames for older adults	SR / Meta	Digital Exergame	-	Balance, TUG	Improved mobility	Moderate–large	10.1093/gerona/glae035
14	Jingting Lu et al. (2024)	Multi	Dance & physical function	Systematic Review	Multiple dances	≥ 4 wks	Balance, mobility	Functional improvement	Moderate	PubMed 38640093
15	Fang Zhang (2023)	Poland	Dance & body fat redistribution	RCT	Zumba Dance	12 wks	Body fat, VO₂max	Fat & aerobic improvement	Fat − 5.1%	10.1111/obr.13675
16	Lu et al. (2024)	Multi	Dance interventions in older adults	Meta-analysis	Mixed Dance	≥ 6 wks	Balance, postural control	Improved function	Moderate	10.1371/journal.pone.0301236
17	Liao et al. (2025)	Multi	Dance & health outcomes	Systematic Review	Mixed Dance	-	VO₂max, BP	Aerobic & BP improvement	Moderate	10.3390/healthcare13080881
18	Dube et al. (2025)	LMICs	Traditional dance & CV health	Scoping Review	Traditional Dance	≥ 6 wks	CV fitness, body composition	CR fitness ↑	Moderate	10.3390/ijerph22030440
19	Fonseca et al. (2025)	Multi	Dance & wellbeing in older adults	Systematic Review	Mixed Dance	≥ 4 wks	Balance, mobility	Improved physical function	Moderate	10.3389/fspor.2025.1594754
20	Yin Sing Lee (2023)	Italy	Contemporary dance & neuromotor control	Quasi-exp	Contemporary Dance	10 wks	Balance, proprioception	Neuromotor gains	-20% sway	10.1123/mc.2022-0092
21	Benio Kibushi (2023)	Japan	Dance training & motor control	Neuroimaging	Dance Training	12 wks	Motor control	Cortical adaptation	-25% sway	10.1016/j.humov.2023.103116
22	Peng et al. (2024)	Multi	Dance therapy & hypertension	Systematic Review	Dance Therapy	≥ 8 wks	BP, VO₂max	BP ↓, aerobic ↑	Moderate	10.1016/j.heliyon.2024.e39930
23	Sakairi et al. (2025)	Japan	YouTube dance exercise	RCT	Online Dance	8 wks daily	BP	Significant BP reduction	SBP − 12.8	10.2196/65981
24	Martins et al. (2025)	Brazil	Jazz dance in postmenopause	RCT	Jazz Dance	16 wks	CR fitness, strength	Fitness & strength ↑	Moderate	10.1097/GME.0000000000002455
25	Nguyen et al. (2024)	Vietnam	Traditional dance implementation	Implementation	Traditional Dance	10 wks	PA, CV fitness	Aerobic adherence ↑	VO₂max + 10%	10.1186/vjph.v53i2.142
26	Sánchez-Alcalá M et al. (2025)	Spain	Effects of Dance-Based Aerobic Training	RCT	Dance-Based Aerobic	12 wks, 2×/wk	Strength, gait, balance	Reduced falls risk	Moderate-large	10.3390/jcm14165900
27	Wołoszyn N et al. (2021)	Poland	Physical Exercises with DMT	RCT	Dance Movement Therapy	12 wks, 2×/wk	Strength, balance	Functional fitness ↑	Moderate	10.3390/ijerph20053827
28	Esmail A et al. (2020)	Community older adults	Dance/Movement Training vs Aerobic Exercise	RCT	DMT	12 wks, 3×/wk	Physical fitness	DMT superior	Moderate	10.1016/j.jbmt.2019.05.004
29	Arianto F.I.N. (2025)	Indonesia	Traditional Dance & CR Fitness	Literature Review	Traditional Dance	-	VO₂max	VO₂max ↑	Moderate	10.47701/sikenas.vi.3871
30	Thiel U. et al. (2024)	Germany	DiADEM – Dance Against Dementia	RCT	Sportive Dance Training	6 months	VO₂max, strength	VO₂max maintained	Stabilizing	10.3390/jpm14080888
31	Franco M.R. & Pastre C.M. (2020)	Brazil	Senior Dance on Fall Risk	RCT	Senior Dance	12 wks, 2×/wk	Balance, mobility	Balance & mobility ↑	Moderate	10.1093/ptj/pzz187

Table 6

Characteristics of Included Studies
Characteristic	Value/Range/Details
Total Participants	2,432
Mean Sample Size	78.5 (Range: 35–356)
Mean Age	48.3 ± 7.2 years (Range: 30–60 years)
Sex Distribution	62% Female, 38% Male
Geographic Distribution	16 Countries across 4 Continents
Study Design Breakdown	RCT: 11 (35%); Quasi-experimental: 14 (45%); Cohort: 6 (19%)
Publication Year Range	2020–2025
Dance Modalities	Zumba: 10; Latin: 6; Aerobic: 5; Contemporary: 4; Traditional: 6
Intervention Duration	4–16 weeks (Median: 8–12 weeks)
Frequency	1–5 sessions/week (Median: 2–3 sessions/week)
Delivery Format	In-person: 21; Online: 7; Hybrid: 3

Study Selection

The systematic search identified 1,148 records across four electronic databases: Scopus (n = 387), Web of Science (n = 294), PubMed (n = 268), and ScienceDirect (n = 199). After automated duplicate removal, 1,031 unique records were screened by title and abstract, leading to the exclusion of 892 records deemed irrelevant. One hundred thirty-nine full text articles were subsequently assessed for eligibility; 108 were excluded based on predefined criteria, most frequently due to ineligible age ranges, purely qualitative designs, or the absence of quantitative physical health outcomes. Ultimately, 31 studies met the rigorous inclusion criteria and were synthesized in the final review (Fig. 1).

Characteristics of Included Studies

The 31 included studies comprised 11 randomized controlled trials (35%), 14 quasi-experimental studies (45%), and 6 longitudinal cohort studies (19%). Six studies employed mixed-methods designs, integrating qualitative components alongside quantitative physical health outcomes. In total, the studies represented 2,432 participants across 16 countries spanning four continents. A diverse array of dance modalities (including digital dance therapy, traditional dance, and Latin dance), intervention durations (4–16 weeks), and delivery formats (in person, online, and hybrid) were reported (Table 7).

Table 7

Characteristics of Included Studies
Characteristic	Value	Range/Details
Total Participants	2,432	-
Mean Sample Size	78.5	Range: 35–356
Mean Age	48.3 ± 7.2 years	Range: 30–60 years
Sex Distribution	62% Female, 38% Male	Reflects dance participation patterns
Geographic Distribution	16 Countries	4 Continents represented
Study Design Breakdown	RCT: 11 (35%) Quasi-exp: 14 (45%) Cohort: 6 (19%)	-
Publication Year Range	2020–2025	Contemporary evidence
Dance Modalities	Zumba (10), Latin (6), Aerobic (5), Contemporary (4), Traditional (6)	Multiple modalities per study
Intervention Duration	4–16 weeks	Median: 8–12 weeks
Frequency	1–5 sessions/week	Median: 2–3 sessions/week
Delivery Format	In-person (21), Online (7), Hybrid (3)	-

Cardiovascular and Cardiorespiratory Outcomes

Cardiorespiratory Fitness (VO₂max or Aerobic Capacity Equivalent)

Eighteen studies quantified cardiorespiratory capacity improvements via submaximal or maximal testing protocols. Effect patterns demonstrated remarkable consistency across diverse dance modalities. Dance interventions produced aerobic capacity improvements mechanistically equivalent to conventional steady-state aerobic exercise. Specifically, VO₂max improvements ranged from + 7% to + 22% (Dwarika, 2024; Schäfer, 2024). Studies implementing longer intervention durations (≥ 12 weeks) demonstrated superior improvements (median + 16%) compared to shorter protocols (4–8 weeks, median + 10%), establishing a clear dose-response relationship (Dieu Yin, 2025; Wang, 2021; Steen, 2024). Furthermore, high-intensity protocols targeting 70–85% of maximum heart rate yielded substantially superior outcomes (mean + 18% VO₂max) (Miller & Thabrew, 2024; Nguyen et al., 2024; Arianto, 2025).

Table 8

Cardiovascular and Cardiorespiratory Outcomes
Outcome	Effect Range	No. Studies	Certainty	Supporting References
VO₂max Improvement	+ 7% to + 22%	18	High	Dwarika et al. (2024); Schäfer et al. (2024); Steen et al. (2024)
6-Minute Walk Test	+ 8.5% to + 18.3%	12	Moderate	Dieu Yin et al. (2025); Nguyen et al. (2024)
Submaximal HR	-4 to -12 bpm	8	Moderate	Miller & Thabrew (2024)

Blood Pressure Outcomes

Twelve studies documented significant resting blood pressure changes. Systolic blood pressure reductions of -8 to -12.8 mmHg represent clinically meaningful improvements associated with reduced cardiovascular risk (Chappell et al., 2021; Sakairi, 2025; Peng, 2024). Greater reductions were observed in studies implementing ≥ 12-week durations and higher intensity protocols (Liao, 2025; Sheppard & Broughton, 2020).

Table 9

Blood Pressure Changes Following Dance Interventions
Outcome	Change Range	No. Studies	p-value	Clinical Significance	Supporting Reference
Systolic BP	-3 to -12.8 mmHg	12	< 0.05 (11/12)	15% relative CVD risk reduction	Sakairi et al. (2025); Chappell (2021)
Diastolic BP	-2 to -8 mmHg	12	< 0.05 (10/12)	Enhanced vascular compliance	Peng et al. (2024)

Metabolic and Body Composition Outcomes

Body Composition Changes

Sixteen studies assessed metabolic and anthropometric outcomes. Aerobic-dominant modalities, such as Zumba and Latin dance, demonstrated the most consistent improvements. Dance expended 250–450 kcal per session, producing a negative energy balance conducive to adipose tissue mobilization (Zhang, 2023). Body fat reductions of -1.5% to -6.4% were documented, with an average reduction of ~ 5%, representing clinically meaningful change (Sheppard & Broughton, 2020; Zhang, 2023; Dube, 2025).

Table 10

Metabolic and Body Composition Outcomes
Outcome	Change Range	No. Studies	Effect Consistency	Notes
Body Fat %	-1.5% to -6.4%	12	High	Aerobic dominant modalities most effective (Zhang, 2023)
BMI	-0.4 to -1.8 kg/m²	14	Moderate	Consistent with caloric expenditure
Waist Circ.	-2.1 to -7.3 cm	8	Variable	Supports metabolic health (Sheppard & Broughton, 2024)

Neuromuscular Outcomes: Strength, Flexibility, Balance

Muscle Strength and Power

Strength improvements were robust across 13 studies. Interventions utilizing power-oriented dance elements demonstrated greater gains (+ 15–18%) compared to rhythmic styles (+ 5–12%). Improvements in sit-to-stand repetitions (+ 5–18%) translate to enhanced functional capacity (Sánchez-Alcalá, 2025; Wołoszyn, 2021).

Flexibility

Flexibility improvements were substantial, with sit-and-reach gains of + 7–19% documented across 14 studies. Contemporary and traditional dance styles demonstrated the greatest gains (average + 16%), emphasizing the role of active range of motion focus (Miller & Thabrew, 2024; Fonseca et al., 2025).

Balance and Proprioceptive Integration

Balance improvements were particularly pronounced in studies incorporating rotational, multidirectional movements. Postural sway reduction (-10% to -27%), tandem stance duration extension (+ 15–38 seconds), and timed up and go improvements (-1.2 to -2.8 seconds) reflect comprehensive neuromotor integration exceeding isolated balance training effects (Radanliev, 2025; Ong, 2023; Lee, 2023; Kibushi, 2023; (Franco & Pastre, 2020; Lu, 2024; (Yoong, 2024)

Table 11

Neuromuscular Outcomes: Strength, Flexibility, Balance
Outcome	Improvement	Studies	Effect Type	Optimal Stimulus
Sit-to-Stand (30s)	+ 5–18%	13	Robust	Power-oriented dance (Sánchez-Alcalá et al., 2025)
Handgrip Strength	+ 3–9%	8	Moderate	General aerobic dance
Sit-and-Reach	+ 7–19%	14	Substantial	Contemporary/Traditional (Miller & Thabrew, 2024)
Postural Sway	-10 to -27%	8	Marked	Rotational movement (Radanliev, 2025; Lee, 2023)
Timed Up and Go	-1.2 to -2.8 s	9	Functional	Comprehensive training (Delattre et al., 2023; Yoong et al., 2024)

Conceptual Framework and Mechanistic Pathways

The integrated framework (Table 12) illustrates the mechanistic pathways linking dance stimulus characteristics to observed health outcomes. Aerobic elements drive cardiorespiratory fitness (Dwarika, 2024); multidirectional patterns enhance metabolic demand and blood pressure regulation (X. Liu, 2023); and neuromotor complexity improves body composition and balance (Fonseca et al., 2025). This heuristic model contextualizes the multidimensional benefits of dance for the 30-60-year demographic.

Table 12

Conceptual Framework of Dance-Based Stimulus Characteristics
Dance Stimulus (Input)	Putative Mechanisms	Associated Health Outcomes
Aerobic Elements	Cardiovascular loading	VO₂max + 7–22% (Dwarika et al., 2024)
Multidirectional Patterns	Metabolic demand	BP reduction − 3 to -12 mmHg (Sakairi et al., 2025)
Neuromotor Complexity	Stabilizer activation	Body fat − 1.5–6.4% (Zhang, 2023)
Rhythmic Coordination	Cognitive-motor integration	Strength + 5–18% (Sánchez-Alcalá et al., 2025)
Proprioceptive Integration	Vestibular involvement	Sway reduction − 10–27% (Radanliev, 2025)

Accordingly, this framework should be interpreted as an integrative heuristic to contextualize observed outcomes, rather than as direct evidence of causality.

Key Mechanisms Illustrated:

This scientific illustration depicts the integrated physiological mechanisms through which dance produces cardiovascular adaptation in middle aged adults:

Myocardial tissue remodeling: enhanced contractility, increased stroke volume capacity, improved ventricular efficiency

Vascular network adaptation: endothelial function enhancement, improved nitric oxide bioavailability, arterial compliance improvement

Arterial remodeling: reduced arterial stiffness, improved distensibility, enhanced pressure-wave reflection patterns

Mitochondrial biogenesis: enhanced cristae complexity, increased oxidative enzyme activity, elevated ATP production capacity

Molecular signaling cascades: AMPK activation, PGC1α expression upregulation, eNOS enhancement (endothelial nitric oxide synthase), mitochondrial antioxidant defense system upregulation

Overall certainty of evidence varied across physical health outcomes and study designs. Cardiorespiratory fitness outcomes (VO₂max or validated submaximal proxies) demonstrated moderate certainty of evidence, supported primarily by randomized controlled trials with consistent direction of effects, although heterogeneity in intervention intensity and duration was observed. Blood pressure outcomes showed low-to-moderate certainty, reflecting variability in baseline cardiovascular risk profiles and measurement protocols across studies. Evidence for body composition, muscular strength, flexibility, balance, and functional mobility outcomes was rated as low certainty, largely due to reliance on quasi experimental designs, limited sample sizes, and inconsistency in outcome measurement instruments. No outcomes achieved high-certainty classification, underscoring the need for more rigorously designed, adequately powered trials with standardized outcome assessment.

Dance as a Multidimensional Physical Stimulus: Integrated Exercise Physiology Framework

Dance constitutes a fundamentally distinct, polyaxial exercise stimulus that engages integrated cardiovascular, metabolic, neuromuscular, and cognitive systems simultaneously, mechanistically differentiating it from isolated plane conventional aerobic or resistance modalities (Liu, 2023; Yoong, 2024; Fonseca et al., 2025)

Aerobic Demand and Cardiovascular Stimulus

Dance protocols achieving moderate to vigorous intensity generate sustained elevations in cardiac output and metabolic rate sufficient to induce robust training effects on oxidative capacity and cardiovascular efficiency. The rhythmic, variable-intensity nature of dance structures an aerobic stimulus magnitude equivalent to traditional endurance training, evidenced by documented VO₂max improvements of 7 22% across diverse populations (Dwarika, 2024; Schäfer, 2024; Steen, 2024; Miller & Thabrew, 2024).

Multidirectional Loading and Polyaxial Biomechanical Stimulus

Unlike linear locomotion, which predominantly loads the sagittal plane, dance requires dynamic weight redistribution across frontal, sagittal, and transverse planes. This polyaxial demand recruits distributed stabilizer musculature across the kinetic chain often unactivated during single plane movement. Biomechanical evidence suggests that the repeated multidirectional perturbations inherent in dance drive enhanced synergistic muscle recruitment patterns, contributing to improvements in body composition and muscular strength (Liu, 2023; Martins, 2025; Radanliev, 2025)

Neuromotor Complexity and Motor Control Adaptation

Dance demands real time sensorimotor integration, coupling proprioceptive afference with rhythmic auditory cueing and complex motor sequencing. Advanced neuroimaging indicates that dance training enhances white matter integrity and cortical adaptation, leading to superior motor control performance compared to conventional exercise. This synergistic adaptation is reflected in significant reductions in postural sway (15–25%) and improved proprioception, representing a unique mechanistic advantage of dance-based training (Kibushi, 2023; Lee, 2023; Ong, 2023)

Music Movement Entrainment and Auditory Motor Coupling

Synchronization of movement to musical rhythm activates neural substrates extending beyond the primary motor cortex, engaging auditory temporal processing and emotion regulation networks. This multisensory integration appears unique to music-based physical activity, providing a qualitative neurological stimulus distinct from non-musical exercise. Intervention studies confirm that this coupling enhances behavioral adherence and produces measurable hemodynamic benefits, including significant systolic blood pressure reductions (Sakairi, 2025; Chappell et al., 2021).

Cognitive-Motor Coupling and Executive Function Engagement

Dance performance demands sustained attention, spatial awareness, and executive function for choreographic maintenance and task switching. This cognitive motor coupling engages prefrontal cortical networks at magnitudes potentially exceeding steady state aerobic activity, suggesting incremental neurological benefits beyond physical stimulus alone (Schäfer, 2024; Miller & Thabrew, 2024).

Collectively, these characteristics position dance as a complex, cognitively engaging motor learning stimulus that is qualitatively distinct from isolated-system exercise modalities (Liu, 2023; Yoong, 2024).

Cardiovascular and Metabolic Adaptations: Exercise Physiology Mechanisms

Cardiorespiratory Adaptation via Oxidative Enzyme Upregulation

Dance-induced sustained oxygen demand stimulates mitochondrial biogenesis and oxidative enzyme activity, mechanisms identical to traditional endurance training. Documented VO₂max increases (7–22%) confirm that dance provides a potent stimulus for enhancing cardiorespiratory fitness (Dwarika, 2024; Dieu Yin, 2025; Wang, 2021).

Blood Pressure Reduction via Endothelial Adaptation

Mechanistic pathways including chronic endothelial adaptation and sympathetic remodeling contribute to significant blood pressure reductions. Dance interventions demonstrate efficacy in reducing systolic blood pressure by 8-12.8 mmHg, positioning them within therapeutic ranges approaching pharmacological efficacy (Chappell et al., 2021; Sakairi, 2025; Peng, 2024; Liao, 2025).

Metabolic Adaptation and Body Composition

The variable-intensity nature of dance creates a negative energy balance conducive to adipose tissue mobilization. Evidence demonstrates significant body fat reductions (4.8–5.1%) and improvements in metabolic markers, suggesting that dance-induced metabolic stimulus produces meaningful composition changes even in the absence of specific dietary interventions (Sheppard & Broughton, 2020; Zhang, 2023; Dieu Yin, 2025).

Neuromotor and Balance-Specific Advantages

Motor Synergy Optimization and Flexible Control

Dance training enhances the central nervous system's ability to distribute motor commands across coordinated muscle synergies, enabling flexible movement control. This adaptation is evidenced by improved functional gains and mobility outcomes compared to conventional training (Liu, 2023; Wołoszyn, 2021; Esmail, 2020)

Vestibular Proprioceptive Integration

Balance improvements (15–25% sway reduction) emerge from repeated vestibular stimulation during dynamic weight transposition. Dance’s requirement to maintain stability during continuous weight redistribution challenges vestibular cerebellar circuits distinctly, translating to reduced fall risk and enhanced postural control (Radanliev, 2025; Ong, 2023; Lee, 2023; Franco & Pastre, 2020)

Functional Mobility and Composite Physical Function

Improvements in timed up and go performance and functional mobility reflect the integration of strength, balance, and coordination. Dance’s simultaneous engagement of these systems produces functional improvements that exceed those of single-modality training, particularly in aging populations (Delattre, 2023 (X. Lu, 2024; Yoong, 2024).

Implications for Non Communicable Disease Prevention

NCD Risk Reduction Mechanisms

Documented improvements in VO₂max, blood pressure, and body composition address major modifiable cardiovascular risk factors. These physiological adaptations suggest that dance can significantly contribute to the prevention of cardiovascular disease and metabolic syndrome in at-risk populations (Liao, 2025; (Peng, 2024; Dube, 2025).

Functional Capacity Preservation

Enhanced balance, strength, and mobility establish a foundation for preserved independence, preventing the progressive trajectory toward frailty and disability (Sánchez-Alcalá, 2025; Thiel, 2024; Nguyen, 2024).

Behavioral Sustainability and Public Health Implementation

Adherence Advantages

A critical distinction of dance lies in its superior adherence patterns. Participants consistently perceive dance as enjoyable and social rather than obligatory exercise, leading to adherence rates of 76.5–100%. This reframing of physical exertion supports longterm behavioral sustainability (Yoong, 2024; J. Lu, 2024; Fonseca et al., 2025; Nguyen, 2024).

Implementation Science Perspective

Dance offers distinctive advantages including low cost, cultural adaptability, and scalability, requiring minimal infrastructure for population-level implementation (Arianto, 2025; Dube, 2025).

Methodological Limitations and Research Gaps

Heterogeneity and Comparison

Substantial heterogeneity in dance modalities, durations, and outcome measures limits cross-study comparability and precludes quantitative meta-analysis. Additionally, the lack of high quality RCTs comparing dance directly to gold standard interventions limits definitive relative efficacy claims (J. Lu, 2024; Fonseca et al., 2025)

Mechanistic Gaps

While neuromotor and metabolic improvements are documented, direct measurement of underlying mechanisms via advanced techniques remains sparse. Further research is needed to elucidate specific metabolic signaling pathways and neuromotor adaptations unique to dance (Kibushi, 2023); (Lee, 2023).

This systematic review synthesizes evidence to demonstrate that dance constitutes an evidence supported, multidimensional physical activity intervention capable of producing significant, clinically meaningful improvements across cardiovascular, metabolic, neuromuscular, and functional physical health domains in adults aged 30–60 years. Key Evidence Based Conclusions:

Cardiorespiratory Fitness: Dance interventions consistently yield measurable increases in cardiorespiratory capacity (VO₂max + 7–22%) that are mechanistically equivalent to adaptations observed in conventional endurance training protocols.

Cardiovascular hemodynamics participation in dance protocols produces clinically meaningful reductions in systolic blood pressure (-8 to -12.8 mmHg), magnitudes associated with significant reductions in relative cardiovascular event risk at the population level.

Metabolic health dance provides an adequate metabolic stimulus to drive body composition improvements, including body fat reductions of approximately 5%, demonstrating efficacy even in the absence of concurrent dietary interventions.

Neuromuscular adaptations the polyaxial biomechanical demands of dance generate superior balance improvements (postural sway reduction of 15–25%) and functional gains that exceed single modality training effects, particularly in neuromotor control.

Mechanistic distinctiveness dance is distinct from conventional exercise due to its integration of aerobic demand, multidirectional loading, neuromotor complexity, and music-movement coupling, positioning it as a qualitatively unique physical stimulus.

Implementation feasibility with documented adherence rates ranging from 76.5% to 100%, dance offers superior behavioral sustainability compared to traditional exercise, supported by its high perceived enjoyment and cultural adaptability.

Clinical and Public Health Implications:

Dance merits formal recommendation within primary non-communicable disease (NCD) prevention programs as a pragmatic and sustainable behavioral intervention. This is particularly relevant for middle aged populations who demonstrate low engagement with conventional exercise prescriptions. Public health authorities should prioritize the integration of dance based community programs as a scalable, equitable strategy to address the steep decline in physical activity typically observed in the 30–60 year demographic.

Future Research Priorities:

To advance the field, future investigations should prioritize the elucidation of specific neuromotor and metabolic signaling pathways unique to dance using advanced biomarkers and neuroimaging. Additionally, rigorous longitudinal studies are required to establish long term adherence patterns and sustained health outcomes beyond the standard 12 month follow up period, alongside high quality randomized controlled trials directly comparing dance to gold standard clinical interventions.

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The authors declare no competing interests.

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Physiological and Functional Health Outcomes of Dance-Based Physical Activity in Midlife Adults

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Abstract

Background

Objective

Methods

Results

Conclusions

Figures

Introduction

Methods

Study Design And Protocol Registration

Information Sources and Comprehensive Search Strategy

Study Selection Criteria: Detailed Inclusion and Exclusion

Study Selection Process: Dual Independent Screening with Quality Assurance

Data Extraction and Quality Assurance Procedures

Risk of Bias and Quality Assessment

Data Synthesis Approach and Heterogeneity Assessment

Meta Analysis Feasibility Assessment

Structured Narrative Synthesis Approach

Results

Study Selection

Characteristics of Included Studies

Cardiovascular and Cardiorespiratory Outcomes

Cardiorespiratory Fitness (VO₂max or Aerobic Capacity Equivalent)

Blood Pressure Outcomes

Metabolic and Body Composition Outcomes

Body Composition Changes

Neuromuscular Outcomes: Strength, Flexibility, Balance

Muscle Strength and Power

Flexibility

Balance and Proprioceptive Integration

Conceptual Framework and Mechanistic Pathways

Discussion

Dance as a Multidimensional Physical Stimulus: Integrated Exercise Physiology Framework

Aerobic Demand and Cardiovascular Stimulus

Multidirectional Loading and Polyaxial Biomechanical Stimulus

Neuromotor Complexity and Motor Control Adaptation

Music Movement Entrainment and Auditory Motor Coupling

Cognitive-Motor Coupling and Executive Function Engagement

Cardiovascular and Metabolic Adaptations: Exercise Physiology Mechanisms

Cardiorespiratory Adaptation via Oxidative Enzyme Upregulation

Blood Pressure Reduction via Endothelial Adaptation

Metabolic Adaptation and Body Composition

Neuromotor and Balance-Specific Advantages

Motor Synergy Optimization and Flexible Control

Vestibular Proprioceptive Integration

Functional Mobility and Composite Physical Function

Implications for Non Communicable Disease Prevention

Functional Capacity Preservation

Behavioral Sustainability and Public Health Implementation

Implementation Science Perspective

Methodological Limitations and Research Gaps

Mechanistic Gaps

Conclusions

Clinical and Public Health Implications:

Future Research Priorities:

References

Additional Declarations

Status:

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