SYSTEMATIC REVIEW
Influence of Friends on Children’s Physical Activity:
A Review
We examined evidence
for friendship influences on
children’s physical activity
(PA) through systematic
searches of online databases
in May 2012. We identified
106 studies (25 qualitative)
published in English since
2000 that analyzed indica-
tors of friendship influences
(e.g., communication about
PA, friends’ PA, and PA with
friends) among persons
younger than 19 years.
Children’s PA was posi-
tively associated with en-
couragement from friends
(43 of 55 studies indicat-
ing a positive relationship),
friends’ own PA (30/35), and
engagement with friends in
PA (9/10). These findings
are consistent with friends
influencing PA, but most
studies did not isolate influ-
ence from other factors that
could explain similarity.
Understanding friendship
influences in childhood can
facilitate the promotion of
lifelong healthy habits. PA
with friends should be con-
sidered in health promotion
programs. (Am J Public
Health. 2013;103:e23–e38.
doi:10.2105/AJPH.2013.
301366)
July 2013, Vol 103, No. 7 | American Journal of Public Health
Claire C. Maturo, MPH, and Solveig A. Cunningham, PhD
EXTENSIVE RESEARCH HAS
linked physical activity to health
and inactivity to poor health, es-
pecially to obesity and other car-
diometabolic problems such as
diabetes and cardiovascular dis-
ease.1---3 Increases in overweight,
obesity, diabetes, and metabolic
syndrome among children and
adolescents over the past few de-
cades4---7 have stimulated a surge
of research into possible contrib-
uting factors, including insufficient
physical activity.8---10
In spite of its health benefits,
physical activity is declining
around the world.11 In the United
States, levels of physical activity in
children and adolescents are not
sufficient to promote optimal
health.12 The Centers for Disease
Control and Prevention recom-
mends that children and adoles-
cents be active for at least 60
minutes per day, but in 2009, only
18.4% of adolescents reported
this much physical activity and
23.1% of adolescents reported not
participating in 60 minutes of
physical activity on any day.13,14
A factor that may affect health
behaviors that has received in-
creasing attention in recent years
is social influence. Research has
suggested that family, friends, and
peers can guide behaviors such as
smoking, sexual initiation, and
eating behaviors.15---19 Influences
from these close contacts can oc-
cur through social pressure, social
modeling and imitation, social
comparison, and behavior ap-
proximation.20 However, not all
social relations are equally impor-
tant: the closer and stronger the
connection, the broader and
stronger the possibilities for influ-
ence.21,22 Information transmitted
from friends is generally more
clearly understood and more
likely to be internalized than is
information from others, meaning
that friends may be more influen-
tial than other social contacts,23---26
such as cliques and peer
groups.24,27,28
Although social influences on
physical activity can occur
throughout life, they are particu-
larly important to study in chil-
dren and adolescents, for several
reasons. First, childhood and ado-
lescence are a formative period
when friends are a primary point
of reference29,30 in deciding
which behaviors, values, and atti-
tudes are desirable and which
activities warrant effort.31---34
Friends have been shown to affect
timing of first sexual intercourse,
drug use, delinquency, and edu-
cational attainment among ado-
lescents.31,32,35---42 Second, physi-
cal activity tracks across life:
activity levels during adolescence
predict adult levels, and active
children and adolescents are more
likely to become active adults.43
Third, physical activity often de-
creases during adolescence, so
children and adolescents may be
the most important age groups to
target for interventions to establish
lifelong activity levels.44 Finally, the
development of successful inter-
ventions to increase physical activ-
ity in children and adolescents re-
quires an understanding of the
unique determinants of physical
activity at these ages.
Quantifying the extent to which
friends can promote or discourage
Maturo and Cunningham | Peer Reviewed | Systematic Review | e23
physical activity is critical for un-
derstanding why physical activity
levels are decreasing and for de-
veloping strategies to promote ac-
tive lifestyles. We reviewed the
literature to determine the role of
friends in shaping physical activity
among children and adolescents.
METHODS
We conducted a systematic
search of peer-reviewed journals
in May 2012 in the PubMed,
Sociological Abstracts, EconLit,
and Web of Science databases.
Because patterns of physical ac-
tivity have changed over time, we
focused on studies published since
2000 to identify the most relevant
information for today’s youths.
Searches used combinations of
keywords that included a friend-
ship term (“friend*” or “peer*”)
and a physical activity term
(“sport*” or “physical activity” or
“exercise”). We included the word
“peer” in searches because it is
sometimes used to mean friend,
but only retained the articles
where peer referred explicitly to
friends rather than to general peer
groups or schoolmates. We did not
include schoolmates and peer
groups not specifically identified
as friends because our goal was to
quantify the importance of friends,
who are more influential than
other social contacts, according to
the literature.23---26
Study Selection
We included articles if they (1)
were published in English, (2)
were published in or after 2000,
(3) presented results from analyses

of primary or secondary data, (4)
used a child or adolescent sample
(aged < 19 years or attending
secondary school or lower), (5)
included a measure of physical
activity as the outcome variable,
and (6) included as a predictor
variable an explicit physical activ-
ity measure (communication with
friends about physical activity,
such as social support, encourage-
ment, or advice; behavior model-
ing by friends, such as a friend’s
own physical activity; or partici-
pation with friends in physical
activity, such as being teammates
in a sport or exercising together).
We required that friend variables
be analyzed separately from other
social contacts, such as family or
classmates.
We defined friends as individ-
uals identified as friends by the
participant, regardless of whether
the friendship was confirmed or
reciprocated. We excluded studies
that measured only the quality or
number of friendships an individ-
ual had or the amount of time
spent with friends but lacked
friendship indicators specific to
physical activity. We included
studies that collected information
from respondents about their
friends (e.g., respondent-reported
activity levels of friends or atti-
tudes of friends toward physical
activity) and that collected data
from friends directly as predictor
variables. For measures of physi-
cal activity, we accepted both
self-reported and objective mea-
sures (e.g., accelerometer data).
Physical activity measures had to
pertain to behaviors, such as in-
tensity of activity or activity done in
a specific context, not to intentions,
such as motivation to engage in
physical activity or preoccupation
with physical activity. We placed
no restrictions on study design.
Searches identified 5357 arti-
cles: 2796 in Web of Science,
e24 | Systematic Review | Peer Reviewed | Maturo and Cunningham
SYSTEMATIC REVIEW
2424 in PubMed, 79 in Sociolog- and compare across studies. We
ical Abstracts, and 58 in EconLit. extracted the following informa-
A review of titles and abstracts tion for each study: authors and
narrowed the results to 271 arti- year of publication, study design,
cles, which each author then sample size and participant age
reviewed independently. The range, physical activity outcome
process is illustrated in Figure 1. variables, friendship exposure
We identified an additional 5 ar- variables, control variables, and
ticles through hand searches of the reported estimated effect sizes and
references of retrieved articles. significance levels.
After all reviews, our analytic We grouped studies by out-
sample comprised 106 studies, of come and exposure measures and
which 25 were qualitative studies analyzed for patterns. We
discussing friends’ influence on assessed studies’ design, popula-
physical activity; we reviewed tion, and method of data analysis.
these separately. We considered the control vari-
ables used, the size and generaliz-
Data Collection and Analysis ability of the sample, whether the
We used a data extraction study used a longitudinal or
spreadsheet to collect information cross-sectional design, whether
about each study, determine physical activity indicators were
whether it met inclusion criteria, self-reported or directly measured,
Records identified through Additional records identified
Identification
database searching through other sources
(n = 5357)
Records after duplicates removed
(n = 3939)
Screening
Abstracts screened
(n = 3939)
Full-text articles assessed
Eligibility
for eligibility
(n = 271)
Studies included in
qualitative synthesis
(n = 25)
Included
Studies included in
quantitative synthesis
(n = 81)
FIGURE 1—Literature search for research on influence of friends on children’s physical activity, 2000–
2012.
American Journal of Public Health | July 2013, Vol 103, No. 7
and whether information on
friends was collected from the in-
dex respondent or directly from
the friend. These characteristics
of the studies meeting inclusion
criteria are summarized in
Table 1.
RESULTS
Eighty-one quantitative articles
met inclusion criteria. Of these
studies, 40 reported significant
positive associations between a
measure of friendship influences
and respondents’ physical activity
in all populations and models,45---84
30 reported significant positive
associations in some but not all
populations or models,26,85---113
and 11 reported no significant
positive associations.114---124
(n = 5)
Records excluded
(n = 3668)
Full-text articles excluded
(n = 165):
Participants were adults (n = 41)
Physical activity behavior not an outcome
variable (n = 40)
Published before 2000 (n = 3)
Friend influence assessed uniquely is
not a predictor variable (n = 40)
Peers not explicitly defined as
friends (n = 26)
Relationship of interest is in the wrong
direction (n = 5)
Review article (n = 6)
Missing key data (n = 4)
 TABLE 1—Summary of Studies of Friends’ Influences on Children’s Physical Activity, 2000–2012
Friend
Indicator Findings
PA Objectively Objectively Longitudinal Sample Age Group, Consistent
Friend Influence Indicator Study PA Indicator (Outcome) Measured Measured Design Size Range or Mean Gender Location Covariates With Influence

Friends’ communication about PA

Friends’ support for PAa Anderson et al.114 VPA 408 13–15 y Both US
a
Friends’ support for PA Kelly et al.92 VPA X 1180 Grade 6 Female US X Xb
a 103
Friends’ support for PA Sallis et al. VPA 781 Grades 1–12 Both US X Xc
a 103
Friends’ support for PA Sallis et al. VPA X 200 Grades 1–12 Both US Xc
a 115
Friends’ support for PA Anderson et al. MPA 408 13–15 y Both US
Friends’ support for PAa Bergh et al.46 MVPA X 1129 11 y Both Norway X X
Friends’ support for PAa Heitzler et al.51 MVPA X 63 10–17 y Both US X X
Friends’ support for PAa Hsu et al.118 MVPA 666 Middle school Both US X
a
Friends’ support for PA Huang et al.52 MVPA 303 9–14 y Both China X

July 2013, Vol 103, No. 7 | American Journal of Public Health

Friends’ support for PAa Hamilton and White117 MVPA 423 12–16 y Both US X
Friends’ support for PAa Kitzman-Ulrich et al.119 MVPA X 669 Grade 6 Both US
a
Friends’ support for PA Kelly et al.92 MVPA X 1180 Grade 6 Female US X Xb
a 107
Friends’ support for PA Wenthe et al. MVPA X 205 12–14 y Both US X
Friends’ support for PAa Patnode et al.106 MVPA X 294 10–17 y Both US X Xd
a 47
Friends’ support for PA Davison and Schmalz Overall PA X 202 Grades 6–8 Both US X X
Friends’ support for PAa Duncan et al.49 Overall PA X 371 12–17 y Both US X Xd
Friends’ support for PAa Lubans and Morgan120 Overall PA X 119 14–15 y Both Australia X
a
Friends’ support for PA Loucaides58 Overall PA 652 Grades 7–9 Both Cyprus X
SYSTEMATIC REVIEW

Friends’ support for PAa Kirby et al.109 Overall PA X 641 11–15 y Both Scotland X Xe
Friends’ support for PAa De Bourdeaudhuij et al.48 Overall PA X 6078 11–19 y Both Belgium X X
a
Friends’ support for PA Raudsepp and Viira62 Overall PA X 193 Grade 6 Female Estonia X X
Friends’ support for PAa Roesch et al.63 Overall PA X 878 11–15 y Both US Xf
Friends’ support for PAa Taymoori et al.122 Overall PA 558 12–17 y Female Iran
a
Friends’ support for PA Wu et al.72 Overall PA 832 12–15 y Both Taiwan X
Friends’ support for PAa Wenthe et al.107 Overall PA 205 12–14 y Both US X Xd
Friends’ support for PAa Duncan et al.87 Overall PA X X 371 12–17 y Both US X
a
Friends’ support for PA Zhang et al.78 Overall PA 285 12–15 y Both US X X
Friends’ support for PAa Ievers-Landis et al.53 WBPA 354 8–11 y Female US X X
Friends’ support for PAa Leslie et al.94 Active travel to/from school 2961 10–14 y Both Australia X Xg,d
Friends’ support for PAa Ommundsen et al.55 Active commute to school 760 9–15 y Both Norway X X
Friends’ support for PAa Ommundsen et al.55 Active commute to school 760 9–15 y Both Norway X X
Friends’ support for PAa Ommundsen et al.55 Participates in active games 760 9–15 y Both Norway X X
at school
Friends’ support for PAa Jago et al.91 MVPA after school, follow-up X X 657 10–11 y Both UK X X
Friends’ support for PAa Jago et al.91 MVPA on weekend, follow-up X X 657 10–11 y Both UK X Xd

Continued

Maturo and Cunningham | Peer Reviewed | Systematic Review | e25

 TABLE 1—Continued

Friends’ support for PAa Anderson et al.115 Participates in sports team 1139 8–15 y Both US
a
Friends’ support for PA Wenthe et al.107 Bouts of MVPA X 205 12–14 y Both US X
Friends’ support for PAa Lytle et al.111 MVPA before school, mean min 3378 Grade 8 Female US X X
Friends’ support for PAa Lytle et al.111 MVPA after school, mean min X 3378 Grade 9 Female US X X
Friends’ support for PAa Lytle et al.111 Weekend MVPA, min 3378 Grade 10 Female US X X
Friends’ support for PAa Lytle et al.111 Total MVPA out of school, min X 3378 Grade 11 Female US X X
Friends’ support for PAa Dunton et al.124 Change in VPA X 63 Grades 10–11 Female US X
Friends’ support for PAa Dunton et al.124 Change in MVPA X 63 Grades 10–11 Female US X
Friends’ support for PAa Prochaska et al.102 Overall PA 138 Grades 6–8 Both US X X
Friends’ support for PAa Prochaska et al.102 Overall PA X 138 Grades 6–8 Both US X
Friends’ support for PA Ha et al.79 Overall PA 1538 11–16 y Both Hong Kong,
Australia
Friends’ support for PA Wu and Pender82 Overall PA 832 12–15 y Both Taiwan
Friends’ support for PA Hohepa et al.110 After school PA 3471 12–18 y Both New Zealand X X
Friends’ support for PA Hohepa et al.110 Lunchtime PA 3471 12–18 y Both New Zealand X X
Friends’ support for PA Hohepa et al.110 Active commute to school 3471 12–18 y Both New Zealand X X

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Friends’ support for PA Johnson et al.54 Sports team participation 145 Grades 9–12 Both US X X
Change in friends’ support Raudsepp and Viira62 Change in PA X 193 Grade 6 Female Estonia X X
for PA
Change in friends’ support Jago et al.91 Change in MVPA after school X X 657 10–11 y Both UK X Xh
for PA
Change in friends’ support Jago et al.91 Change in MVPA on weekend X X 657 10–11 y Both UK X Xh
for PA
SYSTEMATIC REVIEW

Best friend’s support for PA Sabiston and Crocker64 Overall PA 857 15–18 y Both Canada X
Best friend’s support for PA Sabiston and Crocker64 VPA 857 15–18 y Both Canada X
Best friend’s support for PA Sabiston and Crocker64 MVPA 857 15–18 y Both Canada X
Friend influences sport Seabra et al.68 Sport team participation 3352 10–18 y Both Portugal X X
participation
Friend influences PA Seabra et al.76 High-intensity PA 3352 10–18 y Both Portugal X X
Friend influences PA Seabra et al.76 Moderate-intensity PA 3352 10–18 y Both Portugal X X
Best friend encourages PA Wilson and Dollman108 Overall PA 180 Grades 6–9 Male Australia X
Best friend encourages PA Wilson and Dollman123 Overall PA 113 Grades 8–9 Male Australia X
Best friend encourages PA Wilson and Dollman108 MVPA 180 Grades 6–9 Male Australia X
Best friend encourages PA Wilson and Dollman123 MVPA 113 Grades 8–9 Male Australia X
Best friend encourages PA Wilson and Dollman108 VPA 180 Grades 6–9 Male Australia X
Best friend encourages PA Wilson and Dollman123 VPA 113 Grades 8–9 Male Australia X
Friend encourages PA Sharma et al.69 Overall PA 718 Grade 6 Female US X X
Friend encourages PA Sharma et al.70 Overall PA 718 Grade 6 Female US X

Continued

American Journal of Public Health | July 2013, Vol 103, No. 7

 TABLE 1—Continued

Friend encourages PA Sharma et al.69 Jumping activities, d/wk 718 Grade 6 Female US X X
Friend encourages PA Sharma et al.70 Jumping activities, d/wk 718 Grade 6 Female US X

Friend encourages PA Springer et al.71 MVPA 718 10–14 y Female US X X

Friend encourages PA Anderson et al.115 MVPA X 1139 8–15 y Both US X
Friend encourages PA Springer et al.71 VPA 718 10–14 y Female US X X
Friend encourages PA/sports Lemstra et al.113 ‡ 60 min MVPA 7 d/wk 4197 9–15 y Both Canada X X
Friend encourages PA/sports Prochaska et al.102 Overall PA 138 Grades 6–8 Both US X
Friend encourages PA/sports Prochaska et al.102 Overall PA X 138 Grades 6–8 Both US
Friend’s feedback on health Stanford and McCabe104 Frequency of changing exercise 362 12–14 y Male Australia X Xi
behavior to decrease weight
Best friend encourages PA Martı́n-Matillas et al.96 MPA 3007 12.5–17.5 y Both Europe X X
Best friend encourages PA Martı́n-Matillas et al.96 VPA 3007 12.5–17.5 y Both Europe X X
Best friend encourages PA Martı́n-Matillas et al.96 MVPA 3007 12.5–17.5 y Both Europe X X

July 2013, Vol 103, No. 7 | American Journal of Public Health

Best friend encourages PA Martı́n-Matillas et al.96 Overall PA 3007 12.5–17.5 y Both Europe X X
Friend discourages PA Kitzman-Ulrich et al.119 MVPA X 669 Grade 6 Both US
Friends talk about PA positively Coppinger et al.86 Overall PA X X 106 9–11 y Both UK X
Friends remind to be active Coppinger et al.86 Overall PA X X 106 9–11 y Both UK X
Discuss PA with friends Finnerty et al.50 Overall PA X 315 10–13 y Both UK X
Friends do not tease for not Lemstra et al.113 ‡ 60 min MVPA 7 d/wk 4197 9–15 y Both Canada X X
being good at sports
Friends praise sports abilities Lemstra et al.113 ‡ 60 min MVPA 7 d/wk 4197 9–15 y Both Canada X
Being thin (girls) or muscular Kahn et al.97 Change in MVPA X 12 812 10–18 y Both US X
SYSTEMATIC REVIEW

(boys) is important to friends

Pressure from friends de la Haye et al.88 Change in MVPA X 378 12–15 y Both Australia X
Friends not supportive of Coppinger et al.86 Overall PA X X 106 9–11 y Both UK
PA (perceived)
Friends encourage walking or Panter et al.100 Bike to school 2012 9–10 y Both UK X Xj
biking to school
Friends encourage walking or Panter et al.100 Walk to school 2012 9–10 y Both UK X
biking to school
Friends criticize PA Price et al.101 WBPA 1000 9–12 y Female US X X
Friends praise PA/sports Prochaska et al.102 Overall PA 138 Grades 6–8 Both US X
Friends praise PA/sports Prochaska et al.102 Overall PA X 138 Grades 6–8 Both US
Friends praise PA/sports Viira and Raudsepp84 MVPA X 197 Grades 7–8 Both Estonia X X
Friends’ modeling of PA
Mean overall PA of friends Macdonald-Wallis et al.60 Overall PA X X 559 10–11 y Both UK X X
Mean MVPA of friends Macdonald-Wallis et al.60 MVPA X X 559 10–11 y Both UK X X
Friends ever do PA Martı́n-Matillas et al.95 Overall PA 2260 13–18.5 y Both Spain X
Friends do PA now Martı́n-Matillas et al.95 Overall PA 2260 13–18.5 y Both Spain X Xh

Maturo and Cunningham | Peer Reviewed | Systematic Review | e27

Continued
 TABLE 1—Continued

Close friends doing PA, No. Loucaides et al.59 MVPA 2688 15.62 y Both Canada X X
Best friend’s PA Martı́n-Matillas et al.96 MPA 3007 12.5–17.5 y Both Europe X X
Best friend’s PA Martı́n-Matillas et al.96 VPA 3007 12.5–17.5 y Both Europe X X
Best friend’s PA Martı́n-Matillas et al.96 MVPA 3007 12.5–17.5 y Both Europe X X
Best friend’s PA Loucaides et al.112 MVPA 256 Grade 6 Both Cyprus X
Best friend’s PA Martı́n-Matillas et al.96 Overall PA 3007 12.5–17.5 y Both Europe X X
Friends’ PA Ali et al.45 Exercised ‡ 3 times in X X 3898 12–18 y Both US X X
past 7 d
Friends’ PA Ali et al.45 Plays active sports X X 3898 12–18 y Both US X X
Friends’ PA de la Haye et al.75 Participation in organized PA X 385 Grades 8–9 Both Australia X
Friends’ PA de la Haye et al.75 Participation in non-organized PA Xk 385 Grades 8–9 Both Australia X X
75
Friends’ PA de la Haye et al. Change in MVPA Xk X 378 12–15 y Both Australia X X
Friends’ PA de la Haye et al.75 Change in MVPA X 378 12–15 y Both Australia X
Friends’ PA Duncan et al.87 Change in PA X 371 12–17 y Both US X Xd
Friends’ PA Gesell et al.74 Change in percentage of after X X X 81 5–12 y Both US X X
school play that is MVPA

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Friends’ PA Duncan et al.87 Overall PA X 371 12–17 y Both US X Xh
26
Friends’ PA Schofield et al. Overall PA X X 318 15–18 y Female Australia X Xk
70
Friends’ PA Sharma et al. Overall PA 718 Grade 6 Female US X X
Friends’ PA Voorhees et al.105 Overall PA 488 Grades 6 and 8 Female US X
Friends’ PA Luszczynska et al.81 Overall PA 2387 13–20 y Both Hungary, Poland, X
Turkey, US
Friends’ PA Bramoullé et al.83 Overall PA X not listed Grades 6–12 Both US X
SYSTEMATIC REVIEW

Friends’ PA Plotnikoff et al.77 Overall PA (energy expenditure) 2688 Grades 9–12 Both Canada X
Friends’ PA McDermott et al.61 VPA 1407 9–13 y Both US X
Friends’ PA King et al.56 VPA 535 Grades 9–12 Both US X
Friends’ PA King et al.56 MPA 535 Grades 9–12 Both US X
Friends’ PA Springer et al.71 MVPA 718 10–14 y Female US X X
Friends’ PA Springer et al.71 MVPA 718 10–14 y Female US X X
Friends’ PA Price et al.101 WBPA 1000 9–12 y Female US X X
Friends’ PA Sharma et al.70 Jumping activities, d/wk 718 Grade 6 Female US X X
‡ one third of best friends Gilmer et al.116 Overall PA 113 11–14 y Both US
engage in school sports
or hard PA
Friends’ MVPA Jago et al.90 MVPA min/d X X 472 10–11 y Both UK X Xd,k
90
Friends’ overall PA Jago et al. Overall PA in CPM X 472 10–11 y Both UK X
Change in friends’ PA Duncan et al.87 Change in PA X 371 12–17 y Both US X Xh
57
‡ 3 friends are active Leatherdale et al. Moderately active 2379 Grades 5–8 Both Canada X X
‡ 3 friends are active Leatherdale et al.57 Highly active 2379 Grades 5–8 Both Canada X X
‡ 3 friends are active Schofield et al.26 Overall PA X 318 15–18 y Female Australia X

American Journal of Public Health | July 2013, Vol 103, No. 7

Continued
 TABLE 1—Continued

All friends are physically Page et al.98 Does muscle-strengthening 1886 16.5 y Both Hungary, Romania, X Xg
active exercise Czech Republic
All friends are physically Page et al.98 Participates in team sports 1886 16.6 y Both Hungary, Romania, X Xg,d
active Czech Republic
All friends are physically Page et al.98 Is active outside of school 1886 16.7 y Both Hungary, Romania, X Xg
active Czech Republic
All friends are physically Page et al.98 Overall PA 1886 16.8 y Both Hungary, Romania, X Xg
active Czech Republic
‡ 3 friends do sports Keresztes et al.93 Leisure-time sports 548 10–15 y Both Hungary X
All/most friends are active Page et al.99 VPA 2519 Grades 7–12 Both Thailand X
All/most friends are active Page et al.99 Does muscle-strengthening 2519 Grades 7–12 Both Thailand X Xj,d
exercise
All/most friends are active Page et al.99 Participates in team sports 2519 Grades 7–12 Both Thailand X Xj
99
All/most friends are active Page et al. Is active outside of school 2519 Grades 7–12 Both Thailand X Xj

July 2013, Vol 103, No. 7 | American Journal of Public Health

All/most friends are active Page et al.99 Overall PA 2519 Grades 7–12 Both Thailand X Xj
All/most friends are active Page et al.99 VPA 2519 Grades 7–12 Both Thailand X
Best friend engages in Wilson and Dollman108 Overall PA 180 Grades 6–9 Male Australia X
active play
Best friend engages in Wilson and Dollman123 Overall PA 113 Grades 8–9 Male Australia X
active play
Best friend engages in Wilson and Dollman108 MVPA 180 Grades 6–9 Male Australia X
active play
Best friend engages in Wilson and Dollman123 MVPA 113 Grades 8–9 Male Australia X
SYSTEMATIC REVIEW

active play
Best friend engages in Wilson and Dollman108 VPA 180 Grades 6–9 Male Australia X
active play
Best friend engages in Wilson and Dollman123 VPA 113 Grades 8–9 Male Australia X
active play
All friends are active Page et al.98 VPA 1886 16.5 y Both Hungary, Romania, X X
Czech Republic
All friends are active Page et al.98 Does muscle-strengthening 1886 16.5 y Both Hungary, Romania, X X
exercise Czech Republic
All friends are active Page et al.98 Participates in team sports 1886 16.5 y Both Hungary, Romania, Xd X
Czech Republic
All friends are active Page et al.98 Is active outside school 1886 16.5 y Both Hungary, Romania, X X
Czech Republic
All friends are active Page et al.98 Overall PA 1886 16.5 y Both Hungary, Romania, X X
Czech Republic
Friends’ use of facilities for PA Ries et al.121 MVPA X 327 Grades 9–12 Both US X
Best friend does PA Sabiston and Crocker64 Overall PA 857 15–18 y Both Canada X

Maturo and Cunningham | Peer Reviewed | Systematic Review | e29

Continued
 TABLE 1—Continued

Best friend does PA Sabiston and Crocker64 VPA 857 15–18 y Both Canada X
Best friend does PA Sabiston and Crocker64 MVPA 857 15–18 y Both Canada X
All/most friends exercise Saxena et al.67 VPA 305 12–21 y Female US X X
In sports team or class Voorhees et al.105 Overall PA 488 Grades 6 and 8 Female US X
with friend
Invited friend to do PA Voorhees et al.105 Overall PA 488 Grades 6 and 8 Female US X
Friends invite to be active Voorhees et al.105 Overall PA 488 Grades 6 and 8 Female US X
together
Friends’ use of facilities for PA Ries et al.121 MVPA X 327 Grades 9–12 Both US X
Number of active friends Leggett et al.73 Moderately active 31 202 Grades 9–12 Both Canada X X
Number of active friends Leggett et al.73 Active 31 202 9–12 Grades Both Canada X X
Friends’ overall sport Denault and Poulin80 Overall sport participation X 272 Grade 6 Both Canada X X
participation
Participation in PA with friends
PA with friends Lemstra et al.113 ‡ 60 min MVPA 7 d/wk 4197 9–15 y Both Canada X
PA with friends Voorhees et al.105 Overall PA 488 Grades 6 and 8 Female US X X

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PA with friends Fermino et al.89 MVPA (‡ 60 min ‡ 1 d/wk) 1518 14–18 y Both Brazil X X
PA with best friend Wilson and Dollman108 Overall PA 180 Grades 6–9 Male Australia X X
PA with best friend Wilson and Dollman123 Overall PA 113 Grades 8–9 Male Australia X
PA with best friend Wilson and Dollman108 MVPA 180 Grades 6–9 Male Australia X
PA with best friend Wilson and Dollman123 MVPA 113 Grades 8–9 Male Australia X
PA with best friend Wilson and Dollman108 VPA 180 Grades 6–9 Male Australia X X
PA with best friend Wilson and Dollman123 VPA 113 Grades 8–9 Male Australia X
SYSTEMATIC REVIEW

Friends invite to be Lemstra et al.113 ‡ 60 min MVPA 7 d/wk 4197 9–15 y Both Canada X
active together
Friend present during PA Salvy et al.65 PA intensity 20 12–14 y Both US X X
Friend present during PA Salvy et al.66 Distance biked X 88 12–14 y Both US X X
Friends change schedule Coppinger et al.86 Overall PA X X 106 9–11 y Both UK X
to exercise/do PA together
PA/sports with friend Prochaska et al.102 Overall PA 138 Grades 6–8 Both US X
PA/sports with friend Prochaska et al.102 Overall PA X 138 Grades 6–8 Both US
PA with friends Fermino et al.89 MVPA (‡ 60 min ‡ 5 d/wk) 1518 14–18 y Both Brazil X
Exercise with friends Finnerty et al.50 Overall PA X 315 10–13 y Both UK X
Friends plan PA together Coppinger et al.86 Overall PA X X 106 9–11 y Both UK X
Weekly PA with friend Jago et al.90 MVPA min/d X 472 10–11 y Both UK X Xh,l
Weekly PA with friend Jago et al.90 Overall PA in CPM X 472 10–11 y Both UK X Xh,m
90
On sports team/in PA Jago et al. MVPA min/d X 472 10–11 y Both UK X
class with friend
On sports team/in PA Jago et al.90 Overall PA in CPM X 472 10–11 y Both UK X
class with friend

American Journal of Public Health | July 2013, Vol 103, No. 7

Continued
 SYSTEMATIC REVIEW

The types of physical activity

considered in this literature can be
grouped as overall physical activ-
ity, defined as a measure of the
respondents’ total activity of
all types over a given period
(n = 41)26,45,47---50,57,58,60,62---
64,69,70,72,73,77-79,81---83,85---

87,89,90,95,96,98,99,102,105,107---

109,111,116,120,122,123
; engagement in
Finland

Finland

Finland

Finland

Finland

Finland

specific activities, such as weight-

bearing physical activity and
sports team participation (n =
Both

Both

Both

Both

Both

Both

11)53,54,68---70,80,98,99,101,114,123;
physical activity in specific con-
Note. CPM = counts per minute; MPA = moderate-intensity PA; MVPA = moderate-to-vigorous PA; PA = physical activity; VPA = vigorous-intensity PA; WBPA = weight-bearing PA.

texts, such as leisure time or com-

10–11 y

10–11 y

10–11 y

10–11 y

10–11 y

10–11 y

muting to and from school (n =

10)93,94,97---100,68,110,111,123; physical
activity performed at a specific in-
131

131

131

131

131

131

tensity, such as vigorous or mod-

erate (n = 35)46,51,52,55,56,59---
61,64,65,67,71,74,76,84,85,90---

92,96,98,99,103,106---108,112---114,116---

118,120,122,124
; and change in
any of these over time (n =
7).62,74,75,87,91,97,124 Vigorous-
intensity physical activities are
those that have an assigned meta-
bolic expenditure value greater
X

than 6 (requires a large amount

of effort and causes rapid breath-
ing or a substantial increase in
heart rate); moderate-intensity
physical activities have an
assigned metabolic expenditure of
3 to 6 (requires a noticeable
Overall PA

Overall PA
Light PA

Light PA

amount of effort and raises the

MVPA

MVPA

heart rate).126
For the purpose of increasing muscle but not for losing weight.

We identified a priori and con-

Only medium level of support, compared with low support.

firmed empirically from the liter-

ature 3 broad mechanisms
Compared with no or some physically active friends.
Jago et al.85

Jago et al.85

Jago et al.85

Jago et al.85

Jago et al.85

Jago et al.85

through which friends could in-

fluence physical activity: friends’
Compared with no physically active friends.
Only in some grades for girls and for boys.
For Blacks and Whites but not Hispanics.

communication through social

Sallis et al. Social support scale.125

norms and conversations about

physical activity (n = 55), includ-
do PA to be with friends

do PA to be with friends
Neighborhood affiliation,

Neighborhood affiliation,

Neighborhood affiliation,
TABLE 1—Continued

Social affiliation, do PA

Social affiliation, do PA

Social affiliation, do PA

ing positive messaging, such as

For ‡ 5 times/week.
to be with friends

to be with friends

to be with friends

encouragement and social support

Intervention study.

Distance <1 km.

Best friend only.

(n = 54)46---55,58,62---64,68---72,75,76,
do PA to be
with friends

78,79,82,84,86,87,90---92,94,96,97,100,102-
Boys only.

Girls only.

111,114,115,117---120,122,123,113
and nega-
tive messaging, such as criticism
m
b

d
a

h
e
c

k
f

i
j

and teasing (n = 4)86,91,101,119;

July 2013, Vol 103, No. 7 | American Journal of Public Health Maturo and Cunningham | Peer Reviewed | Systematic Review | e31

friends’ modeling of physical ac-
tivity through their own physical
activity, that is, friends’ own be-
havior that might provide guid-
ance, enticement, or pressure for
the respondent (n = 35)26,45,56,57,
59---61,64,67,69---71,73---75,77,80,81,83,85,
87,88,90,93,95,96,98,99,101,105,108,112,116,-
121,123
; and participation in physical
activity with friends, including or-
ganized sports and recreational
play in the company of friends (n =
10).50,65,66,89,90,102,105,108,113,123
We organized our findings ac-
cording to these proposed path-
ways of influence.
Communication About
Physical Activity
Communication about physical
activity most frequently consisted
of social support or friends’ en-
couragement for physical activity.
The items used to measure social
support generally described 1 or
more of the following behaviors:
friends reminding the respondent
to exercise, encouraging the re-
spondent to engage in physical
activity, praising the respondent
for engaging in physical activity, or
discussing physical activity with
the respondent. Other indicators
of communication used in studies
(but not referred to as social sup-
port) included the respondent’s
perceptions of friends’ attitudes
and beliefs about physical activity
(such as the importance of physical
activity to the friend), respondent-
perceived influence from friends
over their participation in physical
activity, and invitations to or from
a friend to engage in physical
activity together. Twenty-nine
studies used the Sallis et al. social
support scale125 to measure
friends’ influence.46,47,49,51---53,55,
58,62,63,72,78,87,91,92,94,102,103,106,
107,109,114,117---120,122,124
This scale
incorporates measures of peer
encouragement and support for
physical activity, as well as 2
e32 | Systematic Review | Peer Reviewed | Maturo and Cunningham
SYSTEMATIC REVIEW
measures of participation in phys-
ical activity together: friends ex-
ercising with the respondent and
friends changing their schedule to
be active with the respondent.125
We categorized separate measures
of friends exercising with the re-
spondent and of friends changing
their schedule to exercise with the
respondent as a combined mea-
sure of participation in physical
activity with a friend.
Of the 55 studies that investi-
gated communication about or
social support for physical activity,
25 showed significant positive
relationships in all models46---55,58,
62---64,69---72,75,76,78,79,82,84,96,
; making fun of the respondent for
18 showed significant associa-
tions in some models or some
groups within the popula-
tion55,86,87,91,92,94,97,100,102---104,106,
107,109---111,113,124
; and 12 did not
show any significant associa-
tions90,101,105,108,114,115,117---120,122,123
(including 1 focused on negative
messages101). One of the studies
with mixed results yielded an un-
expected relationship: lower friend
social support at the beginning of
an intervention was associated with
a greater subsequent increase in
physical activity.124
The most common measures of
physical activity in these studies
were overall physical activity (n =
27)47---50,58,62---64,69,70,72,78,79,82,86,
87,90,96,102,105,107---109,111,120,122,123
and moderate-to-vigorous physical
activity (n = 19).46,51,52,64,76,84,91,92,
97,103,106,107,113-115,117-119,124
Overall
physical activity was more often
associated with friends’ communi-
cation than was activity intensity
(21/27 vs 14/23). Eleven of the 55
studies measured physical activity
directly (with an accelerometer, a
pedometer, or observation).46,48,50,
51,90---92,106,111,118,119
Thirty-six stud-
ies used self- or parent reports,52---
55,58,62---64,68---72,75,76,78,79,82,
84,94,97,100,101,103---105,108---110,113,
114,117,118,122,123,124
and 6 studies
combined indirect and direct
measures.49,86,87,96,102,103 Stud-
ies that used direct measures, or
a combination of direct and in-
direct measures, found significant
associations (at least some sup-
port in 10/1846,48,50,51,68,86,91,92,
106,111
) less frequently than did
studies that used self- or parent
reports of physical activity (at
least some support in 28/3647,52---
55,58,62---64,68,69---72,75,76,78,79,82,84,
94,97,100,103,104,109,110,113
).
Four studies investigated nega-
tive messaging from friends about
physical activity, specifically criti-
cism for being active or exercising,
being active, declining an invita-
tion from the respondent to be
active together, and the respon-
dent’s belief that friends would
not be supportive of being ac-
tive.86,91,101,119 None of these forms
of negative messaging were sig-
nificantly associated with respon-
dent’s physical activity, which was
measured most often in these
studies with objective measures
(e.g., pedometer, accelerome-
ter).86,91,119
Modeling of Physical Activity
Thirty-five studies focused on
friends’ demonstrated or per-
ceived physical activity, which we
called friends’ modeling of physi-
cal activity. Only 9 of these
obtained physical activity data
directly from respondents’
friends.26,45,60,74,75,80,83,88,90
Nineteen of the 35 studies showed
significant positive associations
between friends’ physical activity
and respondents’ physical activity
across specifications,45,56,57,59---
61,64,67,69---71,73---75,77,80,81,83,101
and
11 reported positive associations
only in some specifica-
tions.26,85,87,88,90,93,95,96,98,99,112
Five studies did not find significant
relationships between measures
of friends’ physical activity and
American Journal of Public Health | July 2013, Vol 103, No. 7
respondents’ physical activ-
ity.105,108,116,121,123
The most commonly used
measures of physical activity ex-
plored in the context of friendship
modeling were overall physical
activity (at least some support in
16/21)26,45,57,64,69,70,74,77,80,81,
83,87,95,96,98,99
and physical activ-
ity at a specific intensity (at least
some support in 12/16).56,59,61,64,
67,71,73,85,90,96,98,112
Studies that
used objective measures of physi-
cal activity yielded significant re-
sults less often than studies that
used self-reported measures.
Joint Participation in Physical
Activity
Ten studies investigated the
importance of being physical ac-
tive with friends or in the presence
of friends for respondents’ physi-
cal activity levels.50,65,66,89,90,102,
105,108,113,123
Nine of these reported
significant associations in at least
1 model50,65,66,89,90,102,105,108,113
(4 in all models50,65,66,113). Indi-
cators of joint activity were fre-
quency of physical activity with
friends,50,89,90,102,105,108,123 friends’
presence during physical activ-
ity,65,66 and whether respondents
were on a sports team or in an
exercise class with a friend.90,105
Only 1 study used direct measures
(distance biked on a stationary bi-
cycle in a laboratory)66; the others
relied on self-reports of participa-
tion in physical activity with
friends. The most commonly used
physical activity measure was
overall physical activity level, with
6 of 7 studies reporting significant
relationships in at least some spec-
ifications.50,89,90,102,105,108
Qualitative Studies
Qualitative studies can enhance
our understanding of the mecha-
nisms through which friends could
influence physical activity or
at least illustrate why children

believe their friends matter for
their own behavior. We separately
analyzed the 25 qualitative stud-
ies that met inclusion criteria,
because the data could not be
compared and assessed in the
same way as the quantitative
studies.127---151
These studies found that friends
were important for children’s and
adolescents’ physical activity
levels. Nine studies found that
children and adolescents per-
ceived fun as an important moti-
vator for engaging in physical ac-
tivity and that the presence of
friends during physical activity
was associated with having
fun.128,130,134,141,142,145,146,149,150
Sixteen identified friends as
motivating factors for participat-
ing in physical activity.127,128,131---
142,145,146
In addition, children and
adolescents reported that they
engaged in physical activity to
spend time with their friends
(n = 11127,131---136,138,139,145,146) and
that their friends’ physical activity
guided their own decisions about
physical activity (n = 10127,129,133,
139,141,145---149
). That is, having ac-
tive friends encouraged physical
activity, and having inactive
friends discouraged it.129,147
DISCUSSION
Physical inactivity is a strong
predictor of overweight, obesity,
and other chronic diseases.152
Numerous studies have investi-
gated the determinants of physical
activity in children and adoles-
cents, and social influences have
been proposed as potentially im-
portant forces in determining
physical activity levels. Diverse
analytic approaches have been
taken to define, measure, and un-
derstand social influences. We
synthesized current findings on
the ways friends may influence
physical activity in childhood and
July 2013, Vol 103, No. 7 | American Journal of Public Health
SYSTEMATIC REVIEW
adolescence. Results show a posi-
tive association between physical
activity and indicators of influ-
ences from friends: positive com-
munication about physical activity
from friends, friends’ own physical
activity levels, and the presence
of friends during physical activity.
Our review found substantial
evidence for a relationship be-
tween positive communication
with friends about physical activ-
ity and a child’s own physical
activity (43/55 studies reported
significant associations). The im-
portance of communication is
consistent with findings on other
health behaviors, such as sexual
initiation and eating behav-
iors.153,154 We also found sub-
stantial evidence that children’s
physical activity is associated
with the physical activity of their
friends (30/35 studies), suggesting
that individuals may be guided
by their friends’ behavior. Friends’
behaviors have also been shown
to predict dieting, body dissatis-
faction, and extreme weight con-
trol.155---159 Finally, we found
strong evidence that participation
with friends and the presence of
friends during physical activity is
associated with physical activity
(9/10 studies), consistent with
previous studies reporting that an
individual’s eating behavior is af-
fected by the presence of a friend
while eating160---163 and that
friends match their food intake
more closely than do unfamiliar
peers eating together.162
There is some indication that
children anchor their physical ac-
tivity on friends’ actions and mes-
sages more in some settings than
in others. For example, friends
may be more important for un-
structured physical activity or ac-
tive play but less so for organized
sports involvement.90 Also, being
active with friends at home or
in the neighborhood was more
strongly associated with higher
levels of physical activity than
was being active with friends at
school.90 Friends’ support for ac-
tive commuting predicted biking
to school for children who lived
within a kilometer of school, but
not for children who lived farther
away,100 likely because of the im-
portance of other factors, such as
age, distance, topography, safety,
and parenting styles, in selecting
modes of commuting.164,165 An-
other study showed that children’s
best friends were important for
their activity during winter but not
summer, perhaps indicating that
when the weather and daylight
hours are less conducive to phys-
ical activity, children are only ac-
tive if their friends entice them.112
To effectively engage friends in
health intervention, it will be nec-
essary to map out more clearly
under which circumstances they
can alter physical activity behaviors.
An important consideration is
whether friendship influences are
important only among children
who already have a high propen-
sity for active living. Findings sug-
gest that this is not the case. In-
deed, 3 studies found that the
relationship between friends’ sup-
port for physical activity or pres-
ence during physical activity and
respondents’ physical activity was
stronger in children at high risk for
physical inactivity, such as over-
weight children,47,48,65 children
who thought they were not good
at sports, and girls.47 Thus, the
children in most need of physical
activity may benefit the most from
the involvement of friends.
Also important were friends’
characteristics and the strength of
the relationship. One study high-
lighted that not all friendships
were equally influential, with only
the physical activity of the best
friend significantly predicting re-
spondents’ physical activity.26 In
Maturo and Cunningham | Peer Reviewed | Systematic Review | e33
addition, a study distinguishing
reciprocal and nonreciprocal
friendships found stronger associ-
ations in the former, that is, in
relationships where a respondent’s
nominated friend also nominated
the respondent as a friend.26
Age may be another important
factor in the relevance of friends
for children’s physical activity.
The focus of research on friend-
ship influences has been on older
children, with only 1 (qualitative)
study examining the role of friends
in physical activity among
preschool-aged children. 151 Three
of the 4 studies that focused
on children aged 5 to 8 years
reported results consistent with
friendship influences, as did 39 of
44 studies (89%) among children
aged 9 to 11 years, 45 of 53
studies (85%) among participants
aged 12 to 13 years, 44 of 54
studies (83%) of adolescents aged
14 to 15 years, and 25 of 29
studies (86%) of young adults
aged 18 to 19 years. Younger
children tend to be more heavily
influenced in all aspects of well-
being by family factors,166 al-
though social influences may
commence during the first few
years of life.167,168 A priority for
future research is to begin to un-
derstand at what ages friends’ in-
volvement and support become
important determinants of physi-
cal activity and how the process of
influence begins.
Limitations
Because of the variation in in-
dicators and study populations,
a meta-analysis of this body of
literature was not possible; the
large variability would have lim-
ited meta-analysis procedures to
small subsets of the studies. Our
review was limited to friendships
rather than broader social net-
works. This is because we expect,
in light of previous studies,24,28

that the closer and stronger the
relationship between 2 individ-
uals, the more possibilities for in-
fluence. However, because schools
provide a captive audience for
interventions and a forum that can
be targeted by policy changes,
schools may present the most
practical avenue for interventions
that use social networks to im-
prove health behavior. In addition,
previous physical activity inter-
ventions delivered in school set-
tings have been shown to be suc-
cessful and to change long-term
physical activity trajectories.169
Therefore, for future research and
applications, we can take friends
as an upper bound of possible
levels of social influence, but it will
be important to consider how
other peers, especially within the
school context, can encourage
healthy behaviors such as pro-
moting physical activity. Interven-
tion experiments are already being
carried out to train school-based
peer advocates to disseminate in-
formation about and promote
healthy choices.170,171
Some weaknesses of this litera-
ture remain to be addressed by
future studies. Most studies relied
on cross-sectional data (n = 68
studies) and on respondents’ re-
ports about their friends (n = 72),
approaches that are not suited to
studying influence. Another nota-
ble weakness was the use of in-
sufficient control variables and
statistical methods to understand
the nature of the associations: 20
studies only explored correlations
and bivariate associations,50,52,56,
58,61,63,64,70,72,77,79,81,82,85,86,93,
115,116,119,122
11 used only a limited
set of control variables,26,47,49,
62,65,66,95,96,107,120,123
and only 2
were intervention studies.88,111
Cross-sectional analyses ac-
counting for no or only limited
confounding variables do not per-
mit researchers to assert causality.
e34 | Systematic Review | Peer Reviewed | Maturo and Cunningham
SYSTEMATIC REVIEW
Such study designs also do not
make it possible to distinguish in-
fluence from homophily; that is,
children may behave similarly
because they select friends who
are similar to them, in their in-
terest in physical activity among
other traits, or they may behave
similarly to their friends because
they live in the same or a similar
environment (e.g., neighborhood
sidewalks or playgrounds may
entail similar physical activity pat-
terns within communities). Thus,
significant associations between
friends’ behaviors do not neces-
sarily indicate influence, but many
studies have not clearly addressed
or acknowledged this concern20
and have tended to overestimate
influence.172---174 A large literature
addresses the difficulty of distin-
guishing between influence and
selection, and although there is
disagreement about the best
approach for disentangling
them,19,45,174---176 only 4 of the
studies we reviewed attempted to
use such methods to account for
homophily or to distinguish influ-
ence from homophily.45,74,75,83
To advance our understanding of
the determinants of physical ac-
tivity, future studies should strive
to disentangle the roles of selec-
tion, environmental factors, and
social influences.
Our findings provide evidence
consistent with the existence of
friendship influences on chil-
dren’s physical activity. Specifi-
cally, the studies that attempted
to distinguish between homo-
phily and influence found that
indicators of influence were more
strongly associated with physical
activity over time than were the
indicators of selection.74,75 Fur-
thermore, the 13 longitudinal
studies reported significant asso-
ciations between indicators of
friendship influences and physi-
cal activity, consistent with
friendship influence.45,62,74,
75,80,83,84,86,87,91,97,109,124
Another concern is that reliance
on respondents’ reports about
their friends’ attitudes, beliefs, and
behaviors introduces the possibil-
ity of projection bias, or reflecting
one’s own attitudes and beliefs
onto friends, which would inflate
observed associations between
respondents and friends. Previous
research has found that adoles-
cents tend to misperceive their
friends’ behaviors in ways that are
partially mediated by their own
behaviors.177 However, all 11 arti-
cles that collected data directly
from respondents’ friends showed
significant associations in some
models or population groups,26,45,
60,65,66,74,75,80,83,88,90
6 of them
in all models.45,60,65,66,74,75 A re-
lated weakness is that 55 studies
used subjective measures of re-
spondents’ own physical activity.
These studies more often reported
evidence of a relationship between
respondents’ physical activity and
indicators about friends than did
studies that used objective mea-
sures. In fact, researchers who
used both subjective and objective
measures found the relationship
between indicators of friend in-
fluences and objective physical
activity variables to be weaker
than the relationship with self-
reported physical activity mea-
sures.96,102,103 For example,
Martín-Matillas et al. found that
friends’ physical activity was asso-
ciated with all of the subjective
measures of physical activity but
with none of the objective mea-
sures.96 These patterns may occur
if children exaggerate similarity
with their friends to highlight that
they are socially connected or
engaged with their peers. It may
also be that direct measures, such
as accelerometers and pedome-
ters, pick up all physical activity
and not just voluntary, conscious
American Journal of Public Health | July 2013, Vol 103, No. 7
activity, and respondents may
simply not be aware of the differ-
ences or may only anchor their
voluntary physical activity on their
friends.
It may be that some friends, for
example, those who are more
popular or older, can be more
important than other friends in
guiding behaviors. The studies in
our review did not explore this
possibility, but understanding
which friends are most likely to be
influential will be an important
step for the development of
interventions.
Conclusions
The value of the findings from
the studies in our review comes
in part from understanding the
social processes that guide health
behavior and in part from explor-
ing the possible use of social net-
works to promote healthy behav-
iors. We found extensive research
about and fairly strong evidence
of associations between physical
activity and friends’ behaviors.
The use of friendships to promote
physical activity in experiments or
interventions remains largely un-
explored: only 1 study attempted
to manipulate the influence of
friends in a controlled experiment;
it found that children biked longer
and more intensely in the pres-
ence of a friend than in the pres-
ence of an unknown peer.66 Only
1 study explored the impact of
friends’ social support for physical
activity in an intervention; it con-
cluded that support from friends
predicted change in physical ac-
tivity over time.124 It may be that
some interventions have been
unsuccessful in manipulating
physical activity through friend-
ships and that those results have
not been published. However,
findings from observational stud-
ies suggest that friends have po-
tential to affect physical activity

and that friendships may offer
opportunities to promote the early
development of healthy physical
activity habits and preferences
that can translate into lifelong
habits.43 These opportunities are
worth exploring, because a recent
review of physical activity inter-
ventions found that most inter-
ventions until now have had only
small effects, amounting to an in-
crease in activity of approximately
4 minutes per day.178
The challenge to incorporating
friendship influences into health
interventions is that friendships
are complex. Can an intervention
create friendships? Can a health
professional identify who in a
friendship dyad is influential and
who is influenced or how mutual
influence occurs? Can recommen-
dations alter the type of informa-
tion transmitted by friends in ways
that can overcome habits, tastes,
and social norms? If influence
operates primarily through indi-
viduals’ perceptions of their
friends’ behaviors, can children’s
perceptions of their friends’ be-
haviors be altered or overcome?
To address these complexities,
several observational, experimen-
tal, and implementation steps, de-
veloped through multidisciplinary
collaborations, are needed. These
should include (1) data collection
efforts including both survey in-
struments and direct measure-
ments of attitudes, beliefs, and
behaviors among sets of friends to
understand how, when, and to
what extent influence occurs; (2)
longitudinal studies with data and
methods that permit at least some
causal inferences; and (3) experi-
mental studies that test multiple
possible mechanisms of friendship
influence over the short term (day,
week) and over the longer term
(months, years).
Our systematic review of the lit-
erature revealed strong evidence
July 2013, Vol 103, No. 7 | American Journal of Public Health
SYSTEMATIC REVIEW
that physical activity behaviors
are positively associated with en-
couragement and support for
physical activity from friends, with
friends’ physical activity patterns,
and with engagement with friends
in physical activity. We found
some indication that these associ-
ations may result from friends
influencing each other’s behaviors,
although further research is needed
to understand the magnitude of
influences and to explore the po-
tential for using friendship to pro-
mote a lifetime of healthy physical
activity habits. j
About the Authors
Claire C. Maturo is with the Department of
Behavioral Science and Health Education
and Solveig A. Cunningham is with the
Hubert Department of Global Health and
Department of Sociology, Emory
University, Atlanta, GA.
Correspondence should be sent to Solveig
A. Cunningham, 1518 Clifton Rd, NE, Room
7045, Atlanta, GA 30322 (e-mail:
sargese@emory.edu). Reprints can be ordered
at http://www.ajph.org by clicking the
“Reprints” link.
This article was accepted March 25,
2013.
Contributors
C. C. Maturo conducted and documented
the literature searches. Both authors
evaluated studies and wrote the article.
Acknowledgments
This study was supported by the National
Institute of Diabetes and Digestive and
Kidney Diseases (grant R21DK081878).
We thank Elizabeth Vaquera and K.
M. Venkat Narayan for guidance and
comments and Melissa Matz for assistance
with searches.
Note. The content is solely the re-
sponsibility of the authors and does not
necessarily represent the official views of
the National Institute of Diabetes and
Digestive and Kidney Diseases or the
National Institutes of Health.
Human Participant Protection
No protocol approved was required be-
cause the study had no human participants.
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