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  • Systematic Review
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11 February 2025

Academic Anxiety in Spanish Higher Education: A Systematic Review

,
,
and
1
Department of Evolutionary and Educational Psychology, University of the Basque Country UPV/EHU, 48940 Leioa, Spain
2
Department of Basic Psychological Processes and Their Development, University of the Basque Country UPV/EHU, 20018 Donostia-San Sebastián, Spain
*
Author to whom correspondence should be addressed.
Behav. Sci.2025, 15(2), 192;https://doi.org/10.3390/bs15020192
This article belongs to the Special Issue Well-Being in Educational Contexts: Social–Psychological Perspectives and Innovations
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Abstract

Background: Anxiety disorders are among the most prevalent mental health issues of the 21st century, significantly impacting individuals and healthcare systems worldwide. Within higher education research, academic anxiety is particularly significant, as it encompasses the specific anxieties students face within academic environments, such as exams and public speaking. This study aims to provide a contemporary overview of academic anxiety within Spanish universities by addressing three key questions: (1) How has research on academic anxiety evolved in Spain? (2) What tools have been used to measure academic anxiety? (3) What factors and variables have been analyzed in relation to academic anxiety, and what are the main findings? Methods: A systematic review was conducted following PRISMA guidelines for study selection, data extraction, and synthesis. The analysis focused on PubMed, PsycINFO, and Web of Science databases, examining 25 eligible articles published before January 2023. The objective was to evaluate, organize, and synthesize the evidence presented in these articles. Results: The findings revealed that the majority of studies were conducted in the last decade, employing 20 distinct measurement tools and examining more than 40 associated variables. The academic anxieties investigated included various types such as test anxiety, language learning anxiety, math anxiety, public speaking anxiety, and discipline-specific anxieties like dissection or music performance anxiety. Additionally, the studies explored the relationships between these academic anxieties and other variables such as gender and age. Conclusions: The implications of these findings for education and potential avenues for future research are discussed.

1. Introduction

Anxiety disorders represent one of the most prevalent mental health challenges of the 21st century, imposing significant healthcare costs and contributing substantially to the global burden of disease (Bandelow & Michaelis, 2015). These disorders encompass a spectrum of conditions that disrupt emotional, physiological, and cognitive functioning. Within this broader framework, anxiety emerges in specific contexts, such as educational environments, where academic challenges frequently act as significant stressors.
In educational settings, certain situations, including examinations and public speaking, are commonly associated with heightened anxiety among learners. Academic anxiety, which occurs within the academic context, constitutes a distinct form of anxiety, differing from general categories such as state or trait anxiety (Horwitz et al., 1986; MacIntyre & Gardner, 1991; MacIntyre & MacDonald, 1998). Consequently, academic anxiety can manifest in various forms depending on the specific challenges faced by students. Cassady (2010) introduced the concept of “academic anxieties” to describe the diverse range of anxiety types experienced in educational settings. Among the various manifestations of academic anxieties are test anxiety (Cassady & Johnson, 2002; Pintrich & Schunk, 2002), foreign language anxiety (FLA; Casado & Dereshiwsky, 2001; Horwitz et al., 1986), math anxiety (Alexander & Martray, 1989; Wigfield & Meece, 1988), and public speaking anxiety (MacIntyre & Thivierge, 1995; Raja, 2017).
Foreign language anxiety, as a subtype, includes challenges like speaking anxiety, reading anxiety, and writing anxiety, all of which are influenced by fear of negative evaluation, low self-perceived proficiency, and communication apprehension (Horwitz et al., 1986; MacIntyre & Gardner, 1991). This form of anxiety can significantly hinder language acquisition and academic performance in multilingual or foreign language contexts (Zheng & Cheng, 2018). Additionally, Spain’s multilingual landscape, where regional languages such as Catalan, Basque, and Galician coexist alongside Spanish, may amplify foreign language anxiety due to heightened communication demands and sociolinguistic expectations.
Statistics anxiety, which specifically affects students in disciplines requiring quantitative analysis, is another significant subtype. It has been linked to avoidance behaviors, procrastination, and reduced academic performance (Onwuegbuzie et al., 2000). This anxiety often stems from a combination of low self-efficacy, fear of failure, and a perceived lack of competence in statistical methods, making it a critical area of focus for improving academic outcomes in quantitative fields.
Communication anxiety, often observed in public speaking or group presentation contexts, is closely associated with intrusive thoughts and physiological responses like increased heart rate or sweating (Vera et al., 2020). These symptoms can severely impact academic performance, especially in disciplines where oral presentations are an essential component. Addressing this form of anxiety is vital for fostering effective communication skills, which are increasingly valued in higher education and professional environments.
Academic anxiety is characterized by an array of emotional, physiological, behavioral, and cognitive responses triggered by specific academic situations (Horwitz et al., 1986; Pintrich & Schunk, 2002). Students may experience frustration or excessive worry in response to anxiety-provoking stimuli such as exams or oral presentations. Physical manifestations, including sweating, headaches, or palpitations, are also frequent (Amengual-Pizarro, 2019). Such responses can result in behavioral paralysis (Tobias & Weissbrod, 1980) or the avoidance of academic tasks perceived as intimidating (MacIntyre & Gardner, 1991). Additionally, academic anxiety is often accompanied by expectations of failure and self-doubt (Calvo & Carreiras, 1993). These intrusive thoughts often arise involuntarily, repeatedly, and with significant disruptive potential (Wigfield & Meece, 1988).
Intrusive thoughts have been identified as a critical factor contributing to the adverse impact of academic anxiety on performance (Sarason, 1986). While some studies suggest that anxiety might occasionally facilitate academic performance (Alpert & Haber, 1960; Spielmann & Radnofsky, 2001), the majority of research highlights an inverse relationship between anxiety levels and academic achievement (e.g., Cassady & Johnson, 2002; Sarason, 1986). MacIntyre et al. (1997) proposed that heightened anxiety in academic settings can initiate a feedback loop, leading to poor performance and further amplifying anxiety, thus perpetuating a harmful cycle (see also Andujar & Cruz-Martínez, 2020). Sarason (1986) suggested that intrusive worrying thoughts impair the allocation of attention to relevant academic tasks, resulting in diminished performance.
The profound influence of academic anxiety on performance and overall well-being underscores the necessity for comprehensive studies addressing this issue. In particular, there is a need for systematic investigations consolidating data on the prevalence of various academic anxieties across diverse educational settings. Recent studies, such as those by Silaj et al. (2021) and Kang and Moreau (2023), highlight the importance of innovative interventions and contextual adaptations to mitigate academic anxiety effectively. This systematic review seeks to bridge this gap by examining the incidence of academic anxiety within Spanish universities. Accordingly, this study synthesizes data from investigations into different forms of academic anxiety experienced by university students in Spain to date.

2. Materials and Methods

2.1. The Design

In this review, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist and flowchart were followed to ensure the highest possible rigor of the data obtained (Page et al., 2021).

2.2. Search Strategy

The search was conducted on 18 January 2023 across three databases: PubMed, PsycINFO, and Web of Science. Boolean operators (e.g., AND, OR) were applied to refine the search strategy. The initial search terms included “Anxiety”, “University”, and “Spain”. To ensure comprehensive coverage, the initial search was intentionally broad and later refined to focus on academic anxiety by applying filters and reviewing retrieved articles. Duplicate records were identified and excluded using the RefWorks platform, ensuring that unique references were retained for screening. This review included studies published before 18 January 2023.

2.3. Eligibility Criteria

To ensure consistency and standardization during the screening process, the following inclusion and exclusion criteria were established:
Inclusion Criteria:
Studies were eligible for inclusion if they met all the following criteria:
  • They were peer reviewed scientific articles.
  • They were published in English or Spanish.
  • The study sample consisted of university students in Spain.
  • They employed validated measurement instruments to assess anxiety.
  • They provided data specifically addressing academic anxiety in the Spanish university population.
Exclusion Criteria:
Studies were excluded if they met any of the following criteria:
  • They focused on interventions or the validation of anxiety measurement instruments.
  • They utilized non-validated instruments to measure anxiety.
  • The study sample included individuals outside the Spanish university population (e.g., mixed populations or other educational levels).
  • They were not peer reviewed articles, such as conference abstracts or book chapters.
  • Full-text access to the study was not available.
  • They did not specifically address academic anxiety.
Redundant criteria were consolidated to eliminate overlap and ensure clarity. For example, criteria related to language and sample characteristics were revised to avoid duplication, and consistent terminology (e.g., “study”) was applied throughout.

2.4. Identification of Relevant Evidence and Data Mining

The initial search retrieved 467 results from Web of Science, 597 from PubMed, and 530 from PsycINFO, yielding a total of 1421 documents. References were exported to RefWorks, where 78 duplicates were identified and removed. The remaining 1343 records underwent title and abstract screening by four independent reviewers. Based on the exclusion criteria, 829 documents were excluded, leaving 502 articles for full-text screening. This second stage of screening applied the additional inclusion criterion, “The study provides data on academic anxiety in the Spanish university population”, and the exclusion criterion, “The study investigates other types of anxiety”. Following this comprehensive process, 25 studies were selected for data extraction (see Figure 1).
Figure 1. PRISMA flowchart of study selection.
Data extraction was performed by two researchers and included (a) authors and publication year, (b) sample size and characteristics, (c) measurement instruments for anxiety assessment, (d) other variables analyzed, and (e) reported findings on academic anxiety.

2.5. Assessment of Study Quality

The Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies (National Heart, Lung, and Blood Institute, 2014) was used to evaluate the included studies. Key criteria assessed included the research question, study population, participation rate, inclusion and exclusion criteria, sample size justification, exposure and outcome measurement, blinding of assessors, follow-up processes, and control for confounding variables. Two authors independently evaluated each study, with discrepancies resolved through discussion or consultation with a third author when necessary.

3. Results

The results are discussed in terms of two main aspects: the elements used to categorize the 25 articles presented in Table 1 ((a) authors and year, (b) sample, (c) anxiety scale, (d) other analyzed variables, and (e) results) and (f) total quality assessment score based on Appendix A.
Table 1. Analysis of the papers: (a) authors and year, (b) sample, (c) anxiety scale, (d) other analyzed variables, (e) results, and (f) total quality assessment score based on Appendix A.
The findings of this systematic review offer a comprehensive perspective on academic anxiety in Spanish universities, presenting key insights into its various forms, associated factors, and contextual influences. The discussion integrates both the categorization of reviewed studies and their quality evaluation to provide a holistic understanding of the subject matter.

3.1. Year and Authors

The analysis of academic anxiety in Spanish colleges and universities has gained special relevance in recent decades, with most studies (19 out of 25) conducted since 2010. This surge reflects a growing recognition of the importance of mental health in academic contexts. The pioneering study by Calvo and Carreiras (1993) laid the groundwork for subsequent research, followed by a steady increase in publications during the 2000s and 2010s (e.g., Aguilar et al., 2006; Arnaiz-Castro & Guillén, 2013). Recent studies (2020 onwards) have further expanded the scope, incorporating innovative methodologies and diverse anxiety types (Andujar & Cruz-Martínez, 2020; Trigueros et al., 2020). Two key contributors, Arnaiz and Guillén and Arraez-Aybar, have provided consistent contributions to the field, emphasizing the role of contextual factors and demographic variables in shaping academic anxiety.

3.2. Anxiety Scale

A wide range of validated instruments were employed across the studies to measure academic anxiety, reflecting the complexity of this phenomenon. The State–Trait Anxiety Inventory (STAI) was the most frequently used tool, appearing in six studies (e.g., Arráez-Aybar et al., 2004; Núñez-Peña & Bono, 2019). Other commonly applied scales included the Foreign Language Classroom Anxiety Scale (used in five studies) and the Mathematics Anxiety Rating Scale (used in four studies). These tools facilitated the assessment of specific anxiety types, such as test anxiety, public speaking anxiety, and language anxiety, providing a nuanced understanding of their impact on students’ academic experiences.

3.3. Other Analyzed Variables

The reviewed studies examined a diverse array of variables influencing academic anxiety, with a focus on demographic factors (e.g., gender, age) and contextual elements (e.g., academic task complexity, assessment methods). Notably, gender differences were frequently highlighted, with female students reporting higher anxiety levels across several contexts, such as language learning and mathematics (Arnaiz & Guillén, 2012; Delgado-Monge et al., 2020). Furthermore, innovative pedagogical approaches, such as the use of the Escape Room method, demonstrated significant potential in reducing anxiety compared to traditional evaluation methods (Molina-Torres et al., 2021).

3.4. Results

The findings of the studies reviewed provide valuable insights into the multifaceted nature of academic anxiety in Spanish universities, linking various forms of anxiety to academic contexts and demographic factors. Below, the findings are synthesized into key themes to highlight interconnected patterns and their broader implications.
Academic anxiety was consistently associated with challenging academic tasks. For instance, test anxiety emerged as one of the most prevalent forms of academic anxiety. Higher levels were reported during assessments involving greater complexity or stakes (Aguilar et al., 2006). By contrast, innovative assessment methods, such as the Escape Room approach, demonstrated a reduction in anxiety compared to traditional evaluations (Molina-Torres et al., 2021), suggesting that pedagogical strategies can play a vital role in mitigating academic stress. The method of assessment, therefore, appears central to influencing anxiety levels.
Similarly, foreign language anxiety was identified as a significant issue, with key predictors including fear of negative evaluation, communication apprehension, and exam pressure (Amengual-Pizarro, 2019; Arnaiz & Guillén, 2012). Gender differences were notable, with female students reporting higher anxiety levels than males (Arnaiz & Guillén, 2012). The mandatory nature of language learning further intensified anxiety for students who perceived low proficiency or faced high expectations to succeed (Lahuerta, 2014). This highlights the importance of aligning language curricula with students’ abilities to alleviate anxiety.
Math anxiety disproportionately affected female students and those enrolled in health-related disciplines, while students in technical programs reported lower levels of anxiety (Delgado-Monge et al., 2020; Pérez-Tyteca et al., 2011). Furthermore, math-anxious students exhibited more intrusive thoughts and lower emotional regulation, which negatively impacted their working memory and performance in numerical tasks (Justicia-Galiano et al., 2016; Núñez-Peña & Bono, 2019). These findings emphasize the need for targeted support, particularly in fields where mathematics is perceived as a significant barrier to success.
Although less frequently studied, public speaking anxiety remains a critical concern. Intrusive thoughts and interpersonal anxiety were strongly linked to fear of public speaking, with physiological markers such as increased intraocular pressure observed during oral presentations (Vera et al., 2020; García Fernández et al., 2015). These findings underscore the importance of fostering confidence and providing training to reduce performance-related anxiety.
Among medical and nursing students, dissection anxiety revealed a gradual reduction with repeated exposure, though, initially, high levels persisted in some individuals (Arráez-Aybar et al., 2004, 2008). Emotional preparedness and attitudes toward life and death were identified as key factors influencing anxiety levels during dissection activities, highlighting the need for emotional support and preparatory interventions in these academic contexts.
Finally, broader cognitive and performance impacts of academic stress were evident in studies addressing reading anxiety and music performance anxiety. Anxious readers required greater cognitive effort to achieve comparable comprehension compared to non-anxious peers (Calvo & Carreiras, 1993). Similarly, solo music performers reported higher anxiety levels compared to ensemble performers, suggesting that the nature of academic tasks can significantly shape anxiety levels and coping strategies (Casanova et al., 2018).

3.5. Quality of Included Studies

Appendix A provides an assessment of the methodological quality of the included studies. All studies adequately defined their objectives, population characteristics, inclusion and exclusion criteria, the measured exposure, as well as the independent and dependent variables. However, none of the studies achieved 50% eligible participation or reported blinded outcome assessors, timeframe, or loss of follow-up information. Moreover, only one study (Trigueros et al., 2020) provided sample size justification, six studies assessed exposure more than once (Arráez-Aybar et al., 2004; Calvo & Carreiras, 1993; Grases et al., 2006; Martínez-Sánchez et al., 2003; Pelegrina et al., 2020; Vera et al., 2020), eight studies examined different levels of exposure (Aguilar et al., 2006; Arráez-Aybar et al., 2004; Calvo & Carreiras, 1993; Grases et al., 2006; Martínez-Sánchez et al., 2003; Molina-Torres et al., 2021; Pelegrina et al., 2020; Vera et al., 2020), and only three studies did not conduct statistical analyses where key potential confounding variables were measured (Arráez-Aybar et al., 2004; Arráez-Aybar et al., 2008; Caridad Ocerín et al., 2016).

4. Discussion

This systematic review has several noteworthy strengths in addressing one of the most prevalent mental disorders of the 21st century, anxiety (Bandelow & Michaelis, 2015), specifically focusing on academic anxiety in the context of higher education in Spain. Notably, to the best of our knowledge, this is the first research synthesis to analyze the incidence of academic anxiety within the Spanish university educational context. This review has made two key contributions. Firstly, it has enhanced our understanding of the extent to which this type of anxiety, which is directly related to educational practices, has been studied in Spain. Secondly, it has provided a comprehensive map of the current knowledge base on this topic.
The findings reveal that research on academic anxiety in Spanish colleges and universities has gained increased significance in recent decades, aligning with trends observed in other contexts (Silaj et al., 2021; Stearns, 2023). A plethora of authors have been actively contributing to this area of study, reflecting a growing concern within the scientific community (Kang & Moreau, 2023). However, the multitude of scales used to measure the construct (more than 20) and the wide range of variables analyzed (more than 40) pose challenges in extracting generalized results or conducting a meta-analysis, representing a limitation. Nevertheless, this systematic review followed the steps of research synthesis with scientific rigor (Cohen et al., 2018).
A critical finding is that academic anxiety has predominantly been studied in the contexts of exams, language learning, and mathematics. By contrast, less attention has been devoted to other domains, such as public speaking, medical studies, reading, and music-related degrees. This imbalance highlights potential areas for future research, particularly subgroup-specific analyses that could enable more targeted meta-analyses. Longitudinal studies would also be highly beneficial, as they could provide a dynamic understanding of how academic anxiety evolves across different stages of the academic journey. Expanding research to include group or individual work settings, private versus public universities, or various academic disciplines could offer valuable insights into the dynamics of academic anxiety (Silaj et al., 2021; Kang & Moreau, 2023).
The unique cultural and linguistic diversity of Spain adds an additional layer of complexity to academic anxiety. Multilingual demands in regions where Spanish coexists with languages like Catalan, Basque, and Galician may exacerbate foreign language anxiety (Zheng & Cheng, 2018). These findings underline the necessity for tailored interventions that consider regional and cultural contexts. Additionally, observed gender disparities in math anxiety emphasize the need to challenge societal stereotypes and implement targeted interventions through early educational reforms and support mechanisms (Delgado-Monge et al., 2020). Moreover, distinct subtypes of academic anxiety—such as communication anxiety, foreign language anxiety, and statistics anxiety—each have unique implications and require targeted strategies. For example, foreign language anxiety, often linked to fear of negative evaluation, significantly affects language learning outcomes (MacIntyre & Gardner, 1991). Similarly, statistics anxiety impacts performance in quantitative fields and necessitates specialized support mechanisms (Onwuegbuzie et al., 2000).
The implications of this review extend beyond academic research to practical applications in higher education policy and practice. Recognizing assessments as a significant source of anxiety, universities should adopt active learning methodologies such as gamified evaluations or collaborative assessments. These approaches have been shown to reduce test anxiety and foster engagement (Molina-Torres et al., 2021). Tailored language programs must address students’ proficiency levels while incorporating informal practice opportunities, such as peer-led groups or conversation workshops. Institutionalized stress management workshops could further equip students with proactive strategies to manage anxiety effectively.
Public speaking anxiety warrants particular attention, especially in academic programs where oral communication is critical. Structured, incremental training programs complemented by mindfulness techniques could significantly alleviate students’ fears and improve performance (Vera et al., 2020). Similarly, dissection anxiety in medical education could be mitigated through preparatory workshops and virtual simulations, easing students into hands-on experiences while building their confidence (Arráez-Aybar et al., 2004, 2008). Future research into underexplored domains such as reading and music-related anxieties could broaden our understanding of how academic anxiety manifests across diverse disciplines.
A noteworthy observation from this review is that academic anxiety has primarily been studied in relation to exams, language learning, and mathematics, with less emphasis on areas such as public speaking, medical studies, reading, and music-related degrees. This finding suggests numerous avenues for future research, including subgroup-specific analyses and meta-analyses focusing on specific domains. Extending the focus to encompass general anxiety and its prevalence among both students and university faculty could provide a more holistic understanding of anxiety within academic environments. Moreover, as all the studies reviewed here are cross-sectional, longitudinal research could offer valuable insights into how academic anxiety develops and changes over the course of students’ academic careers.
Conducting future meta-analyses on specific subtypes of anxiety could help unify fragmented data, providing a clearer picture of overarching trends. The recommendations provided aim to bridge the gap between research and practice, fostering an academic environment that prioritizes both educational success and student well-being.

5. Conclusions

This systematic review aimed to evaluate the current state of the literature on academic anxiety in Spanish higher education, identifying insights to guide strategies for addressing this issue. The findings highlight a predominant focus on individual contexts of academic anxiety, with a notable lack of studies exploring this phenomenon across different contexts or academic stages.
This review’s practical implications underscore the need for innovative pedagogical approaches to mitigate academic anxiety. Assessments, as a significant source of anxiety, can be improved through active learning methodologies like gamified evaluations and collaborative projects, which reduce stress and increase engagement (Idoiaga et al., 2024; Molina-Torres et al., 2021). Institutional workshops on stress management and exam strategies also equip students with tools to navigate high-pressure situations and enhance resilience.
Language learning anxiety, often tied to fear of communication and negative evaluation, requires tailored interventions. Structured language programs, informal conversation clubs, and peer mentoring networks provide safe, supportive spaces for students to build confidence and linguistic competence (Amengual-Pizarro, 2019; Dafouz, 2020). Similarly, mathematics anxiety could be addressed through inter-faculty tutoring programs and initiatives aimed at encouraging women’s participation in mathematics, given the higher anxiety levels observed among women and in feminized disciplines like health and education (Delgado-Monge et al., 2020; Pérez-Tyteca et al., 2011).
Public speaking anxiety, a common but under-researched issue, can be mitigated through incremental skill-building exercises, supported by mindfulness and relaxation techniques, to foster confidence and reduce physiological stress responses (Vera et al., 2020; García Fernández et al., 2015). In medical and nursing education, preparatory workshops and virtual dissection tools can help students manage dissection anxiety while addressing emotional and ethical aspects (Arráez-Aybar et al., 2004; Arráez-Aybar et al., 2008).
Finally, broader strategies are required to address cognitive and performance-related anxiety. Workshops on cognitive–behavioral techniques, such as reframing intrusive thoughts and enhancing working memory, can benefit students facing reading or performance anxiety. In music education, encouraging ensemble performances rather than solo activities can reduce pressure and foster collaboration (Calvo & Carreiras, 1993; Casanova et al., 2018).
The increasing prevalence of anxiety, especially among younger generations, demands institutional responsibility in addressing this issue. Academic anxiety is closely linked to pedagogical frameworks and institutional practices. Regular reviews of these practices are essential to minimize stress-inducing factors. By integrating innovative teaching and assessment methods that prioritize emotional well-being alongside academic rigor, universities can create supportive environments that promote both mental health and academic success. These measures emphasize the critical role of institutions in fostering a balanced and sustainable higher education system.

Author Contributions

Conceptualization: N.I.-M. and I.Y.; methodology: N.I.-M. and M.G.; software: I.Y.; validation: N.I.-M., M.G. and E.P.-S.; formal analysis: M.G.; investigation: N.I.-M. and E.P.-S.; resources: I.Y.; data curation: E.P.-S.; writing—original draft preparation: N.I.-M. and E.P.-S.; writing—review and editing: N.I.-M., M.G., I.Y. and E.P.-S.; visualization: I.Y.; supervision: N.I.-M.; project administration: N.I.-M.; funding acquisition: I.Y. All authors have read and agreed to the published version of this manuscript.

Funding

This research was funded by ERASMUS + AWARE (2022-1-PL01-KA220-HED-000087038).

Data Availability Statement

The data presented in this study are available upon request from the corresponding author.

Conflicts of Interest

The authors declare no conflicts of interest.

Appendix A

Table A1. Quality of included studies.
Table A1. Quality of included studies.
Academic Anxiety ResearchQ1Q2Q3Q4Q5Q6Q7Q8Q9Q10Q11Q12Q13Q14TOTAL YES
(Aguilar et al., 2006)YesYesNRYesNoYesNoYesYesNoYesNoNAYes8/13
(Amengual-Pizarro, 2019)YesYesNRYesNoYesNoNoYesNoYesNoNAYes7/13
(Andujar & Cruz-Martínez, 2020)YesYesNRYesNoYesNoNoYesNoYesNoNAYes7/13
(Arnaiz-Castro & Guillén, 2013)YesYesNRYesNoYesNoNoYesNoYesNoNAYes7/13
(Arnaiz & Guillén, 2012)YesYesNRYesNoYesNoNoYesNoYesNoNAYes7/13
(Arráez-Aybar et al., 2004)YesYesNRYesNoYesNoYesYesYesYesNoNoNo8/13
(Arráez-Aybar et al., 2008)YesYesNRYesNoYesNoNoYesNoYesNoNANo6/13
(Calvo & Carreiras, 1993)YesYesNRYesNoYesNoYesYesYesYesNoNoYes9/13
(Caridad Ocerín et al., 2016)YesYesNRYesNoYesNoNoYesNoYesNoNANo6/13
(Casanova et al., 2018)YesYesNRYesNoYesNoNoYesNoYesNoNAYes7/13
(Delgado-Monge et al., 2020)YesYesNRYesNoYesNoNoYesNoYesNoNAYes7/13
(Fernández Rodríguez et al., 2019)YesYesNRYesNoYesNoNoYesNoYesNoNAYes7/13
(García Fernández et al., 2015)YesYesNRYesNoYesNoNoYesNoYesNoNAYes7/13
(Grases et al., 2006)YesYesNRYesNoYesNoYesYesYesYesNoNAYes9/13
(Justicia-Galiano et al., 2016)YesYesNRYesNoYesNoNoYesNoYesNoNAYes7/13
(Lahuerta, 2014)YesYesNRYesNoYesNoNoYesNoYesNoNAYes7/13
(Martínez-Sánchez et al., 2003)YesYesNRYesNoYesNoYesYesYesYesNoNAYes9/13
(Molina-Torres et al., 2021)YesYesNRYesNoYesNoYesYesNoYesNoNAYes8/13
(Nortes Martínez-Artero & Nortes Checa, 2014)YesYesNRYesNoYesNoNoYesNoYesNoNAYes7/13
(Núñez-Peña & Bono, 2019)YesYesNRYesNoYesNoNoYesNoYesNoNAYes7/13
(Pelegrina et al., 2020)YesYesNRYesNoYesNoYesYesYesYesNoNAYes9/13
(Pérez-Tyteca et al., 2011)YesYesNRYesNoYesNoNoYesNoYesNoNAYes7/13
(Smyth et al., 2021)YesYesNRYesNoYesNoNoYesNoYesNoNAYes7/13
(Trigueros et al., 2020)YesYesNRYesYesYesNoNoYesNoYesNoNAYes8/13
(Vera et al., 2020)YesYesNRYesNoYesNoYesYesYesYesNoNAYes9/13
TOTAL YES100%100%0%100%8%100%0%32%100%24%100%0%0%88%
Q1 = clear objective; Q2 = clearly defined population; Q3 = 50% eligible participation; Q4 = inclusion and exclusion criteria of participants; Q5 = sample size justification; Q6 = exposure measured; Q7 = sufficient time frame; Q8 = different level of exposure examined; Q9 = clear independent variables; Q10 = exposure assessed more than once; Q11 = clear dependent variables; Q12 = outcome assessors blinded; Q13 = loss at follow-up; Q14 = confounding variables. NR, not reported. NA, not applicable.

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