Walking participation and health-related quality of life: an ecological analysis across 229 districts in Korea

Background Walking is a widely accessible form of physical activity and has been consistently associated with improved health-related quality of life (HRQoL) at the individual level. However, less is known about how walking participation relates to HRQoL at the population level, particularly when mental health indicators are considered within an ecological framework. Methods This study conducted an ecological analysis using publicly available aggregated data from 229 administrative districts in South Korea. District-level measures of walking participation, moderate-to-vigorous physical activity (MVPA), depressive symptoms, perceived stress, and HRQoL (EQ-5D) were analyzed. Pearson correlation analyses and multiple linear regression models were employed to examine associations among variables. Results Walking participation was positively associated with HRQoL in the initial ecological models. However, these associations were attenuated and became non-significant after adjustment for district-level aging structure, while model explanatory power increased substantially. MVPA showed no significant association with HRQoL. Depressive symptoms were negatively associated with HRQoL, whereas perceived stress demonstrated a positive association at the district level. Walking participation was also positively associated with depressive symptoms and perceived stress at the district level, suggesting that district-level ecological associations may differ from individual-level relationships. Conclusions At the ecological level, walking participation showed significant associations with HRQoL, although these associations were partly attenuated after adjustment for district-level aging structure. These findings highlight the importance of cautious interpretation when examining population-level health relationships using district-level aggregate data. Overall, the results suggest that walking participation may serve as a population-level marker associated with regional HRQoL patterns, rather than providing direct evidence that increasing walking alone would improve district-level HRQoL.