Walking for leisure among adults from three Brazilian cities and its association with perceived environment attributes and personal factors

  • Grace AO Gomes1Email author,

    Affiliated with

    • Rodrigo S Reis2,

      Affiliated with

      • Diana C Parra3,

        Affiliated with

        • Isabela Ribeiro2,

          Affiliated with

          • Adriano AF Hino2,

            Affiliated with

            • Pedro C Hallal4,

              Affiliated with

              • Deborah C Malta5 and

                Affiliated with

                • Ross C Brownson3, 6

                  Affiliated with

                  International Journal of Behavioral Nutrition and Physical Activity20118:111

                  DOI: 10.1186/1479-5868-8-111

                  Received: 15 March 2011

                  Accepted: 13 October 2011

                  Published: 13 October 2011

                  Abstract

                  Background

                  Walking is a popular form of physical activity and a convenient option to prevent chronic diseases. However, most of the evidence on this topic derives from high-income countries and little is known about walking patterns and its association with environmental features in low and middle income countries.

                  Objectives

                  To describe walking for leisure and to identify its association with perceived environment and personal factors among residents of three state capitals from different regions of Brazil

                  Methods

                  Cross sectional phone surveys were conducted in Recife, Curitiba and Vitória (n = 6,166) in 2007, 2008 and 2009 respectively. Physical activity was measured using the leisure-time sections of the long version of the International Physical Activity Questionnaire (IPAQ). Perceived environment characteristics were assessed using a modified version of the Neighborhood Environment Walkability Scale (NEWS). Multivariable analysis tested the associations between walking for leisure and perceived environment characteristics across the cities using logistic regression.

                  Results

                  The proportions of respondents meeting physical activity recommendations through walking for leisure were 9.6%, 16.0% and 8.8% in Curitiba, Recife and Vitoria, respectively. Engaging in 150 min/wk or more of walking for leisure was significantly associated with younger age, higher education, better self-rated health and with lack of sidewalks on nearby streets. We did not find positive associations between walking for leisure and traffic conditions and safety related to cycling/walking during the day or night.

                  Conclusion

                  Most environmental features were not associated with walking for leisure. Personal factors were stronger predictors of walking for leisure as compared with perceived environment factors.

                  Introduction

                  Regular practice of physical activity is associated with reduced risk of developing chronic diseases and mortality [13]. In spite of the evidence about the benefits of physical activity for health, inactivity prevails in both high and low and middle income countries [4].

                  In high income countries, such as the United States, the percentage of people not meeting recommended levels of total physical activity is about 50,0% [5]. In addition, only 34,0% of people in the United States reports walking regularly [6]. Lack of physical activity is also a concern in low and middle income countries, such as Brazil. Studies have shown that only 10,5% to 21,5% % of people meet recommended levels for physical activity during leisure-time in several states from Brazil [7, 8].

                  Physical inactivity is a complex behavior, determined by a series of factors at different levels. Over the last years, physical activity has been linked to personal barriers and to environmental factors [9, 10]. The World Health Organization [4] cites some examples of environmental factors related to physical activity such as over-crowding, increased poverty, increased levels of crime, high levels of traffic, low air quality and lack of parks, sidewalks and sports and recreation facilities.

                  Changes in the environment can encourage people to be more physically active [11] and many environmental variables, such as accessibility or safety are significantly associated with physical activity [12]. Public health recommendations have emphasized common daily activities, such as climbing stairs, walking or bicycling to increase physical activity [13]. Walking is a popular form of physical activity and it has been described as a convenient and accessible option to promote health [14]. Additionally, walking has been shown as the most accessible way for achieving physical activity goals among groups who are typically sedentary, such as the elderly and low-income individuals [14, 15].

                  There are few studies of the associations of the perceived environment and walking in Brazil [16, 17]. Most studies have analyzed only the relationship with personal factors [18]. Also, most of the evidence on the influence of the perceived environment on physical activity is derived from high-income nations [12] and social, cultural and environmental factors in countries from Latin America such as Brazil vary greatly from those found in developed nations. The aims of the present study are: to describe the prevalence of walking for leisure in three state capitals from different regions of Brazil and to explore the association between walking for leisure and perceived environment and personal characteristics.

                  Methods

                  Study Settings

                  The state capitals of Recife, Curitiba and Vitória have different social and environmental characteristics; however, they have in common the fact that they provide public PA programs free of cost to their population, Academia da Cidade in Recife, CuritibAtiva in Curitiba and Serviço de Orientação ao Exercício (Exercise Orientation Service) in Vitoria [1921]. The surveys from Recife and Curitiba were part of a larger effort implemented by Project GUIA (Guide for Useful Interventions for Physical Activity in Brazil and Latin America)[22, 23] to better understand physical activity promotion in cities from Brazil. Table 1 shows some characteristics and indicators of the three cities related to population, traffic conditions and safety. Characteristics related to safety were included to describe the cities, population, automobile Fleet (units), inhabitants/cars and crime. The number of inhabitants/car can indicate less traffic density in the city. Curitiba has the smaller inhabitants/car ratio (2.1) indicating higher traffic density while Recife has a less dense traffic. Moreover, number of homicides by inhabitants is related with safety perception. In this sense Recife has a higher crime rate indicating a less safe environment while Curitiba is potentially safer compared to its counterparts.
                  Table 1

                  Sample characteristics in Recife, Curitiba and Vitória, Brazil, 2007-2009.

                   

                  Study site (year)

                  Recife (2007)

                  Curitiba (2008)

                  Vitória (2009)

                  Sampling

                  criteria

                  Eligible respondents

                  3632

                  3406

                  2690

                   

                  Random sample

                  2400 households with at least 1 telephone landline from each stratum, 12 clusters of 200 telephone numbers each.

                  1000 people distributed across 9 strata and 1000 distributed in 4 extreme SES** strata.

                  Stratified according to presence or not of SOE* modules in the neighborhood

                   

                  Final sampling

                  2046

                  2097

                  2023

                   

                  Response rates

                  64,5%

                  60,5%

                  75,2%

                  Environmental characteristics

                  Population

                  1,561,659

                  1,851,215

                  320,156

                   

                  Automobile fleet (units)

                  307,166

                  867,066

                  109,305

                   

                  Inhabitants/cars

                  5.1

                  2.1

                  2.9

                   

                  Crimes (Homicides/100,000 inhabitants)

                  87.5

                  45.5

                  75.4

                  *SOE-Serviço de Orientação ao Exercício (Exercise Orientation Service)

                  ** SES-Socio Economic Status

                  Population and sample

                  Eligible respondents were non-institutionalized residents of the three cities who were 18 years or older. A random-digit-dialing telephone survey was applied using the methods of the Brazilian Chronic Disease Risk Factor Surveillance [7]. The coverage of land lines in Brazil is over 70% at the national level and we oversample low income populations since they tend to have lower access to telecommunications [24]. Stratified and clustered multistage sampling was used as detailed in Table 1. The sampling procedure was similar in all three cities with some differences in the stratification process which varied according to specific characteristics of the city. Institutional Review Board approval was obtained prior to data collection from São Paulo Federal University, Pontiff Catholic University of Parana in Curitiba and Washington University in St. Louis.

                  Measures and data collection

                  A questionnaire was administered by trained interviewers with experience in telephone population surveys in 2007, 2008 and 2009. Averaging 20 minutes, the questionnaire included sociodemographic characteristics (gender, age, marital status, and education level); health (perceived health, self-reported weight and height); physical activity (walking for leisure-time); and perceived environment (accessibility and safety).

                  Body mass index (BMI) was calculated based on self-reported weight and height and was categorized as normal (less than 24.9 kg/m2), overweight (25-29.9 kg/m2) and obese (more than 30 kg/m2). The International Physical Activity Questionnaire (IPAQ) long version was used to assess physical activity. Walking for leisure was the dependent variable and a cutoff of 150 min/wk was used based on the most recent recommendations for physical activity and health [20].

                  Perceived environment information was obtained through a modified and culturally adapted version of the the Neighborhood Environment Walkability Scale (A-NEWS)[25] using categorical response options The modified version of the questionnaire was used in the three surveys. Prior studies with population from Brazil have shown that people have difficulty understanding questions in which the answer options are organized as a likert scale. Based on cognitive interviews during a pilot study and on prior research using the NEWs scale, several modifications to the response options as well as cultural adaptation to the questions and translation into Portuguese were done to the scale [26, 27]. The modified scale has been previously used in other surveys in Brazil [16, 28]. Only questions that were included in all three surveys were selected for this study to allow for comparability. These included perceptions of safety (walking/bicycling during the day and the night), traffic conditions, and presence of sidewalks.

                  Data analysis

                  A descriptive analysis of walking for leisure according to personal and environmental factors, stratified by cities was conducted. A bivariate analysis was performed (using hierarchic model of logistic regression) between walking for leisure and selected independent variables stratifying by city. Three different models were run using multivariable logistic regression with walking for leisure as the dependent variable, stratifying by cities. We used the command svy to account for the complex sampling design and account for sampling weights. Model 1 included only demographic factors, model 2 included demographic factors, BMI, and perceived health, and model 3 included all previous variables plus perceived environment characteristics. We used the Stata 10 for data analysis.

                  Results

                  Study population characteristics

                  Table 2 shows the characteristics of the study population, which consisted of 2.276 men (41.2%) and 3.890 women (58.8%), with mean age of 45,0 (± 17,0). The education level varied across the three cities. In all three cities, the majority of the participants reported good health status (75.5%) and were married (48.0%). Overall, 59.7% were overweight by BMI (25-30 kg·m2), and the proportion of respondents that met physical activity recommendations through walking for leisure varied slightly between cities, 8.8%, 9.6% and 16.0% in Vitória, Curitiba and Recife, respectively. Most of the respondents reported presence of sidewalks on nearby streets (75.9%) and perceived safety when cycling/walking during the night (59.2%); however, cycling/walking during the day was not considered safe by the majority (80.6%) of the respondents in all three cities. More than half of the participants reported that traffic makes cycling/walking more difficult, this proportion was higher in Vitória (62.1%) than in Curitiba (54.9%) and Recife (43.6%).
                  Table 2

                  Demographic characteristics of participants according to the city of residence, Brazil, 2007-2009

                  Variables

                  Categories

                  Curitiba

                  Recife

                  Vitória

                  All

                    

                  n

                  %1

                  n

                  %1

                  n

                  %1

                  n

                  %1

                  Gender

                  Men

                  768

                  37.4

                  761

                  43.7

                  747

                  37.8

                  2276

                  39.8

                   

                  Women

                  1,329

                  62.6

                  1,285

                  56.3

                  1,276

                  62.2

                  3890

                  60.2

                  Age categories

                  16-34

                  611

                  47

                  700

                  47.6

                  614

                  44.8

                  1925

                  35.1

                   

                  35-45

                  861

                  37.3

                  761

                  34.1

                  798

                  35

                  2420

                  39.7

                   

                  55+

                  625

                  15.6

                  585

                  18.3

                  611

                  20.2

                  1821

                  25,5

                  Education level

                  < High

                  671

                  28.6

                  631

                  46.1

                  492

                  20.4

                  1794

                  34.1

                   

                  High school

                  724

                  41.2

                  765

                  38.2

                  652

                  33.6

                  2141

                  34.7

                   

                  > High school

                  692

                  30.1

                  612

                  15.7

                  879

                  46.0

                  2183

                  31.2

                  Marital status

                  Single

                  522

                  34.7

                  764

                  46.3

                  603

                  38.7

                  1889

                  33.1

                   

                  Married

                  1,199

                  56

                  940

                  42.9

                  1053

                  50.4

                  3192

                  50.5

                   

                  Other

                  376

                  9.3

                  342

                  10.9

                  367

                  10.9

                  1085

                  16.4

                  Perceived health

                  Poor/Regular

                  541

                  24.6

                  774

                  37.8

                  608

                  27.7

                  1923

                  29.6

                   

                  Good

                  963

                  48.0

                  822

                  41.6

                  771

                  38.8

                  2556

                  38.7

                   

                  Very good/excellent

                  592

                  27.5

                  450

                  20.6

                  631

                  33.6

                  1673

                  31.8

                  Body mass index

                  Normal

                  1,133

                  60.2

                  1,115

                  58.1

                  1,010

                  56.7

                  3258

                  59.7

                   

                  Overweight/Obese

                  912

                  39.8

                  830

                  41.9

                  888

                  43.3

                  2630

                  40.3

                  Walking for leisure (150 min/week)

                  Yes

                  361

                  15.1

                  378

                  14.3

                  387

                  17.6

                  5032

                  14.7

                   

                  No

                  1,736

                  84.9

                  1,666

                  85.7

                  1,630

                  82.4

                  1126

                  85.3

                  Sidewalks on nearby streets

                  No

                  541

                  29.3

                  284

                  18.9

                  1,036

                  53.3

                  1861

                  24.2

                   

                  Yes

                  1,556

                  70.7

                  1762

                  81.1

                  936

                  46.7

                  4254

                  75.8

                  Traffic makes it difficult to cycle/walk

                  No

                  967

                  45.1

                  1,077

                  56.4

                  692

                  37.9

                  2736

                  51.2

                   

                  Yes

                  1,130

                  54.9

                  968

                  43.6

                  1,231

                  62.1

                  3329

                  48.8

                  Safe to cycle/walk during the night

                  No

                  1,760

                  84.8

                  1,551

                  79.5

                  1,128

                  58.2

                  4439

                  80.5

                   

                  Yes

                  337

                  15.2

                  495

                  20.5

                  816

                  41.8

                  1648

                  19.5

                  Safe to cycle/walk during the day

                  No

                  775

                  37.2

                  806

                  44.4

                  408

                  21.6

                  1989

                  40.5

                   

                  Yes

                  1,322

                  62.8

                  1,240

                  55.6

                  1,530

                  78.4

                  4092

                  59.5

                  1Weighed prevalence rates

                  Individual and environmental correlates of walking for leisure

                  Results of crude and adjusted logistic regression are depicted in Tables 3 and 4, respectively. The associations found in the crude analysis remained even after adjusting for potential confounders. Logistic regression analysis showed that younger respondents (16-34 yrs) tended to walk for leisure more in all three cities ((Odds Ratio (OR) = 3.0, Confidence Interval (CI) = 2.1-4.3). With the exception of Curitiba, higher levels of education (OR = 1.9, CI = 1.4-2.6) and better self-rated health (OR = 1.8, CI = 1.3-2.4) were found to be associated with walking for leisure time. Walking for leisure was negatively associated with presence of sidewalks nearby in the city of Vitória. No statistical associations were found with sex, marital status and BMI in relation to walking for leisure time in any of the cities.
                  Table 3

                  Unadjusted prevalence odds ratios for personal and environmental factors associated with walking in leisure time, Brazil, 2007-2009.

                  Variables

                  Categories

                  Curitiba1

                  Recife1

                  Vitoria1

                  All1

                    

                  %

                  OR (CI)

                  %

                  OR (CI)

                  %

                  OR (CI)

                  %

                  OR (CI)

                  Gender

                  Men

                  15,3

                  0.9 (0.7-1.3)

                  13,6

                  1.1 (0.7-1.5)

                  18,1

                  0.9 (0.7-1.2)

                  14,3

                  1.0 (0.8-1.3)

                   

                  Women

                  14,9

                  Ref

                  14,8

                  Ref

                  17,3

                  Ref

                  15,0

                  Ref

                  Age categories

                  16-34

                  13,1

                  1.8 (1.2-2.7)

                  12,3

                  2.3 (1.5-3.7)

                  11,8

                  2.6 (1.9-3.7)

                  11,0

                  2.1 (1.6-2.9)

                   

                  35-45

                  14,7

                  1.1 (0.7-1.6)

                  13,3

                  1.9 (1.2-3.0)

                  20,0

                  1.8 (1.3-2.5)

                  16,4

                  1.5(1.1-2.1)

                   

                  55+

                  22,0

                  Ref

                  21,8

                  Ref

                  26,3

                  Ref

                  21,2

                  Ref

                  Education level

                  < High

                  14,9

                  Ref

                  12,3

                  Ref

                  16,4

                  Ref

                  13,2

                  Ref

                   

                  High school

                  12,1

                  0.7 (0.5-1.1)

                  13,3

                  1.0 (0.7-1.6)

                  16,1

                  0.9 (0.6-1.3)

                  12,9

                  1.6 (1.2-2.2)

                   

                  > High school

                  19,5

                  1.3 (0.9-2.0)

                  21,8

                  1.9 (1.2-3.0)

                  19,3

                  1.2 (0.8-1.6)

                  20,4

                  0.9 (0.7-1.3)

                  Marital status

                  Single

                  13,9

                  1.5 (0.9-2.5)

                  10,5

                  2.8 (1.5-5.2)

                  15,1

                  1.5 (1.0-2.2)

                  11,8

                  2.2(1.5-3.4)

                   

                  Married

                  15,0

                  1.0 (0.7-1.5)

                  15,4

                  1.5(1.0-2.2)

                  18,8

                  1.3 (0.9-1.7)

                  15,4

                  1.3 (1.0-1.7)

                   

                  Other

                  20,0

                  Ref

                  25,3

                  Ref

                  21,2

                  Ref

                  23,4

                  Ref

                  Perceived health

                  Poor/Regular

                  13,7

                  Ref

                  13,1

                  Ref

                  14,4

                  Ref

                  13,3

                  Ref

                   

                  Good

                  12,8

                  0.9 (0.6-1.3)

                  13,0

                  0.9 (0.6-1.5)

                  17,8

                  1.2 (0.9-1.7)

                  13,1

                  0.9 (0.7-1.3)

                   

                  Very good/

                  excellent

                  20,2

                  1.5 (1.0-2.4)

                  19,1

                  1.5 (0.9-2.4)

                  20,2

                  1.5 (1.0-2.1)

                  19,7

                  1.5 (1.1-2.1)

                  Body mass index

                  Normal

                  15,9

                  0.9(0.6-1.2)

                  14,2

                  0.9 (0.6-1.3)

                  16,3

                  1.2(0.9-1.5)

                  14,9

                  0.9 (0.7-1.1)

                   

                  Overweight/

                  Obese

                  14,6

                  Ref

                  13,6

                  Ref

                  19,2

                  Ref

                  14,2

                  Ref

                  Sidewalks on t nearby streets

                  No

                  11,6

                  1.5 (1.0-2.2)

                  8,0

                  2.1(1.1-3.9)

                  15,7

                  1.3 (1.0-1.7)

                  10,3

                  1.6 (1.2-2.2)

                   

                  Yes

                  16,5

                  Ref

                  15,8

                  Ref

                  19,9

                  Ref

                  16,1

                  Ref

                  Traffic makes it difficult to cycle/walk

                  No

                  13,6

                  Ref

                  14,3

                  Ref

                  17,2

                  Ref

                  14,2

                  Ref

                   

                  Yes

                  16,8

                  0.7(0.5-1.0)

                  14,3

                  1.0 (0.7-1.4)

                  18,0

                  1.0 (0.8-1.4)

                  15,2

                  0.9 (0.7-1.1)

                  Safe to cycle/walk during the night

                  No

                  17,9

                  0.8 (0.6-1.0)

                  15,5

                  0.7 (0.5-0.9)

                  17,0

                  0.9 (0.6-1.2)

                  16,4

                  0.8 (0.630-1.021)

                   

                  Yes

                  13,4

                  Ref

                  13,3

                  Ref

                  18,4

                  Ref

                  13,6

                  Ref

                  Safe to cycle/walk during the day

                  No

                  15,4

                  0.8 (0.5-1.2)

                  14,2

                  1.0 (0.6-1.4)

                  19,1

                  0.8 (0.6-1.0)

                  14,8

                  0.9 (0.7-1.2)

                   

                  Yes

                  13,1

                  Ref

                  14,4

                  Ref

                  16,0

                  Ref

                  14,2

                  Ref

                  1Weighed prevalence rates and prevalence odds ratios

                  Table 4

                  Adjusted prevalence odds ratios for personal and environmental factors associated with walking in leisure time, Brazil, 2007-2009.

                  Variables

                  Model*

                  Categories

                  Curitiba

                  Recife

                  Vitoria

                  All

                     

                  Adjusted OR1

                  (95% CI)

                  p-value

                  Adjusted OR1

                  (95% CI)

                  p-value

                  Adjusted OR1

                  (95% CI)

                  p-value

                  Adjusted OR1

                  (95% CI)

                  p-value

                  Gender

                  1

                  Men

                  Ref

                   

                  Ref

                   

                  Ref

                   

                  Ref

                   
                    

                  Women

                  0.9 (0.7-1.3)

                  0.90

                  1.0 (0.7-1.5)

                  0.64

                  1.0 (0.7-1.2)

                  0.86

                  1.0 (0.8-1.2)

                  0.84

                  Age categories

                  1

                  16-34

                  2.0 (1.2-3.4)

                  0.00

                  4.3 (2.6-7.1)

                  0.00

                  4.2 (2.8-6.5)

                  0.00

                  3.0 (2.1-4.3)

                  0.00

                    

                  35-45

                  1.2 (0.8-1.9)

                  0.30

                  3.1 (1.9-5.0)

                  0.00

                  2.3 (1.6-3.4)

                  0.00

                  2.0 (1.4-2.7)

                  0.00

                    

                  55+

                  Ref

                   

                  Ref

                   

                  Ref

                   

                  Ref

                   

                  Education level

                  1

                  < High

                  Ref

                   

                  Ref

                   

                  Ref

                   

                  Ref

                   
                    

                  High school

                  1.5 (1.0-2.2)

                  0.04

                  1.5 (1.0-2.4)

                  0.03

                  1.3 (0.8-2.1)

                  0.15

                  1.3 (0.9-1.7)

                  0.07

                    

                  > High school

                  0.8 (0.5-1.3)

                  0.61

                  2.1 (1.3-3.3)

                  0.00

                  1.6 (1.0-2.5)

                  0.02

                  1.9 (1.4-2.6)

                  0.00

                  Marital status

                  1

                  Single

                  1.2 (0.6-2.1)

                  0.47

                  1.1 (0.6-2.1)

                  0.62

                  0.7 (0.5-1.0)

                  0.19

                  1.2 (0.8-1.8)

                  0.36

                    

                  Married

                  1.0 (0.6-1.5)

                  0.22

                  0.9 (0.6-1.5)

                  0.87

                  0.7 (0.4-1.1)

                  0.08

                  0.9 (0.7-1.3)

                  0.99

                    

                  Other

                  Ref

                   

                  Ref

                   

                  Ref

                   

                  Ref

                   

                  Perceived health

                  2

                  Poor/Regular

                  Ref

                   

                  Ref

                   

                  Ref

                   

                  Ref

                   
                    

                  Good

                  0.9 (0.6-1.4)

                  0.77

                  1.2 (0.8-1.8)

                  0.30

                  1.4 (0.9-2.1)

                  0.07

                  1.1 (0.8-1.4)

                  0.49

                    

                  Very good/excellent

                  1.5 (0.9-2.4)

                  0.05

                  2.2 (1.4-3.4)

                  0.00

                  1.7 (1.1-2.6)

                  0.01

                  1.8 (1.3-2.4)

                  0.00

                  Body mass index

                  2

                  Normal

                  0.8 (0.6-1.1)

                  0.35

                  0.8 (0.6-1.1)

                  0.35

                  1.1 (0.8-1.5)

                  0.25

                  0.8 (0.6-1.0)

                  0.22

                    

                  Overweight/Obese

                  Ref

                   

                  Ref

                   

                  Ref

                   

                  Ref

                   

                  Sidewalks on nearby streets

                  3

                  No

                  1.2 (0.8-1.8)

                  0.34

                  1.8 (0.9-3.5)

                  0.08

                  1.3 (1.0-1.7)

                  0.04

                  1.5 (1.0-2.1)

                  0.01

                    

                  Yes

                  Ref

                   

                  Ref

                   

                  Ref

                   

                  Ref

                   

                  Traffic makes it difficult to cycle/walk

                  3

                  No

                  Ref

                   

                  Ref

                   

                  Ref

                   

                  Ref

                   
                    

                  Yes

                  0.8 (0.5-1.1)

                  0.22

                  1.0 (0.7-1.5)

                  0.63

                  0.9 (0.7-1.3)

                  0.88

                  0.9 (0.7-1.2)

                  0.77

                  Safe to cycle/walk during the night

                  3

                  No

                  0.7 (0.5-1.0)

                  0.09

                  0.8 (0.5-1.2)

                  0.42

                  0.9 (0.6-1.2)

                  0.61

                  0.8 (0.6-1.0)

                  0.12

                    

                  Yes

                  Ref

                   

                  Ref

                   

                  Ref

                   

                  Ref

                   

                  Safe to cycle/walk during the day

                  3

                  No

                  0.9 (0.5-1.5)

                  0.83

                  0.9 (0.6-1.4)

                  0.87

                  0.8 (0.6-1.1)

                  0.23

                  0.9 (0.7-1.3)

                  0.93

                    

                  Yes

                  Ref

                   

                  Ref

                   

                  Ref

                   

                  Ref

                   

                  1Weighed prevalence odds ratio adjusted for Gender, Age categories, Education level, Marital status, Perceived health and BMI; 2Weighed prevalence odds ratio adjusted for Gender, Age categories, Education level, Marital status, Perceived health, BMI and City

                  * Model: level 1 = demographics; level 2 = BMI and perceived health; level 3 = perceived environment variables

                  The adjusted logistic regression in the combined analysis (all three cities) showed some associations. Age group was significantly correlated with meeting recommendations through walking for leisure time. Younger age, having more than high school and reporting very good/excellent perceived health were found to be positively and significantly associated with walking for leisure. Presence of sidewalks on nearby streets was the only perceived environmental factor found to be associated with walking for leisure in a negative direction in the city of Vitoria.

                  Discussion

                  This is one of the first studies examining personal and environmental factors associated with walking for leisure across cities in Brazil. We found that higher levels of walking for leisure were associated with lower age, higher educational status and better perceived health in all cities and with lack of nearby sidewalks in the city of Vitória and in the combined data. No associations were found with sex, marital status, BMI, perceived traffic and perceived safety to cycle/walk during day or night across all three cities. Some of the perceived environment characteristics presented correlations in the opposite directions than expected; for instance, presence of sidewalks was negatively associated with a higher likelihood of walking during leisure time.

                  Our findings can be interpreted in light of other research from the region. For example, Matsudo and colleagues [29] examined trends of physical activity during leisure time in different regions of Brazil from 2002 to 2008. Taking into account geographic region, people from the coastline were more active than the ones from the countryside and the ones from the metropolitan region. Similarly, Moura et al. [7] found the highest rates of leisure time physical activity in Vitória (21.2%) and the lowest in Recife (15.0%) out of all the cities from Brazil. Our data, which only looked at walking for leisure, found different rates, the lowest level of walking for leisure was 8.8% in Vitoria versus 16.0% in Recife, both coastal cities from the country. It is possible that the majority of the reported physical activity during leisure time in Vitoria and Recife in the Matsudo study corresponded to moderate and vigorous physical activity and not necessarily walking. Regarding personal characteristics, our findings are consistent with most of the national and international literature, in that, younger age, higher educational level, and better perceived health are shown to be positively associated with physical activity [8, 18, 3032].

                  In addition, according to findings from all State capitals of Brazil, men tend to be more active during leisure time when compared to women [8, 31, 32]. In our study, the proportion of women that walk for leisure (15.0%) was higher than the proportion of men (14.3%); sex was not an effect modifier of the associations. Simões et al. [20] found that men were more active than women during leisure time in Recife, taking into account vigorous, moderate and walking during leisure, and not just walking like in this case. This could explain the differences found in this study which used the same database for Recife.

                  Research derived from high and low-middle income countries, shows associations between several perceived environment attributes and physical activity [16, 33, 34], and in particular with walking for leisure [35, 36]. Duncan et al. [11] conducted a meta-analysis of studies examining the association between perceived environment and physical activity, they found that perceived environment has a modest, yet significant association with physical activity. In our study we did not find any correlations between perceived environment attributes with the exception of a negative correlation between having sidewalks on nearby streets and walking for leisure in the city of Vitoria. The same finding was observed in the combined model but it is probably explained in its entirety by the strong association found in Victoria. Our inability to find significant associations may be due to the fact that some of the characteristics of the environment captures with the scale used are not sensible for identifying critical features related to the culture and social environment factors. Further research should explore in more detail which are the characteristics and factors of the environment that are associated with practice of physical activity in Brazil. We indicated some environment differences about population, number of automobiles and crimes among the cities, however they were not able to explain the results. In addition, self reported information in regards to features of the environment are likely to differ from those captured with objective methods. Thus, the use of geographic information systems in studies that explore the association between the environment and physical activity levels is needed.

                  The contradictory finding of a positive association between walking for leisure and lack of sidewalks on nearby streets, could be explained by the fact that in some cities of Brazil sidewalks may serve more as a barrier rather that a facilitator for walking. This is due to their poor quality and maintenance as well as overcrowding which limits the ability and the enjoyment of walking. This highlights the importance of developing scales that are culturally relevant and context specific for cities in Latin America, that have very different characteristics from cities found in North America and Europe. Despite the cultural adaptation of the A-News scale conducted for this study, the scale is capturing attributes of the environment that are based on findings from studies conducted in the United States, which has significant differences in terms of socio-demographic, economic, and cultural characteristics when compared to Brazil [37].

                  This study adds to the evidence base on determinants of physical activity by incorporating a range of individual and environmental measures. It is one of the few such studies from Latin America. In summary, personal factors were more strongly related to walking for leisure than perceived environmental features. Further studies should explore other environmental characteristics, including similar analyses in other cities in Brazil and Latin America. Future research should also examine these associations longitudinally.

                  List of abbreviation used

                  PA: 

                  physical activity.

                  Declarations

                  Acknowledgements

                  This study was funded through the Centers for Disease Control and Prevention's Prevention Research Centers Program contract U48/DP001903 (Applying Evidence-Physical Activity Recommendations in Brazil). The findings and conclusions in this article are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention. The authors thank all members of Project GUIA for their valuable contribution and input. The authors are also thankful for the contribution of CAPES (Coordenação de Aperfeiçoamento Pessoal de Nível Superior) for funding researchers from Brazil. The study was approved by the Institutional Review Board from Washington University in St. Louis.

                  Authors’ Affiliations

                  (1)
                  Physical Education Departament, Bioscience Institute, Physical Activity, Health and Sport Laboratory (NAFES), UNESP-Univ Estadual Paulista
                  (2)
                  Physical Education Departament, CCBS, Pontiff Catholic University of Paraná
                  (3)
                  Prevention Research Center in St. Louis, George Warren Brown School of Social Work, Washington University in St. Louis
                  (4)
                  Epidemiology of Physical Activity Research Group, Federal University of Pelotas
                  (5)
                  Health Surveillance Secretariat, Ministry of Health
                  (6)
                  Division of Public Health Sciences and Alvin J. Siteman Cancer Center, School of Medicine, Washington University in St. Louis

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                  © Gomes et al; licensee BioMed Central Ltd. 2011

                  This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://​creativecommons.​org/​licenses/​by/​2.​0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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