Physical activity and perceived environment among adults from a city in Southern Brazilian.

The article aimed to verify the association between physical activity (PA) and perceived environment among adults from a city in southern Brazil. This is a population-based cross-sectional study with 820 adults living in the city of Criciúma-SC. Perceived environment was assessed using the Neighborhood Environmental Walkability scale and PA in the leisure and transportation domains using the long version of the International PA Questionnaire. It was observed that the neighborhood with public spaces for the practice of physical exercises and dog walking was associated with higher prevalence of compli-ance with moderate-to-vigorous physical activity (MVPA) guidelines. The fact of having an invitation from friends and/or relatives for PA, sporting events and the habit of dog walking were associated with leisure-time walking. Access to places for the purchase of fresh fruits/ vegetables, light/diet foods, to have sidewalks in most streets, to have pedestrian crossings and sporting events in the neighborhood were associated with higher prevalence of active transportation. Conversely, places for snacks or fast food in the neighborhood were associated with lower prevalence of active transportation. The perception of environmental variables was associated with MVPA, walking and active transportation. The results of analyses adjusted for sex, age, marital status, skin color, schooling, socioeconomic level and time living in the neighborhood indicated that public place for the practice of physical exercises (PR = 1.4; 95%CI: and dog walking (PR = 1.9; 95%CI: 1.5-2.6), were environmental aspects associated with higher prevalence of performing a period equal to or greater than 150 minutes / week of MVPA.


Introduction
According to the World Health Organization (WHO), physical inactivity is one of the top ten global causes of mortality and disability worldwide, accounting for approximately two million deaths per year 1 . The literature shows robust evidence of health benefits related to the regular practice of physical activities (PA) 2, 3 . In the Global Action Plan on PA broadcasted around the world, there are five policy actions that address the need to create supportive spaces and places that promote the rights of all people to have equitable access to safe places and spaces in cities and communities in which they can engage in regular PA 4 .
The neighborhoods in which people live represent an important environment and can establish limits for the engagement in healthy lifestyles 5 , being one of the contextual determinants of non-communicable Diseases (NCD) 5 . In addition to being natural, the environment must be built to meet the social and community demands adapted to the specific needs of the population for the provision of PA programs in community environments and creation or improved access to places for the practice of PA 6 .
Studies have reported that the attributes of a neighborhood environment, including residential density, population density, land use, connectivity of streets and sidewalks, are closely associated with various types of PA 2,7 . The perception of a neighborhood's environment plays a fundamental role in the relationship between PA and environmental factors; generally, people's perceptions and explanations about their surroundings affect their involvement in PA, and perception measures can be used to assess potentially important factors, such as aesthetics and the feeling of security, which cannot be objectively measured 8 .
As the practice of PA occurs in specific locations, investigating the characteristics of the environment that facilitate this behavior is important in view of the fact that environmental factors may present a relationship or determination of the physically active behavior 8 . In addition, the monitoring of PA and the relationship of this behavior with environmental characteristics is an object of debate by international public health organizations, and one of the recommendations is the constant investigation of the relationship between PA and environmental characteristics of cities 9,10 . Thus, the aim of the study was to verify the association between practice of PA and per-ceived environment among adults from a city in southern Brazil.

Methods
A population-based cross-sectional study was carried out with individuals aged 18 years or older living in the urban area of the city of Criciúma-SC, Brazil. The municipality had estimated population of 215,186 inhabitants in 2019, spread over a territorial extension of 234,865 km 11 . The human development index (HDI) of the municipality was 0.788 in 2010 and the percentage of the population with per capita monthly income of up to half the minimum wage was 26.2%. The schooling rate was 98.5% in 2010 and the infant mortality rate was 8.71 deaths per thousand live births in 2017) 11 . The study was approved by the Research Ethics Committee of the "Extremo Sul Catarinense" University under protocol number 3.084.521 on 12/14/2018, and all individuals who agreed to participate signed the informed consent form.
The sampling process took place in two stages based on data from the 2010 Demographic Census: primary units, which are the census tracts, and secondary units, which are the households. Initially, all urban census sectors (n = 306) with private properties in the municipality of Criciúma were placed in ascending order according to the code for each sector. Subsequently, a random selection of 25% (n = 77) of census sectors was carried out. The number of households was determined by means of sampling proportional to the size of the sector, with 618 households systematically selected within census sectors being visited. All adults in the selected households were invited to participate in the research.
The reference population consisted of individuals of both sexes aged 18 years or older living in the urban area. It was estimated that this population was 215,186 inhabitants in 2019 11 . To calculate the sample size, 95% confidence interval was considered, unknown prevalence for the outcomes (50%), sampling error of five percentage points, design effect of 1.5 and increment of 15% for eventual losses and refusals, which resulted in 661 necessary interviews.
The study included all individuals aged 18 years or older living in the urban area of the city of Criciúma. Individuals with physical and/or mental disabilities to answer the questionnaire were not included in the study.
Data were collected from March to December 2019 through face-to-face interviews.
Because the present study used a set of information to examine issues different from those that were the primary objective of the macro-project from which the analyzed data came, the statistical power, which refers to the probability of rejecting a false null hypothesis (i.e., to determine that there is no difference when in fact it exists -values > 80% are considered adequate to avoid this error) 12 , it was calculated, and the results can be seen in full in Table 1.
Previously trained interviewers used a pre-coded questionnaire with closed questions printed on paper. Data were tabulated in Epidata in the form of double entry to check for any discrepancies in the tabulation.

Study variables
Dependent variable PA was measured through the leisure and transportation section of the International Physical Activity Questionnaire (long version) 13 , which consists of questions about weekly frequency and daily duration of activities such as walking,  moderate-intensity PA and vigorous-intensity PA. Only moderate-to-vigorous physical activity (MVPA) with duration of at least 10 minutes in a typical week was considered. Moderate activities were those that make breathing and heartbeat a little faster than normal, and vigorous activities were those that make breathing and heartbeat much faster than normal. The instrument has good reproducibility indicators and validity was assessed with accelerometer, showing good psychometric characteristics 14 .
For analyses, the following outcomes were estimated: 1) practice of MVPA during leisure time and transportation, based on the sum of weekly time spent walking at leisure and transportation, activities of moderate and vigorous intensity at leisure and time spent cycling during transportation. So, those who reached 150 minutes or more per week in these activities were considered to meet sufficient MVPA recommendations and those who did not were considered not to meet sufficient MVPA recommendations 15 ; 2) practice of leisure-time walking, for at least ten minutes, so that those who reported walking, were considered as practitioners and those who did not, as non-practitioners; 3) active transportation (walking or cycling), so that those who reported practicing such activities, for at least ten minutes, were considered as practitioners and those who reported not practicing, as non-practitioners.

Independent variables
Environmental variables were collected using a modified perceived environment scale validated for Brazilian adults 16 , adapted from the international questionnaire called Neighborhood Environmental Walkability Scale (NEWS) 17 . This tool was used in other studies developed in Brazil 18,19 , and includes characteristics of the neighborhood environment (built, natural and social): access to commerce and places of practice of PA, traffic safety, safety in relation to crimes, aesthetics and satisfaction of the neighborhood, quality of streets and sidewalks, lighting, pollution, weather, social support and presence of dogs.
These variables were individually analyzed as absence and presence, and were also analyzed together, as the total sum of each question (scores 0 and 1). Twenty-three questions from the perceived environment questionnaire were used (excluding four questions whose responses depended on the previous question) 16 . Subsequently, the score (which could vary from 0 to 23 points) was divided into environment tertiles (neighbor-hoods) more or less favorable to the practice of PA according to the individuals' perception (1 st tertile = from zero to 12, 2 nd tertile = from 13 to 15, 3 rd tertile ≥ 16 up to 23). By sum, the score of the unfavorable questions for the practice of physical activity was inverted.

Control variables
The variables used to describe the sample and that were considered covariates were sex (female / male), age in full years and, later, classified into age groups (18-29; 20-39; 40-49; 50-59; 60-69; 70-79; ≥ 80), skin color (white, brown, black, yellow and indigenous), marital status (single, married or in a stable relationship, separated or divorced, widowed), schooling in successfully completed years and grouped into 0 to 4, 5 to 8, 9 to 11, 12 years or more, time of living in the neighborhood (collected in years and classified into one, 1 to 4, 5 or more) and economic level, according to the purchasing power, classified in descending order (A, B, C, D-E) 20 .

Data analysis
Initially, information was described by means of percentages and respective 95% confidence intervals (95%CI). Poisson regression was used, with robust variance adjustment, and estimates of prevalence ratios (PR) and respective 95%CI were presented using the p-value for heterogeneity to test the association between compliance with MVPA recommendations, practice of leisure-time walking and active transportation, and the characteristics of the neighborhood environment. Separate analysis models were built for MVPA, leisure-time walking and active transportation.
In the crude analysis, variables MVPA, walking and active transportation were individually investigated with each environment variable. In the adjusted analysis, each association was controlled for sex, age, marital status, skin color, schooling, purchasing power and time of living in the neighborhood. Variables were entered in the adjusted model regardless of significance value of the crude model.
In addition, adjusted probabilities predicted by the adjusted model between MVPA, walking and active transportation and variable environmental score in tertiles were estimated and graphically presented. All analyses were performed using the Stata 13.0 statistical package (StataCorp LP, College Station, USA).

Results
This study included 820 participants, of which about two thirds were women (63.8%), with higher prevalence of individuals aged 60-69 years (24.5%), married or in a stable relationship (60.4%) and white skin color (80.7%). In addition, one in three respondents of the survey had 9-11 years of schooling and was classified as member of economic level "C" (54.0%). In addition, eight out of 10 individuals (81.2%) reported living in the neighborhood for five or more years. In relation to the practice of PA, one in four individuals (25.1%) performed a period equal to or greater than 150 minutes/week of MVPA, three out of ten participants (30.0%) practiced leisure-time walking and two out of the three individuals (65.3%) performed active transportation (Table 2).
Regarding the variables of interest investigated in this study, 70 individuals did not respond to the question regarding "Sporting events in the neighborhood" (highest item refusal response rate -91.5%). For the other variables, the response rate ranged from 96.3% to 99.9%.
As for affirmative responses referring to the characteristics of the environment in which research participants were inserted, the most expressive response frequencies indicated that 93.4% of them reported that they enjoyed living in the neighborhood, 88.9% and 87.1 %, respectively, reported that the streets near their houses were well lit at night and that were safe to walk/ cycle/perform exercises in the daytime. With regard to unfavorable environment conditions, the most expressive response frequencies indicated that 72.3% of the sample reported the presence of places for snacks or fast food in the neighborhood where they live. Further information for each item in the environment can be seen in Figure 1.
Information regarding the percentage and the association between MVPA, walking and active transportation and environmental variables are described in Table 3. The results of analyses adjusted for sex, age, marital status, skin color, schooling, socioeconomic level and time living in the neighborhood indicated that neighborhood with public place for the practice of physical exercises (PR = 1.4; 95%CI: 1.1-1.8), and dog walking (PR = 1.9; 95%CI: 1.5-2.6), were environmental aspects associated with higher prevalence of performing a period equal to or greater than 150 minutes / week of MVPA.
Access to places for the purchase of fresh fruits and vegetables (PR = 1.2; 95%CI: 1. 3) were characteristics associated with higher prevalence for the adoption of active transportation. Conversely, places for snacks or fast food in the neighborhood near home (PR = 0.8; 95%CI: 0.7-0.9) were associated with lower prevalence for the adoption of active transportation (Table 3). Figure 2 shows the adjusted probabilities predicted for the relationship between MVPA, leisure walking and active transportation, according to tertiles of the environmental perception score, with higher values indicating more favorable environment for the practice of PA. In relation to MVPA, greater probability of performing 150 minutes or more per week was identified concomitantly with the increase in the environmental perception score (Tertile 1 = 22.7%; Tertile 2 = 24.5%; Tertile 3 = 30.0%, p value <0.05). With regard to the practice of leisure-time walking, higher environmental perception score was related to the increased likelihood of leisure-time walking (Tertile 1 = 28.3%; Tertile 2 = 28.7%; Tertile 3 = 36.2%, p value <0.05). In addition, higher probability of adopting active transportation was directly related to the increase in the environmental perception score (Tertile 1 = 61.7%; Tertile 2 = 64.0%; Tertile 3 = 72.2%, p value < 0.05).

Discussion
In recent years, Latin America has undergone an accelerated urbanization process, with significant demographic, epidemiological and socio-economic changes. These changes resulted in improvements in the general health and education indicators, but also in a decrease in the regular practice of PA 21 . This process was accompanied, in many places, by lack of urban planning, which results in the lack of social and physical environ- it continues ment for the practice of PA. One of the main result of the present study is the fact that greater probabilities of practicing MVPA, leisure-time walking and active transportation were observed in people living in neighborhoods with environ-ments (built, natural and social) more conducive to the practice of PA.
The present study indicated that the presence of public spaces for the practice of physical exercises was an environmental aspect associated  with the higher prevalence of performing a period equal to or greater than 150 minutes/ week of MVPA. Other studies have reported direct association between PA and presence of facilities and locations conducive to the practice of PA 4,16,18 . A study carried out by Sallis et al 22 in 11 countries (n = 11,541) including Brazil showed that the perception of greater access to commercial areas, bus stops, sidewalk streets, places to cycle and free public spaces is associated the greatest practice of MVPA. It is noteworthy that, although the existence of facilities conducive to the practice of PA does not determine an increase in the levels of PA, their presence in the neighborhood offers greater opportunity for this activity.
It was also found in the present study that dog walking was an environmental aspect associated with higher prevalence of meeting MVPA recommendations and the practice of leisure-time walking. Such results corroborate findings of previous studies [23][24][25] . Westgarth et al 23 developed a literature review of studies published from 1990 to 2012 and found that higher levels of PA were more observed in individuals who walked their dogs in the neighborhood. In addition, researchers observed that if all dog owners (between 20-40% of the population) walked their animals for at least 30 minutes a day, they would easily reach PA recommendations. In this environmental aspect, the practice of walking stands out for being a pleasant activity commonly performed with animals 25 and can be performed in different public spaces 7 .
The presence of sidewalks on streets and the presence of pedestrian crossings near home were aspects associated with active transportation. Such results corroborate other studies [26][27][28] . In the study by Teixeira et al. 26 developed in the urban region of a city in southeastern Brazil, 36.8% of interviewees perceived the existence of pedestrian crossings near their homes and this environmental variable was significantly associated with the practice of PA. In this sense, a research carried out in Florianópolis-SC 28 found that when individuals had better perception of traffic safe-  ty attributes, such as the presence of pedestrian crossings and sidewalks, they performed more transportation and leisure-time PA. Once individuals perceive that walking and/or cycling on public roads is safe, either due to the presence of signs on public roads or to a greater sense of security in the neighborhood, there is greater encouragement to practice outdoor PA, with consequent benefits for mental and physical health 27 . Association between individuals who reported receiving an invitation from friends or relatives to walk/cycle/perform physical exercises in the neighborhood and leisure-time walking was observed. This can be explained by the fact that group activities provide motivation for their social environment, thus providing greater probability of meeting PA recommendations 3 .
The present study found that access to places for the purchase of fresh fruits and vegetables, light/diet foods near home and the presence of sporting events in the neighborhood were characteristics associated with greater probabilities for the adoption of active transportation. One of the great debates about improving urban mobility in cities is how to transform such spaces into more sustainable cities. One of the options highlighted in literature are compact cities, in which in the same urban space, people have easy access to different services 28 . In addition, the proximity to places that present positive characteristics to health behaviors also facilitates the adoption of practice of PA 29 . In this sense, the promotion of sporting events and availability of services for the acquisition of healthy foods is suggested as one of the ways to stimulate active transportation.
Some aspects of the environment were perceived as barriers to the practice of leisure-time walking such as garbage accumulation near home and the weather. In addition, the fact of having a place in the neighborhood for the purchase of snacks or fast food was also associated with less active transportation. All these aspects have already been highlighted in literature as barriers to PA [29][30][31] . The food environment with fast food and the presence of convenience stores and grocery stores are related to increases in overweight, obesity, diabetes, hypertension and colorectal cancer, directly impacting the risk of developing cardiometabolic diseases, as these foods have a high nutritional deficiency. The consumption of these foods causes changes in lifestyle, especially in the reduction of physical activity. The search for practicality and convenience has led people to condition their diet to unhealthy solutions with increased calorie intake. In general, neighborhoods where garbage accumulation is evident are aesthetically unpleasant and are more likely of having urban violence, which impair the practice of PA 30 . High and low temperatures and high rainfall rates are climatic factors that hinder involvement in PA 31 . In this sense, governmental strategies that offer air-conditioned and covered public spaces in cities can also be an alternative to stimulate involvement in PA 31 .
The present study has strengths, including the high number of perceived environment variables investigated in association with different contexts related to the activity, and the high response rate for the investigated variables, which gives greater reliability that the information analyzed represents fact the investigated sample. However, this study had some limitations such as the cross-sectional design, which does not allow the identification of cause and effect relationships between variables. Furthermore, reverse causality cannot be ruled out. Another limitation of this research was not to research other domains of PA. Another limitation of the research was the use of the cut-point of 150 minutes/week for MVPA. PA guidelines suggest the cut-point of 150 minutes/week for MVPA when analyzing all PA domains. PA measure was self-reported, which may increase the chance of overestimating or underestimating this classification. The low statistical power available to test the associations of interest in this study is considered a limitation.
It could be concluded that the perceived characteristics of the built environment in neighborhoods are associated with MVPA, practice of walking and active transportation. Investments in facilities for the practice of PA in green areas, in the construction of planned neighborhoods with access to different services, with public signs and security can stimulate leisure-time walking, active transportation and, consequently, compliance with MVPA recommendations.

Collaborations
LZ Monteiro collaborated in the article writing, and final approval. JM Farias, TR Lima and FO Meller collaborated in data analysis and interpretation, article writing, and final approval. AA Schafer collaborated on article writing and final review. DAS Silva collaborated in data interpretation, article writing, and final approval.