ORIGINAL RESEARCH

Journal of Physical Activity and Health, 2010, 7(Suppl 2), S137-S145 2010 Human Kinetics, Inc.

Promoting Physical Activity Through Community-Wide Policies and Planning: Findings From Curitiba, Brazil
Rodrigo S. Reis, Pedro C. Hallal, Diana C. Parra, Isabela C. Ribeiro, Ross C. Brownson, Michael Pratt, Christine M. Hoehner, and Luiz Ramos
Background: Community programs have been suggested to be an important and promising strategy for physical activity (PA) promotion. Limited evidence is available regarding knowledge of and participation in these programs in Latin America. Objective: To describe participation in and knowledge of community PA programs and to explore associations with leisure-time PA in the city of Curitiba, Brazil. Methods: A cross sectional telephone survey was conducted among adults in Curitiba, Brazil (n = 2097). The International Physical Activity Questionnaire was used to determine levels of PA, and specific questions were used to evaluate the extent to which respondents knew about or participated in the programs conducted by the municipality. Logistic regression was used to assess the meeting of PA recommendations in leisure time based on program knowledge and participation. Results: Knowledge of PA programs was high (91.6%) and 5.6% of population participated in the programs. After adjusting for individual characteristics, exposure to Curitibas PA community programs was associated with leisure-time PA (POR = 2.9, 95% CI = 2.93.0) and walking for leisure (POR = 2.4; 95% CI = 2.32.4). The associations were stronger among men than among women. Conclusions: Knowledge and participation in Curitibas community PA programs were associated with meeting recommended levels of PA in leisure time. Keywords: community research, Latin America, program evaluation, health promotion Over the past few decades a growing amount of evidence has shown that regular physical activity (PA) reduces the risk for several chronic diseases including cardiovascular disease, diabetes, cancer, and obesity.1 These chronic diseases, along with respiratory diseases, account for 60% of all deaths worldwide2 and 80% of them take place in low and middle income countries.3 Even with the growing evidence supporting the benefits of PA, a large proportion of the population does not achieve recommended levels of PA in both developed and developing countries.4 The burden of chronic disease in
Reis is with the Dept of Physical Education, Pontiff Catholic University of Parana, Curitiba, Brazil. Hallal is with the Postgraduate Program in Epidemiology, Federal University of Pelotas, Brazil. Parra, Brownson, and Hoehner are with the Prevention Research Center in St. Louis, George Warren Brown School of Social Work, Washington University in St. Louis. Brownson is also with the Alvin J. Siteman Cancer Center, Washington University School of Medicine, Washington University in St. Louis. Ribeiro is with the National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA. Pratt is with the National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA. Ramos is with the Dept of Preventive Medicine, Federal University of So Paulo, So Paulo, Brazil.

different populations has led governmental health agencies to recognize the need for actions to increase PA at the population level.5,6 Evidence from systematic literature reviews has demonstrated that population-based-interventions may be effective to promote increases in physical activity levels.7,8 Moreover, community based interventions are costeffective when compared with other strategies.9 Despite this growing body of evidence, limited information on the effectiveness of community physical activity interventions is available in Latin America.10 Project GUIA (Guide for Useful Interventions for Physical Activity in Brazil and Latin America) was initiated in October 2005 to build cross-national, collaborative relationships with researchers, practitioners, and institutions in Brazil and the United States. The goal of GUIA is to enhance capacity to identify and evaluate evidence-based interventions that promote PA at the community level in Latin America, with a particular focus on Brazil. A systematic review identified 3 promising new community based intervention strategies for increasing population levels of PA, including delivery of short PA-related messages, PA classes in community settings, and community-wide policies and planning.10 The current study of PA promotion programs in Curitiba is an evaluation of the community-wide policies and planning Strategy. Based on the results of the systematic

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S138 Reis et al

review, 2 community-based interventions were selected to be evaluated: the Academia da Cidade Program (city gyms), in the city of Recife, in northeast Brazil,11 and the interventions taking place in the city of Curitiba, including the program CuritibAtiva. A comprehensive evaluation of the PA promotion programs in Curitiba (using both qualitative and quantitative methods) was recently conducted.12 The evaluation included the development of a logic model using a participatory approach,13 an historical evaluation of the PA programs in Curitiba, and the use of a direct systematic method to observe physical activities in community recreation settings (SOPARC).14 A separate component included an analysis of the perceived environment and its association with physical activity.15 In this paper, we describe participation in and knowledge of community based PA programs delivered to the citys population and explore the association between both participation and knowledge with leisure-time PA.

ment and SES) were produced and compared in a matrix allowing the classification of the 75 neighborhoods into 9 different strata. The overall sampling frame was comprised of 337,127 eligible phone lines (classified according to the strata). The sample was drawn to obtain geographic representativeness and variability of urban characteristics with 1000 subjects distributed across all 9 strata and another 1000 people distributed in the 4 extreme strata. After random selection the final sample was composed of 2097 respondents (a 60.5% response rate).

Measures and Data Collection

The questionnaire was pilot tested before data collection. The questionnaire was modeled after a similar instrument used in the evaluation of a PA promotion program in Recife, Brazil.11 Data were collected by telephone interviews conducted by experienced interviewers, who received a two-day training. The protocol was approved by the institutional review boards at the Pontiff Catholic University of Parana in Curitiba and Washington University in St. Louis.

Methods
Population and Study Design
Curitiba is in southern Brazil and is the 7th largest city in the country. It is internationally recognized for its creativity in facing common problems associated with urban development (eg, traffic congestion, loss of public space, and adverse environmental impacts) typically found in large urban agglomerations across Latin America.16,17 A cross-sectional random-digit-dial telephone survey was conducted between May and June 2008. Eligible respondents were individuals 18 years or older residing in Curitiba for at least 1 year at the time of the survey. The primary sampling units were all 75 neighborhoods of the city, which were classified in 9 strata based on a built and social environment score. Built environment information was obtained through the City Urban Planning Institute18 and was computed using park density (km2/inhabitants), plaza density (km2/inhabitants), bike lane density (Km/inhabitants), and sports and leisure department units (# units/inhabitant). Socioeconomic status (SES) was determined based on the median family income obtained from the Brazilian Institute of Geography and Statistics19 Crime rate (crimes/1000 inhabitants) and traffic accident (accidents/1000 inhabitants) data were collected from the Curitiba Urban Planning Institute;20 and these variables were used as social environment indicators. To compute the built and social environment score, the original variables were standardized to a common scale (from 0100). Scores for each component (eg, park density) were added to produce a single total score representing the built and social environment for each neighborhood. These indicators were based on previous research and evidence from Latin America indicating that particular characteristics of the built environment are associated with PA levels,21,22 Finally, tertiles for each score (built and social environ-

Physical Activity Interventions in Curitiba

Physical activity programs in Curitiba have a close relation with the citys characteristics. These characteristics are result of several policy and environmental changes implemented in the urban planning. Curitiba has a long tradition of innovative and integrated urban planning toward the strategic of making the city a better place to live. For instance, in 1970, there was less than 1 m2 of green space per person; now there are 52 m2 for each person. Flood waters diverted into new lakes in parks solved the problem of dangerous flooding and provided aesthetic and recreational value to the people who use city parks.23 Another key element in this process is the integration of public transportation and land-use regulation providing access to several recreational facilities in which PA services are provided. Various PA promotion programs carried out in Curitiba are implemented and monitored by the Municipal Sports and Leisure Secretary and the Municipal Health Secretary. These departments coordinate and promote public physical activity programs throughout the city free of charge to the population. The activities offered are mostly carried out in public (free access) recreation facilities, including sports and leisure department units (that usually include a gymnasium, an exercise room, and/or a pool), plazas, and bicycling and walking paths.24 A complete description of these programs can be found elsewhere.13

Physical Activity Outcomes

PA was assessed with a culturally adapted long version of the International Physical Activity Questionnaire (IPAQ).25 The cultural adaptation included examples of

Promotion of PA in Brazil S139

physical activities usually performed in the Brazilian context and the use of plain language so people with low literacy levels could understand all the questions. Validity and reliability of the long IPAQ has been tested among adults in 12 countries, including Canada, United States, Brazil, and Guatemala.26 Although the long IPAQ covers 4 domains of PA, only leisure time and transport-related physical activity were used for this study. Respondents reported time per day spent walking and/or engaging in moderate and/or vigorous PA during leisure time and also time spent walking or bicycling as a means of transportation. The use of these 2 domains of IPAQ has been validated with accelerometers in a Brazilian population.25 Participants were classified according to the current recommendations for PA.27 A score for leisure-time physical activity (LTPA) was computed by adding minutes per week of walking, minutes per week of moderate PA, and minutes per week of vigorous PA multiplied by 2.28 Respondents were classified into 2 categories, meeting recommendations (those achieving at least 150 minutes per week of LTPA) and not meeting recommendations (0149 minutes per week of LTPA). Total minutes per week spent walking during leisure time (walking for leisureWLEIS) was used as a separate outcome variable and respondents were also classified into the 2 categories mentioned earlier.

Covariates
Demographics and other individual variables were collected and used in the analysis as potential confounders: age in years, classified into 3 categories, 1834 years, 3554 years, and 55 years and older; skin color, classified as white versus other; education level, categorized into 3 categoriesless than high school, high school, and more than high school according to the last level of education completed; marital status, classified as single versus others. We also included car ownership as a covariate using it as a proxy for socioeconomic status. We categorized this covariate into 2 categories, no car versus 1 or more cars in the household. Finally, we included perceived health status as a control variable, classified into poor or fair, good, and very good or excellent.

Data Analysis
Differences between categorical variables were compared using Chi square tests (2) for heterogeneity and linear trend. Logistic regression analyses were used to test the association between knowledge of and participation in PA programs in Curitiba and meeting recommended levels of PA for both LTPA and WLEIS. All the models were adjusted for age, skin color, education level, marital status, self-reported health status, and car ownership. Descriptive and regression analyses were weighted and stratified by gender. Analyses were conducted with SPSS 16.0.

Knowledge of and Participation in Community Physical Activity Programs

Two questions were used to assess knowledge of and current participation in physical activity programs promoted by the city administration: (a) Which of the following physical activity programs promoted by the Prefeitura Municipal de Curitiba (City administration) do you know about or have you heard of? and (b) Do you participate in any of the following physical activity programs promoted by the Prefeitura Municipal de Curitiba? For each question respondents were asked to indicate yes or no to the 5 main components of Curitibas community PA programs, which are Fitness assessment and physical activity counseling during the citys public service fairs, educational brochures, PA classes/city gyms at the sport and leisure department units or the regional city hall centers, Curitibas Marathon, and PA classes (e.g. walking) at the primary care health units. Responses for each question were summed and a score from 0 (no to all 4 questions) to 4 (yes to all) was obtained. These scores were categorized into 2 binary variables using 0 (no to all) versus 1 (combining scores 1 to 4) using Ever heard about the program and Current participation as reference variables. Finally, 1 question about previous participation was also used and respondents were asked to respond yes or no to the following question: (c) Have you ever participated in any of the PA programs promoted by the City Administration of Curitiba or used the public recreational facilities?

Results
The sample was predominantly female (63.7%), 41.8% were in the age category of 3554 yrs, and 40.1% reported an educational level of completing high school. Most subjects in the sample were married (58.2%), perceived their health as good (45.4%), and had at least 1 car in the household (76.4%). For all SES variables, significant differences were observed between males and females (Table 1). The proportion of subjects who ever participated in any of the PA programs in Curitiba was 11.0% in the general sample; women (12.4%) were more likely than men (8.7%) to report ever participate (Table 2). Current participation in the programs was reported by 5.6% of the subjects; although the differences were not large, they were statistically significant between men (4.4%) and women (6.3%; P < .001). More than 90% of the subjects reported they had heard about the ongoing physical activity programs in the city; no significant differences were observed between men and women. Current participation in the programs was positively associated with age (Table 2). Previous and current participation were inversely associated with education level and were more frequent among subjects in the lowest education category. Having heard about the programs was more frequent in the highest education category. Previous and current participation proportions were higher

Table 1 Description of the Sample Characteristics by Gender, Curitiba, Brazil, 2008

Variable Socio-demographics Age 1634 3554 55+ Skin color Education level White Other < High-school High-school Grad College or more Marital status Married Single Other Perceived health Poor/regular Good Very good/excellent Car ownership None 1 or more 31.5 45.0 23.5 64.8 35.2 28.6 40.1 31.3 68.2 24.7 7.2 22.8 47.7 29.5 23.6 76.4 29.4 39.9 30.7 67.6 32.4 37.4 33.3 29.4 52.6 25.1 22.3 28.9 44.1 27.0 35.2 64.8 P < .001 P < .001 P < .001 P < .001 P < .001 P < .001 30.2 41.8 28.1 66.6 33.4 34.2 35.7 30.1 58.2 25.0 16.8 26.7 45.4 27.9 31.0 69.0 Category Male (%) (N = 768) Female (%) (N = 1329) P All (%) (N = 2097)

Table 2 Sample Characteristics by Knowledge and Participation in the Curitiba Community Physical Activity Programs, Curitiba, Brazil, 2008 (N = 2097)
Ever participated (%) 8.7 12.4 11.0 9.8 14.1 11.6 9.9 11.6 9.5 10.7 10.6 11.1 12.6 9.5 10.7 13.0 11.3 10.3 P < .001 P < .001 P < .001 P < .001 P < .001 P < .001 P < .001 Chisquare (P) Current participation (%) 4.4 6.3 3.8 6.9 8.1 5.5 5.6 6.0 4.1 4.5 6.4 4.6 4.6 4.9 5.5 6.4 7.8 4.8 P < .001 P < .001 P = .004 P = .005 P = .042 P < .001 P < .001 Chisquare (P) Ever heard about the program? (%) 91.8 91.7 91.2 94.4 89.5 92.4 91.7 90.0 92.6 93.4 93.6 90.2 90.6 90.4 91.9 94.1 91.9 92.2 P < .001 P < .001 P < .001 P < .001 P < .001 P < .001 P = .979 Chisquare (P)

Variable Socio-demographics Gender Age

Category Male Female 1634 3554 55+

Skin color Schooling

White Other < High-school High-school grad College or more

Marital status

Married Single Other

Perceived health

Poor/regular Good Very good/excellent

Car ownership

None 1+

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among those 55 years and older, having heard about the program was less frequent among this same age group. Table 3 presents data on LTPA and WLEIS by former or current participation and knowledge about physical activity programs in Curitiba. In every comparison, those who currently participate or are aware of the physical activity programs in Curitiba were more active compared with those who did not participate or know about the programs. Adjusted prevalence odds ratios (PORs) for meeting physical activity recommendations during LTPA among former participants of the programs, were 1.5 for men, 1.4 for women, and 1.4 for the whole sample (Table 4). Similar associations were found for walking for leisure but these were stronger for males (POR = 1.4) than for females (POR = 1.1). Men who were current participants in the physical activity programs had more than 3 times the odds of meeting physical activity recommendations during leisure time as compared with those who did not participate. The equivalent POR for females was 2.9 (Table 4). Similar findings were observed for the outcome walking for leisure, albeit the magnitude of the effect was even greater among males. Having heard about the programs was associated with increased odds of meeting physical activity recommendations among males (POR = 1.8) but not among females (POR = 0.8).

Discussion
This study described participation in and knowledge of community PA programs and explored their association with leisure-time PA and walking for leisure in the city

of Curitiba, Brazil. There are only a few documented evaluations of community based PA programs in Latin America.10,11 We found that 9 out of 10 people in Curitiba knew about the programs promoted by the city administration. Although measurement approaches differ, a higher prevalence of knowledge of the citys programs was found in this study as compared with other PA promotion programs from Brazil. An evaluation of Agita Sao Paulo, one of the best documented programs in Brazil, which takes place primarily in the State of Sao Paulo, showed that the program is recognized by 39% of the states residents.29 In Recife, Brazil, where the community PA program Academia da Cidade was recently evaluated by project GUIA, 61.7% of the population reported knowledge of the program.11 However, these comparisons are limited due to the fact that in Curitiba reported knowledge is of any city PA program while in Sao Paulo and Recife the questions regarding knowledge referred specifically to the branded programs Agita Sao Paulo29 and Academia da Cidade.11 The PA promotion programs in Curitiba offer a combination and variety of activities rather than emphasizing a program trademark or brand,13 thus explaining the higher recognition of city supported activities in general instead of a specific name. This finding is partially supported by other qualitative research conducted in the city showing that 75% of people reported seeing any PA promoted by the municipality, while less than 1 percent recognized a specific program name.30 Knowledge was greater among younger people, those with the highest education level, and among participants who reported having a car. This finding is consistent with the available evidence suggesting that awareness of PA messages and programs is greater among people in higher

Table 3 Physical Activity and Walking for Leisure Levels by Past and Current Participation and Knowledge About the Program, Curitiba, Brazil, 2008 (N = 2097)
Leisure-time physical activity Physical activity categories Ever participated? No Yes Current participation? No Yes Ever heard? No Yes 73.8 69.2 26.2 30.8 P < .001 86.1 85.0 13.9 15.0 P < .001 70.5 47.5 29.5 52.5 P < .001 85.8 70.2 14.2 29.8 P < .001 70.0 62.4 30.0 37.6 P < .001 85.3 82.2 14.7 17.8 P < .001 Not meeting recommendations (0149 min/week) Meeting recommendations (150 min/week) Chisquare (P) Walking for leisure Not meeting recommendations (0149 min/week) Meeting recommendations (150 min/week) Chisquare (P)

Table 4 Crude and Adjusted Odds Ratios of Participation and Knowledge About the Physical Activity Programs for Meeting 150 Min/ Week on Leisure Physical Activity and Walking for Leisure, by Gender, Curitiba, Brazil, 2008
Leisure-time physical activity 95% CI P POR (adjusted) 95% CI P P 95% CI 95% CI POR (crude) POR (adjusted) P Walking for leisure

S142 1 (1.51.6) 1 (1.41.5) 1 (1.31.4) P < .001 1.5 (1.31.4) P < .001 1.2 (1.21.3) 1 P < .001 P < .001 1.4 (1.41.5) P < .001 1.1 (1.11.2) P = .009 1 1 1.1 1 1.1 P < .001 1.3 (1.21.3) P < .001 1.4 (1.41.5) P < .001 1.4 1 1 (1.41.5) (1.01.1) (1.11.2) P < .001 P < .001 P < .001 1 (3.03.3) 1 (2.62.7) 1 (2.91-3.05) P < .001 2.9 (2.93.0) P < .001 P < .001 2.9 (2.82.9) P < .001 1.4 1 2.5 (2.52.6) P < .001 1 (1.41.5) P < .001 P < .001 3.2 (3.13.4) P < .001 7.0 1 (6.77.3) P < .001 1 7.0 1 1.4 1 2.4 (6.77.3) (1.41.5) (2.32.4) P < .001 P < .001 P < .001 1 (1.61.7) 1 (1.01.0) P < .001 1.0 1 (1.21.3) P < .001 1.3 P < .001 2.0 (1.92.) (1.01.1) (1.21.3) P < .001 P < .001 P < .001 1 1.7 1 0.8 1 1.1 (1.071.13) P < .001 (0.80.9) P < .001 (1.61.8) P < .001 1 1.8 1 0.8 1 1.0 (1.71.9) (0.80.9) (1.01.1) P < .001 P < .001 P < .001

Categories Ever participated?

POR (crude)

Men

No

Yes Women

1.6

No

Yes All

1.4

No

Yes Current participation?

1.4

Men

No

Yes Women

3.1

No

Yes All

2.6

No

Yes Ever heard about the program? Men

2.64

No

Yes Women

1.6

No

Yes All

1.0

No

Yes

1.2

Note. Odds ratios and 95% confidence interval are adjusted for age, ethnicity, education, marital status, health perception, and car ownership; 1 = Crude Prevalence Ratio; 2 = Adjusted Odds Ratio.

Promotion of PA in Brazil S143

socioeconomic groups.11 This pattern is also observed in Brazil with other health indicators such as perceived health status,31 chronic disease,32 and PA,28 suggesting important health knowledge disparities. Current and previous participation in PA community programs were higher in Curitba compared with the participation reported in the evaluation of other PA promotion programs in Brazil. For example, current and former participation in the Academia da Cidade in Recife were 1.9% and 3.9% respectively compared with 5.6% and 11.0% in Curitba.11 Another study conducted in Curitiba33 demonstrated a participation of 15% in PA community programs which supports the relatively high prevalence observed in our study. Overall, our results showed a high prevalence of recommended levels of PA in leisure time (31.2%) as compared with data from other regions of the country34 and other developing countries.4,35 These comparisons are limited due to the use of different methods to measure PA levels across the cited studies. The prevalence of walking for leisure (15.1%) was similar to that observed in Pelotas, a midsized city in southern Brazil, where a walking prevalence of 15% using the same cut points was reported.36 We also explored the association between participation in and knowledge of the PA programs with LTPA. We found that current participants and those who ever participated and who had ever heard about the programs were more likely to achieve recommended physical activity levels in leisure time. This association was still significant after controlling for potential confounders. This association has also been documented by other studies, both cross-sectional11 and prospective.37,38 This finding may be explained by the fact that an important characteristic of Curitibas PA programs is the use of free public facilities which are distributed across all 9 regional districts providing high accessibility.13 This unique environmental aspect coupled with the high awareness of the programs demonstrated in our results suggests a high exposure of the population to the city sponsored PA programs. The associations found in this study were stronger for walking during leisure time compared with overall LTPA. This could be due to the fact that walking is the most common type of PA reported by the population of Brazil34,36 and it could be easier to adopt than higher intensity activities.39 We hypothesized that the association with PA programs would be stronger for walking for leisure in part because the most common facilities available for the PA programs in the city, are parks that have walking paths and trails. The effects of participation, current and previous, were stronger for men than for women in all PA categories. A community PA intervention conducted in United States found similar result with stronger effects for men than women, consistent with our findings.40 Furthermore, studies in Brazil have consistently documented that men are more likely to engage in LTPA compared with women.4,34 This difference may be partially explained by

gender differences in utilization of public PA facilities and programs. A separate analysis conducted among the sample population of this study, found that accessibility to PA facilities was associated with LTPA among men but not among women.15 Some methodological aspects of this study should be considered while interpreting the results. Self-report physical activity surveys may overestimate actual PA levels. However, IPAQ has been used in other studies in Latin America with acceptable reliability,26 particularly the estimates for LTPA.25 We also employed the most recent PA recommendation for adults which41 add valuable information in terms of predictors of PA compliance. Causal relationships between exposure to and knowledge of PA programs and participation in LTPA cannot be established due to the cross-sectional nature of the data. Nonetheless, indicators of exposure, knowledge, and participation related to the PA programs in Curitba show consistent associations with PA regardless of gender and other potential confounders. The large sample size of this study allowed the use of different analytic procedures by providing adequate power for multiple comparisons and covariates. This study is an important addition to the evidence suggesting that community-based PA interventions combining environmental and policy strategies with educational and behavior change strategies can increase population levels of physical activity. It is especially important as it is one of the very few studies which have addressed this issue in the context of urban areas in middle-income countries. It also directly assesses the community wide policies and planning category of PA interventions identified as an important strategy in Latin America by the Project GUIA systematic review.10 The incorporation of a mix of individual and environmental measures was used in the analyses reported in this paper; quantitative and qualitative methods as employed in the overall evaluation of PA promotion programs in Curitiba appears to be very useful if we are to better understand multicomponent community interventions which involve integrated approaches to improving urban infrastructure, health, equity, and quality of life.

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