Artigos

Introduction
The regular practice of physical activity is associated with reduced risk of mortality1 and non-communicable diseases (NCDs)2, better quality of life and sleep3, and improved physical and mental well-being4. However, physical inactivity is high around the world5, it being the fourth highest risk factor for global mortality6. Moreover, it is important to remember that the practice of physical activity is a complex behavior influenced by biological, psychological, interpersonal, cultural, environmental, and social support factors7.
The interest in verifying health inequalities has grown in recent years8, especially related to leisure-time physical activity (LTPA) among men and women9, given that men tend to be more active in this realm10. A study which verified gender differences in physical inactivity in 142 countries identified that a 4.8% reduction in physical inactivity among women around the world would be enough to reach the World Health Organization (WHO) goal of reducing the global level of physical inactivity until 20259. In a more recent publication, the WHO expanded this target of reducing the global level of physical inactivity by 15%11.
Investigating LTPA is important because this domain is more related to pleasurable, cultural meaning, which ultimately impacts people's willingness to engage in physical activity, than other domains such as work and domestic-based activities, for which physical activity is likely to be associated with a necessity12. To plan actions which promote LTPA, it is imperative to reflect on the context of countries that present a high social inequity, as in the case of Brazil, which can in fact impact gender inequality13. The role attributed to women, who are generally held responsible for family care and housekeeping, and their insertion in the formal labor market, with many accumulating double shifts because of domestic work, considered to be a responsibility of women rather than of men, may also influence in terms of the free time available to practice LTPA14,15.
In Brazil, studies demonstrated inequalities in the practice of LTPA between men and women16-19. A temporal series study analyzed the four domains of physical activity (leisure, occupational, transportation, and domestic), with representative data from Brazilian state capitals and from the Federal District, observed that the only domain which showed an increase was leisure, for both sexes18. Another study, which also used data from Brazilian capitals and focused on LTPA, verified an increase in the practice of physical activities in both sexes, and that the increase was higher among women, reducing inequality, even though it was not enough to reach the same levels as among men17.
The justification for this study is based on an approach which is more specific about gender inequality, thus shedding light on the power relationships between men and women, which generate, in most cases, negative consequences for women, as occurs in the case of LTPA. By adopting a more specific approach, strategies may be identified and more properly aimed at fighting gender inequality in terms of presenting differentiated opportunities for women with the goal of correcting injustices in access to LTPA. Moreover, this study used data from the most recent reports by VIGITEL, allowing for a more updated analysis of the inequalities between sexes in the domain of free time. Finally, this study presents data from Brazil, one of the most populous countries in the world and one of the few countries considered to be medium-high income20. Brazil also has an advanced surveillance system to identify NCDs and is considered as one of the most promising countries in terms of monitoring those diseases21.
The present study aimed to write the absolute and relative differences in the recommended practice of LTPA of Brazilian men and women (?18 years) between 2010 and 2019, to verify the differences between the sexes according to age group and schooling, and to analyze the trends of these differences over the period.
Methods
Data from 512,968 individuals were used, from ten cross-sectional telephone surveys in the 27 Brazilian state capitals from 2010 to 2019. The inquiry “Surveillance System for Risk and Protective Factors for Chronic Diseases by Telephone Survey” (VIGITEL, in Portuguese) has taken place annually since 2006 and uses probabilistic samples of the Brazilian adult population (?18 years of age) from every state capital of Brazil, through the telephone directory of those cities22. The smallest sample was collected in 2014 (n=40,853) and the largest in 2010 (n=54,339), with an annual average of approximately 51,000 participants.
Every year, the initial sampling phase consisted of the drawing of at least five thousand telephone lines in each capital. Later, to reproduce the distribution in the original directory, the chosen lines were organized in replicas of 200 lines. Finally, the confirmation of validity of the chosen lines was conducted, and one adult member residing in each home was randomly selected22.
Individualized databases available in the site of the Brazilian Ministry of Health were used in the analysis22. To correct possible sampling bias, a post-stratification weight was applied to adjust difference in the probabilities of the selection of interviewees related to the quantity of adults and of telephone lines in each home and the sociodemographic make-up of the population served by home telephone lines in each town, in each year of the survey.
VIGITEL has information regarding physical activity in the four domains. In the current study, only information related to the LTPA was considered. We should mention that the reason for choosing LTPA was due to the domain in which public policies may play an important role in promotion, and it is in this domain that individuals can express their experiences related to pleasure in physical activity13. Therefore, the dependent variable was the recommended practice of LTPA, defined in VIGITEL at least 150 minutes of moderate intensity physical activity, or at least 75 minutes of intense and vigorous activity per week. Such criteria follow the recommendation of the WHO23. The variable was accessed based on two questions: “In the last three months, have you practiced any kind of exercise or sport?” In the case of a positive answer, other questions were asked: “What kind of physical exercise or sport have you practiced?”; “Do you exercise at least once a week?”; How many times a week do you practice exercises or sports?”; “When you practice sports or exercises, how long do you practice?”22. Walking, walking on treadmill, weightlifting, water aerobics, gymnastics, swimming, martial arts, bicycling, volleyball or kick volleyball, and dancing were classified as moderate intensity activities. Running, running on a treadmill, aerobics, soccer, basketball, and tennis were classified as vigorous intensity activities22.
The use of VIGITEL and its indicators for surveillance of physical activity has been previously described24,25. Study conducted in the city of São Paulo identified good indicators of reproducibility and accuracy of physical activity measurements25. Similarly, a study conducted in Belo Horizonte evaluated the reproducibility and validity of the VIGITEL physical activity indicators and identified that the questionnaire used is suitable for analysing the practice of physical activity in adults26.
The prevalence of LTPA was calculated for men and women in the total sample, by age group (18 to 24; 25 to 34; 35 to 44; 45 to 54; 55 to 64; and ?65 years) and by education level (0 to 8; 9 to 11; and ?12 years). In the total sample, the prevalence of LTPA for men and women was adjusted by age groups and education level, in the age groups the prevalence was adjusted by educational level, and in the educational level the prevalence was adjusted by age groups.
To estimate inequality in the recommended practice of LTPA between sexes, two measurements were calculated: 1. Absolute differences were calculated by subtracting the prevalence of women from the prevalence of men, presented in percentage points. The calculation of that measure is important to show the magnitude of the difference, or the “distance” of the outcome between sexes8. 2. Relative differences in the recommended practice of LTPA between men and women based on the Prevalence Ratio (PR) using Poisson regression, with robust variance, and the 95% Confidence Intervals (95% CI). That measurement shows the proportional difference of the prevalence of the outcome between sexes8. For the temporal trend analysis of this measurement, Joinpoint regression was applied, which allows one to identify the outcome tendency, the modification points, and the Average Annual Percentage Change (AAPC). This model analyzes a series of straight lines in a logarithmic scale to identify trends in the annual value of the indicator. If there is a Joinpoint, the result indicates a significant change in the straight line27. For this analysis, the dependent variable was defined as the PR of the recommended practice of LTPA between men and women, while the independent variables were defined as the year of assessment. The final models considered the number of statistically significant inflection points within a 5% significance level. For both regression models, the 95% CI was considered. Positive and negative values indicate increases or decreases in trends, respectively.
The data was tabulated and analyzed by Microsoft Excel® 2013, Statistical Package for the Social Sciences (SPSS), version 19.0, and Stata version 14.2. For the tendency analysis, the Joinpoint Regression Program, version 4.9.1.0 and the method Grid Search were used. The results presented graphically were built by using “equiplots” (http://www.equidade.org/equiplot), where each point of the graph represents the prevalence of the recommended practice of LTPA among men and women, and a horizontal line represents the absolute difference in percentage points.
The VIGITEL procedures were approved by the National Commission of Research Ethics from the National Health Council (CAAE: 65610017.1.0000.0008) of the Brazilian Ministry of Health. The interviewees’ consent was obtained orally at the time of the telephone interviews22.
Results
Most of the sample was made up of women (62.4%). There was a lower proportion of young individuals (18 to 24 years of age) (13.3% men and 8.6% women) and a higher proportion of individuals ?65 years of age (18.9% men and 25.3% women). In terms of education, the sample had a higher percentage of individuals with up to 8 years of education (25.3% men and 29.7% women), as well as a higher proportion of individuals with intermediate education (38,0% men and 35.2% women) and with 12 or more years of education (36.7% men and 35.1% women), for both sexes (Table 1).


Table 1- Sociodemographic characteristics of men and women (?18 years) from Brazilian capital cities and the Federal District, VIGITEL, 2010-2019 (n=512,968).






INSERT TABLE 1








Source: VIGITEL.



In general, men were more active than women. When comparing the absolute differences in LTPA practice between men and women by age group, it was observed that the largest inequalities occurred in younger age groups. In the 18 to 24, 25 to 34, and 35 to 44 years of age groups, a significant difference was found in the prevalence of LTPA among men and women in each analyzed year. However, that changed in the 45 to 54 and the 55 to 64 years of age groups, in which the smallest inequalities were observed. Moreover, in those two age groups, in most years, no significant difference was observed. Among the oldest group (?65 years of age), the difference increased, and was less significant in the majority of the years (Figure1).

Figure 1-Absolute difference in LTPA recommended practice between men and women in Brazilian capitals, according to age group, VIGITEL, 2010-20191.


INSERT FIGURE 1

Source: VIGITEL. 1Prevalences adjusted by level of education; *Significant differences between the prevalence of LTPA in men and women verified using the 95%CI of the prevalence.


Lower prevalence was observed in individuals with lower levels of education and higher prevalence among those with the highest level of education, considering that the absolute differences were observed in those with a lower level of education. This difference is due mainly to the low prevalence of LTPA in that group (Figure 2).


Figure 2- Prevalence of LTPA recommended practice among men and women in Brazilian capitals, according to education level, VIGITEL, 2010-2019¹.


INSERT FIGURE 2

Source: VIGITEL (2010-2019); ¹Prevalence adjusted by age group; *Significant differences between the prevalence of LTPA in men and women verified using the 95%CI of the prevalence.

Regarding the gap of the relative measure according to age group, we observed that men had a higher level of LTPA among individuals aged 18 to 44 years in each period studied. In the other age groups, these differences were not significant in all years, as in the case of the 55-64 age group (Table 2).
In the total sample, the largest relative difference was in the first year (2010) (PR=1.90; 95% CI:1.80-2.06) and the smallest in 2017 (PR=1.36; 95% CI:1.30-1.42). In terms of age group, the largest difference was observed in younger individuals, in 2010 (PR=3.19; 95% CI: 2.67-3.78), and the lowest in individuals aged 55 to 64 years in 2014 (PR=0.96; 95% CI: 0.83-1.12). When compared to 2010, a smaller difference was observed from 2012 onwards, in the two younger age groups (18 to 24 years and 25 to 34 years). However, from 2012 on, a smaller difference was observed only in the oldest individuals (?65 years of age) in 2014 (PR=1.10; 95% CI: 0.94-1.28) (Table 2).
In regards of education, the smallest relative difference was in 2014, among the individuals with the lowest level of education (PR=1.13; 95% CI: 0.98-1.27), and the largest in 2010, among those with intermediate level of education (PR=2.08; 95% CI: 1.93-2.25). Men were more active than women in all categories of education in all years. Only in 2014, among individuals with the lowest level of education, the difference proved to be insignificant. When compared to 2010, the difference was smaller from 2012 on among individuals with an intermediate level of education (PR 2010=2.08; 95% CI: 1.93-2.25; PR 2012=1.66; 95% CI: 1.54-1.78) and with lowest level of education (PR 2010=1.99; 95% CI: 1.74-2.31; PR 2012=1.49; 95% CI: 1.33-1.69). When comparing 2012 with the following years, the smallest differences can be observed in 2014 and 2017 among individuals with lowest level of education (PR=1.13; 95% CI: 0.98-1.27 and PR=1.18; 95% CI: 1.04-1.32, respectively) (Table 2).

Table 2- Prevalence Ratio (PR) of the recommended practice of LTPA for men and women (?18 years) of the Brazilian capitals, stratified by age range and education level, VIGITEL, 2010-2019 (n=512,968).


INSERT TABLE 2

Source: VIGITEL; 1Adjusted by age range and education level; 2 Adjusted by education level; 3Adjusted by age range; 4PR: Prevalence Ratio
(Prevalence men/Prevalence women); 595% CI: 95% Confidence Interval.








The Jointpoint analysis verified a tendency of reduction in inequality in the practice of LTPA between the sexes (PR) in the period from 2010 to 2013 in the overall sample (APC = -8.7%; 95% CI: -14.8; -2.1), in individuals aged 18 to 24 years (APC=-16.6%; 95% CI: -22.3; -10.6), and those with a low level of education (APC= -14.6%; 95% CI: -25.8; -1.8). In the individuals aged 35 to 44 years, a decrease was identified in the period from 2010 to 2017 (APC=-2.3; 95% CI: -4.0; -0.7), while among those with a low level of education, a decrease was observed from 2010 to 2014 (APC=-3.5%; 95% CI: -6.3; -0.6). Only among individuals with an intermediate level of education was this decrease considered significant between 2012 and 2019 (APC= -2.2%; 95% CI: -3.9; -0.4). Considering the entire period of the study (2010-2019), a declining trend was found in inequalities in the overall sample (AAPC=-3.5%; 95% CI: -5.3; -1.1), in individuals aged 18 to 24 years (AAPC=6.3%; 95% CI: -8.4; -4,1), among those aged 25 to 34 years (AAPC= -4.1%; 95% CI: -8.0; -1.0), and among those with an intermediate level of education (AAPC= -4.1%; 95% CI: -6.2; -1.8) (Table3).
Table 3 – Analysis of the temporal trend calculated by Joinpoint Regression of the relative inequality in the practice of LTPA among men and women from the 26 Brazilian capital cities and the Federal District, 2010-2019.


INSERT TABLE 3




1APC: Annual Percentage Change - Period 1
2APC: Annual Percentage Change - Period 2
3AAPC: Average Annual Percentage Change

Discussion
The larger absolute and relative differences in LTPA between men and women were observed in the youngest individuals. In comparison to 2010, the relative inequality was lower from 2012 on, in the overall sample, among the youngest (18 to 34 years of age) and among those with an intermediate and a low level of education. However, when comparing 2012 with the following years, a smaller relative difference was only observed in 2014 and 2017. In terms of education, smaller relative differences appeared in the intermediate group, while the absolute differences were smaller among those with a low level of education. A significant decrease was observed in the relative inequality in the overall sample in the two youngest age groups and among individuals with an intermediate level of education.
The analysis of gender inequality LTPA over a period of ten years is a strength of this study. As it is a domain related to preference and opportunity for choices, where its practice is generally carried out during leisure time, being physically active in this domain is often more of a privilege than a right in Brazil12 and when there is a comparison between men and women, according to the results presented, its practice is more restricted to men. Therefore, it is an injustice that, in general, affects women more. Considering that one of the main themes of health promotion is equity, related to social justice14, and one of the main causes of morbidity and mortality from chronic non-communicable diseases is physical inactivity2, the results of this study can be important in the formulation of public policies and in the organization of actions that aim to reduce gender inequalities in the practice of LTPA.
Larger differences, relative and absolute, in the practice of LTPA between the sexes were observed among the youngest in each year studied. Similar results were observed in previous study, where the authors observed greater relative differences of LTPA recommended practice in younger Uruguayan adults (15 to 34 years old)28. The decrease in inequality between men and women in the practice of LTPA is a highly relevant matter in the planning of public policies. This issue involves multiple factors, such as the different roles attributed to gender and social construction, as well as the previous experiences and the different events that occur throughout life, which may influence the adoption of the practice of LTPA29,30. Older men, in general, are more socially encouraged to practice LTPA, while for women, there is a greater obligation to handle family care activities, which end up filling most of the women’s time30.
Another observed result was the fact that the curve in relation to the difference in the practice of LTPA by age group forms a “U” shape, meaning that the difference started larger in the younger age groups (18 to 34 years of age), diminished in the next age groups (25 to 64 years of age), and increased again among the oldest age group (?65 years). This pattern was observed in another study carried out with Brazilian adults, where the prevalence of physical inactivity in free time was higher in women than in younger men (15 to 34 years old), becoming lower in the age groups from 35 to 64 years old and increased again in older people (?65 years)19.
As indicated in Figure 1, the reduction in the difference can be explained more by the decrease in LTPA among men than by the increase in practice among women, indicating a need to encourage better levels of LTPA among women, as well as to promote LTPA in general so that its levels do not drop among men according to their age. In the oldest age group (?65 years of age), the decline was more pronounced among women, which may well explain the increase in difference between the sexes in this age group. Although the practice of LTPA is an important protective factor for older individuals31, the increase in difference may be justified by the fact that older women continue to perform the role of taking care of the husband, children, and grandchildren, making it impossible for them to have a more active life in their free time, although many are retired in that phase of life32.
In terms of education level, the relative difference in prevalence in the practice of LTPA was larger in the intermediate-level education group, whereas the absolute differences tended to be lower in individuals with a low level of education. It is important to highlight that even though the difference is lower among individuals with a lower level of education, that group showed the lowest prevalence in the practice of LTPA. In other words, leisure-time physical inactivity is higher among individuals with a lower level of education, among both men and women, which explains the lowest absolute difference; however, it does not explain the relative difference. Individuals with a higher level of education, although with a larger absolute difference between the sexes, were those who presented a higher prevalence in the practice of LTPA practice. Although the main objective was to reduce inequalities between the sexes, it is important that the initiatives promoting physical activity and a decrease in inequality are also directed towards increasing the prevalence in the groups that are the most inactive during leisure-time activities, as occurs with those who have a lower level of education30. It is also important to mention that even though these results are different in relation to the analysis of inequalities, when they are conducted in a relative and absolute manner, they are not uncommon; this emphasizes the importance of the complementarity of measures.
A trend toward a decline in relative inequality in the practice of LTPA was observed in the overall sample, in the youngest age groups and in the group with an intermediate level of education. If on one hand these results can be considered positive in the sense that they indicate a decrease in inequality between men and women in the practice of LTPA, on the other hand, the largest differences continued in those groups, in terms of age groups and of education. Although previous VIGITEL editions had shown an increasing trend in the practice of LTPA among both sexes22, especially among the youngest individuals, such an increase was not enough to reduce inequality in that age group17. It is also important to note that most of the tendencies with a reduction behavior occurred in the first years analyzed in our study, from 2010 to 2014. In the following years, the measurement presented stability. Although the adoption of the practice of LTPA, as in the case of any other health behavior, is complex and multifactorial, an economic crisis began to affect Brazil and the country had to face problems related to funding for SUS and cuts in public policies, explaining partially the stabilization of the differences34,35.
Therefore, it is important for each region to create local strategies according to their specific needs in order to reduce these differences, including programs for physical activities that are already in place in many Brazilian towns. Such programs may aid in the creation of favorable environments, contributing to a greater adherence to the practice of LTPA among women, in turn reducing gender inequality. These actions may also be important in achieving the goals established by the WHO of diminishing the global prevalence of physical inactivity by 10% until 2025 and by 15% until 203011.
The differences in the practice of LTPA between men and women discussed in this study may be considered gender inequality, in other words, inequality resulting from some form of injustice8,36. Differently from the biological concept of sex, gender is associated with social constructs, which determine the differences in the roles that define what it means to be a man or a woman14,15. One of these differences is the process of the division of labor. Historically, men were entitled with the role of performing paid work and supporting the family. Women were entitled with functions related to private work, caring for the home and family37. In the Brazilian context, if on the one hand the participation of women in the labor market has been a positive aspect, on the other hand, women are still most often responsible for domestic work, often performing a double work shift38. Therefore, gender inequality can be identified in the four domains of physical activity, in which men are only more inactive in the home domain14.
Another aspect to be highlighted is the inclusion of sports or physical exercise as LTPA practices. Surveys such as VIGITEL itself and the Brazilian National Health Survey ask questions about the practice of physical exercise or sport and relate them to LTPA22,39. The Physical Activity Guide for the Brazilian Population characterizes LTPA as a practice carried out during leisure time, based on choices, preferences, tastes, and opportunities. Among the possibilities of practice are physical exercises and sports, such as walking, running, dancing, swimming, cycling, surfing, football, volleyball, basketball, bodybuilding, among others40. This option to consider physical exercise and sport as LTPA practices was also made by other studies17,18,41.
The current study does, however, present limitations. VIGITEL uses telephone surveys to verify levels of LTPA practice among individuals. Since it is based on self-reports, it does not directly measure the practice of LTPA, and it may under or overestimate the real levels. Moreover, another limitation based on self-reports is the gender difference in the self-perception of health, which may also influence the answers42. It is also important to highlight that these interviews ask about the participants’ gender, allowing only two answer options: male or female. Such an approach may hamper the participation of individuals who do not identify themselves with the binary standards, and may compromise the sensitivity of the gender analysis of the results43,44. However, surveys often use self-reported information because it is simple and affordable to use with population samples45,46. The restriction in the VIGITEL sample, of using only individuals with a telephone landline, may be seen as a limitation, since it may affect the sampling representativeness, restricting the participation of a portion of the population, more specifically those with the lowest levels of income. However, VIGITEL itself uses ponderation factors in its data in order to adjust the demographic characteristics of its sample with those of the total population22. VIGITEL does not provide information regarding income and other variables such as access to public leisure spaces, which renders it unfeasible to apply other confounding variables. Finally, there is need for caution with the interpretation of the results of the equiplots based on p-values. Since it is a large sample, with more than 700,000 individuals, some absolute differences may be the same, and yet not be significant. For example, the 45 to 54 age group for the years 2010, 2013, and 2015, shows evidence of when inequality was significant, but in 2016 and 2019, these inequalities were quite similar and no significant differences were identified.
The monitoring of LTPA among women and men may be relevant for the planning of actions that seek to reduce inequalities. It is also important to mention that programs and public policies may contribute in that sense. In Brazil, important public policies have been created in recent years, such as the National Policy for Health Promotion; the Strategic Action Plan for Fighting NCDs in Brazil; the Expanded Center for Family Health and Primary Care, which allows for the contribution of different professionals in the context of primary health care, among other public programs that aim to promote the practice of physical activities. A study which evaluated the participation of the users of those programs shows that the majority are women, a result which may be positive in terms of reducing gender inequality46.
Conclusion
It was observed that the reduction in inequality occurred mainly in the first years of the 2010s, followed by stability in subsequent years. Despite this reduction, the biggest differences remained among younger people. In terms of education, although the decrease in relative inequality was observed in subjects in the intermediate group, the differences remained greater in this group, however, in those with less education, largely due to both sexes having the lowest prevalence of LTPA practice, they had smallest absolute difference.
A large change from one year to the next is not expected in a complex behavior such as the practice of LTPA. More important than the “size” of the reduction from one year to the next is observation over time. Another aspect to be considered is the promotion of physical activity in younger women, as well as in older women, where the absolute difference was greater than in intermediate age groups. In relation to subjects with less education, actions to promote LTPA should focus on both sexes considering the low prevalence observed in both sexes.
Future studies may be able to evaluate the impact of public policies on inequalities regarding the practice of LTPA between men and women, as well as the relationship with those and other indicators, such as economic, violence, female political participation indicators, among others. Furthermore, it is important for studies to carry out intersectional analyzes of factors associated not only with behaviors, but also with other health-related outcomes such as mortality, morbidity, perception of health, access and use of health services, among others.
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