Artigos

Introduction
Family violence refers to interpersonal violence committed against family members or intimate partners, usually, but not exclusively, taking place at home 1. It is an abusive behavior whereby one person gains power over another, resulting in potential harm, harm, or threat to harm 2. Family violence can be manifested by psychological, physical, and sexual abuse or involve neglect or deprivation 1. It is a global public health problem due to its high prevalence and serious health consequences for all victims regardless of their age group 3.
Physical family violence is the most prevalent violence’s nature4. Global estimates of prevalence ranged from 60.2% in Africa to 21.9% in Asia for boys, 59% in South America, and 12% in Europe for girls 4. Evidence has shown that children and adolescents exposed to family violence are exposed a higher risk of post-traumatic stress disorder, adverse psychosocial outcomes, impaired development, and academic problems 5-7. Additionally, they are more likely to adopt risky health behaviors throughout their life 2,8
Physical activity’s benefits for health are well known. To obtain its benefits World Health Organization (WHO) recommends children and adolescents do 60 minutes per day of moderate to vigorous-intensity physical activity across the week, primarily aerobic exercises9. Considering mental health outcomes, physical activity positively controls anxiety and depression and promotes self-esteem in this age group9. However, roughly 80% of global children and adolescents do not meet the WHO recommendations9. Physical inactivity is recognized as the fourth leading risk factor for death causes worldwide10. Besides, according to WHO 2018-2030 global action plan to reduce at 15% the prevalence of physical inactivity in the adult population11, promoting an active lifestyle for adolescents is necessary. Thus, identifying its predictors is required for the development of effective public health programs to meet the WHO’s global plan target. Noteworthy, a systematic review found that exposure to a high level of stress negatively influences the time spent on physical activity, and this time varied according to sex, age, and clinical condition12.
Epidemiological studies about the association between violence and physical activity in children and adolescents focus on bullying, violent behavior, peer violence/injury, and adverse childhood experiences7,13-19. Retrospective cohort of regular students from the USA’s public schools exposed to Adverse Childhood Experiences (ACEs) reported lower physical activity amount than their peers not exposed16. A cross-sectional survey aimed to evaluate the association between health behaviors and exposure to ACEs in adolescents found that those exposed had a lower chance of meeting physical activity’s guidelines17. A populational sample of children and adolescents between 10 and 17 years old from the USA reported an inverse association between exposure to ACEs and physical activity19. A cohort study with adolescents aged between 9 and 10 years old from the USA reported that exposure to ACEs affects aerobic, but not total and anaerobic physical activity18.
However, fewer know regarding the association between some violence aspects and physical activity features. Previous studies do not assess if exposure to violence could differently be associated with total and domain-specific physical activity in children and adolescents. Moreover, it is not known that violence can be associated with adolescents who practice physical activity at variable levels. Studies evaluating violence as ACEs present their results grouping different adverse experiences, making it difficult to disentangle the association of each violence’s nature with physical activity. Furthermore, has a scarcity of research that investigated this association in low-and-middle economic countries. Finally, it is important to point out that there are no studies that evaluate the association between family violence and total and domain-specific physical activity among adolescents.
Therefore, the present study aimed to assess the association between family physical violence and total and domain-specific physical activity in Brazilian adolescents. We hypothesized that the associations between family physical violence and physical activity differ by domains of physical activity, by sex, and are variable according to adolescents’ physical activity levels.
Material and Methods
Study design and sample
We used data from the Brazilian National Survey of Student’s Health (Pesquisa Nacional de Saúde do Escolar – PeNSE), a national representative, school-based survey carried out in 2015. The main objective of PeNSE was to assess the prevalence of risk and protective factors for health in adolescents from public and private schools in Brazil20. Participants were selected by multiple-stage cluster sampling. Primary sampling units were schools and classrooms were second. All students from selected classes were invited to participate in the study. Schools with less than 15 students enrolled in 9th grade and those which had 9th grade only during the night period were excluded. Participants were not included in the study if they did not attend school during data collection, refused to participate or did not report their age and sex. Overall, the PeNSE 2015 sample account included 102,072 students enrolled in 9th grade from the 26 state capitals and Federal District – the sample’s response rate was 97.3%. Our study comprised all 102,072 respondents in the PeNSE 2015.
Data was collected from April to September 2015. Participants responded to a self-administrated, multi-thematic questionnaire through a smartphone. The questionnaire included health risk factors, health behaviors, demographic and socioeconomic characteristics, familiar context, and type of school. Further details of PeNSE can be found elsewhere20.
Instruments
Physical activity time was measured using a validated questionnaire21, including information on the frequency and duration of commuting to and from home-school, leisure-time physical activity, and physical education classes in the last seven days.
Each domain comprises a specific type of physical activity practiced by adolescents daily. Commuting physical activity measures the time spent by adolescents shuttling to and from school. It includes the frequency and roughly the time the adolescent went to school cycling or walking. Leisure physical activity is compounded from activities practiced on the adolescent’s free waketime. It includes participation in a sport team, weightlifting practice, dance, gymnastics, or another physical activity practiced. Physical education refers to the time adolescents spend actively during the physical education class. Each physical activity domain in the week was estimated by multiplying the frequency by the time spent in it.
Total physical activity time (in minutes) per week was calculated based on the sum of each physical activity domain. Adolescents who declared to spend lower than 300 minutes were classified as insufficient active, and those who spent 300 or more minutes of physical activity were classified as physically active9. This classification was used to estimate the prevalence of adolescents meeting WHO’s guidelines and to describe the sample.
Family physical violence was measured through the following single question: “in the last 30 days, how many times have you been physically assaulted by an adult of your family”. Answers options varied from not once to twelve times or more. Adolescents who responded positively at least once in the last 30 days were considered victims of violence.
Demographic and socioeconomic variables were sex, age (in years), ethno-racial identity (white, black, brown/mixed, yellow, or indigenous), and household economic status score. Ethno-racial identity classification is compatible with the Brazilian Institute of Statistics and Geography (IBGE) 22 guidelines. The household economic status score was based on the ownership of the following goods and/or services: ownership of a landline, cell phone, computer, car and/or motorcycle, the number of bathrooms with shower, internet access in-home and hiring of housekeeper three or more times for a week. For each positive answer by these questions were attributed one point. The household economic status was formulated adding each positive answer obtained was a scale from 0 to 10. Participants were classified with three or lower properties and four or more than properties23. The family context included the family structure (living with both parents, single parents, and without father or mother) 24. Variable related to school context was the type of school (public, private).
Statistical analysis
Descriptive analysis was performed to characterize the study sample. Means, standard deviations (SD), proportion and 95% confidence interval (95% CI) were calculated using Stata 15.0 svy25 suite to address the complex sampling structure.
We performed a multivariable quantile regression model to examine the associations of family physical violence with total and domain-specific physical activity. Physical activity was not normally distributed, and the homoscedasticity assumption was not reached. Furthermore, the presence of outliers and an overly skewed distribution of the data would affect the residuals. Thus, quantile regression can accommodate these conditions26. In addition, physical activity variables were zero-inflated (i.e., the lowest positive values were at 60th percentile or higher), therefore coefficients were estimated from the 60th to 85th percentiles by every five centiles by sex. Is common in the physical activity research field that the distribution of physical activity tends to be right-skewed and zero-inflated, representing the high prevalence of individuals which not practice physical activity27. Selection of the adjustment variables was guided by the theoretical model developed from the synthesis of the literature on violence and physical activity (Figure 1). Multivariable models were adjusted by the following potential confounders: age, ethno-racial identity, household economic status, family structure, and school type, due to evidence of their associations with exposure and outcome variables28-31. Quantile regression coefficients express how much a specific quantile of the physical activity distribution is affected, in minutes, across the categories of family physical violence. For instance, the 60th percentile of commuting physical activity in boys exposed to family physical violence was, in minutes, 57.5 minutes higher compared with the 60th percentile in non-exposure boys. Confidence intervals (95% CI) were estimated using 200 bootstrap resampling. The coefficient for each percentile was graphically plotted jointly with their 95% CI. When the 95% CI of a coefficient does not cross the abscissa axis (i.e., the line representing the value 0), it indicates that the populational parameter is not equal to zero considering the level of 5%, suggesting an association between the predictor and outcome variable. The procedure PROC QUANTREG in the SAS On-demand for academics was used for the quantile regression analysis.


Results
Table 1 shows socioeconomic, demographic profile, and prevalence of family physical violence, physical activity practice, and means and standard deviation for each physical activity domains among Brazilian school adolescents.

Table 2 shows the means, standard deviation, and 95% CI of the amount for each physical activity domain practiced by adolescents according to the sex and family violence exposure condition.

The multivariable quantile regression model showed different associations of family physical violence with commuting, leisure-time physical activity, physical education class, and total physical activity for boys and girls (Table 3 and Figure 2 a1 to d2). Overall quantile regressions’ percentiles predictive difference in minutes estimated and 95% CI, for total and domain-specific physical activity by sex is shown in Table 2.
Regarding commuting physical activity, both sexes at the exposure group reported spending more time than those not exposed in all percentiles (Figure 2 a1 and a2).
For leisure-time physical activity, the association between family physical violence differs for boys (Figure 2 b1) and girls (Figure 2 b2). Family physical violence was inversely associated with leisure-time physical activity in boys across the entire percentiles, except at 60th percentile (Figure 2 b1). Girls who were exposed to family physical violence were positively associated with leisure-time physical activity only from 80th percentile (Figure 2 b2).
At the physical education class, exposure to family physical violence was associated with higher physical activity only in 80th percentile in boys (Figure 2 c1), but not in girls (Figure 2 c2).
Finally, exposure to family physical violence was not associated with total physical activity in boys (Figure 2 d1), but exposed girls reported higher total physical activity throughout all percentiles (Figure 2 d2).



Discussion
Results shows that physical family violence affects different specific domains and total physical activity between the sexes. Boys exposed to physical family violence tended to increase commuting and decrease leisure-time physical activity in overall percentiles. Also in all percentiles, exposed girls spend more commuting and total physical activity than non-exposed peers. Exposure positively associations with physical education activity in 80th percentile for boys. Finally, exposure was positively associated with leisure physical activity for girls above the 80th percentile.
Quantile regression analysis allowed an estimate of the association between family physical violence and total and domain-specific physical activity in adolescents in different groups allocated throughout different percentiles. The results support the idea that individuals included in different percentiles could respond differently to the same exposure condition32. The linear regression approach to examining this association assumes that the estimated differences would move along the distribution in the same direction. If we used the linear regression method some associations identified could not be found. However, our research result shows a diversity of coefficients from quantile regressions, suggesting that the association changes over each percentile group. This analytical method should be more adopted in future studies which can better explain how different groups within each percentile particularly respond to exposure conditions.
Our findings showed that all percentiles of family physical violence had a positive relation with commuting physical activity in both sexes. Additionally, Table 2 information shows that in both groups girls and boys practice the same mean time in commuting physical activity. A study that investigated the association of exposure to cumulative ACEs and health behavior during the COVID-19 pandemic using a nationally representative sample of adolescents (range 10 – 14 years) from the USA reported that adolescents exposed to 4 or plus ACEs had few hours by the week of physical activity and least days meeting WHO’s physical activity guidelines33. However, no previous research investigated the relationship between exposure to family violence and commuting physical activity exactly. One potential explanation is that adolescent victims of family physical violence choose to make a longer journey home-school to increase the time spent away from home, where the violence occurs, thus avoiding longer time with the aggressor and the occurrence of new episodes. The COVID-19 pandemic allowed us to visualize the impact of longer time spent together between victim and aggressor and increased violence within the home34. For some children and adolescents, home is not the safest place to be, whereby the higher time the victim spends with the aggressor more vulnerable to conflicts and violence.
Our results showed that boys engaged more in leisure physical activity than girls. It reflects a worldwide reality in which girls report less time doing this physical activity domain than boys35. The strongest evidence for health benefits is from the time engaged in leisure physical activity9. Therefore, it is important to identify evidence-based interventions to promote leisure physical activity in girls, so that they can obtain health benefits. In boys, in the overall percentiles, exposure to family physical violence was negatively associated with leisure physical activity. Quantile regressions’ coefficients allowed us to identify that which higher the percentile, bigger the difference in leisure physical activity between the boys exposed to physical family violence and those not exposed. Research investigating the involvement in fights in the last 12 months and different types of physical activity in a school-based sample of adolescents (15-19 years) from Santa Catarina, a southern state in Brazil, reported that those boys more involved in fight practice more individual and in group physical activity than not exposure36. However, this study used an exposure condition involving a fight with peers, not exposure to family physical violence, which would explain the difference between results.
On the other hand, family physical violence was positively associated with leisure physical activity in girls above the 80th percentile. Noteworthy, using only Table 2 information does not have a difference in leisure physical activity between exposure and not exposure girls. However, quantile regression allowed us to identify the difference only on the higher percentile. This shows that girls who engaged more frequently in leisure physical activity when exposed to family physical violence tend to spend more time doing so. Engaging in regular physical activity has a role in managing stress37, which could stand for emotion-focused coping eliminating displeasure feelings38. Seigel et al., 39 support a behavioral activation theory in which women's exposure to stress-induced conditions could boost physical activity to higher levels, but this response varies by emotional and behavioral traits individual. This mechanism can explain partially the results obtained. Those who regularly respond to practice physical activity to cope with stress report higher exercise behavior than they do not37,39. These results are not corroborated with previous findings. Research of a birth cohort of adolescents (aged 15 at follow-up) from 20 large cities of the USA investigated the association of exposure to community and family violence in childhood (5 to 9 years old) in health behaviors in adolescence, including physical activity, and not identify association8. Harada et al17 investigated the association of exposure to ACEs and weight-related health behavior in a national sample of children (aged 6 to 17 years) from the United States and found a negative association with physical activity daily between exposure for parent divorce, household mental illness, and household substance abuse, but not with domestic violence. However, both researchers used parents as a source of measure for exposure and outcome, which differs from our data, collected by adolescent interviews. Unfortunately, PeNSE questionnaire did not investigate the types of and reasons for doing leisure physical activity, which would be helpful to better explain these results.
Regarding physical education classes, the boys show a mean time of participation in these classes higher than girls, corroborating with previous research40,41. For boys, we can identify a small higher mean of time in exposure (68.9, 95% CI: 65.3 – 72.5) than not exposure group (62.8, 95% CI: 61.1 – 64.6). However, the quantile’s regression coefficients show an association only in the percentile 80th in boys. Study that investigated peers’ physical violence victimization episodes and involvement in fights and participation in physical education observed a positive association between participation in physical education classes and physical violence victimization and involvement in fights42. A study using a national representative sample of children (10 to 17 years) from the United States collected information from children’s parents about exposure to ACEs and sports participation in the least 12 months and identified a negative association for boys between those exposure to only once ACEs, but not than those exposure to two or more ACEs19. Generally, sport is a typical physical educations’ classes component and has been associated with the physical fight in youth14. It is important to mention that the literature points to family violence as a risk factor for involvement in fights. Adolescents who are victims of this type of violence learn that violence can be one way of resolving conflicts43. In this sense, our results may conceal a possible perpetration role of this group, once adolescents’ exposure to physical abuse has more chance of being violence perpetrator44. Further research should evaluate the possible link between exposure to family physical violence, violence perpetration, and domain-specific physical activity in adolescents.
We identify in research a great difference between total physical activity means between sexes, with boys engaging more than girls. Regarding the quantile regressions coefficients’ data, we identify a positive association between total physical activity with exposure to family violence for girls only. Moreover, regressions’ coefficients identify that the difference in the time of total physical activity between the groups is the same along all percentiles for the girls. Earlier study identified a negative association only for boys19. A longitudinal study using data from a national representative sample of adolescents (aged 10 to 11 years) from 21 United States cities investigated the relationship of exposure to accumulative ACEs with health-related behavior and found a negative association in those children exposure to two or more ACEs only in aerobic activities, but not in total or anaerobic activities18. Therefore, our study results support the evidence of the heterogeneity of the influence of the different types of violence exposure and physical activity, its relationship should be investigated in future research.
Epidemiological evidence has suggested an association between ACEs and health risk behavior in adolescence and adulthood45. Family physical violence also has been associated with the development of obesity and physical inactivity16, cardiovascular disease, psychiatric disorder, and premature mortality45. Some evidence suggests that exposure to violence is associated with higher stress response hormone levels throughout life and a frame of dangerous chronic stress conditions46, with impaired function hypothalamic-pituitary-adrenal axis and immune system46. Moreover, exposure to ACEs it is associated with poor mental health in adolescents47-49. Therefore, poor mental health originates from exposure to family violence can be the pathway between the exposure condition and the physical activity practice. Previous results reported that adolescents with poor mental health engaged less in physical activity50,51. However, evidence has shown it could be changed with the maintenance of an active lifestyle in adolescence52. Physical activity could work as a prophylactic component for toxic stress due to its effect on the brain, endocrine, and immune functioning9. Indeed, other unhealthy behaviors, such as smoking, drinking alcohol, excessive television viewing, and drug use, to be generally coping and stress management behavior, which could probably be the same mechanism affecting regular physical activity12. This relation is few explored, mainly in the adolescent population12, and other studies with different sample and methodologic designs are needed to evaluate its relationship and to support evidence-based public health programs aiming to promote adolescents’ health conditions.
Exposure to family violence in early life is a public health problem, and schools are key institutions to appraise these issues. Adolescents spend most of the day inside the school, the strict and extended bond maintained between students’ family members and the school community allows a relationship of security and intimacy. US Centers for Disease Control and Prevention (CDC), along with universities, federal agencies, non-governmental organizations from the state, and local voluntary organizations, summarized the major guidelines for the implementation to prevent unintentional injuries, violence, and suicide in youth. The guidelines recommend that schools and communities adopt its guidance with higher priority based on their owner necessity and resource availability53. Furthermore, Brazil has the School Health Program, which aims to contribute to health promotion and peace culture addressing the identification, notification, and prevention of violence through joint actions of public education and public health54.
The study has some strengths that should be considered. The originality of the research question can be highlighted. There are no studies that investigated the association between family physical violence and total and domain-specific physical activity in adolescents. In addition, the large and representative sample size, and the high survey response rate (97.3%) of Brazilians’ capitals student adolescents, permit generalizability of the results for this population. The use of quantile regression is also a strength of this study, as it provides additional insights into the association of family physical violence with physical activity.
However, the findings should be interpreted with caution, as there are some limitations. Firstly, the cross-sectional design may be challenging to quantify causal effects. Other limitation concerns the measurement error of the exposure. Family physical violence was measured through a single question and until 30 days early exposure that was not permitted assess the intensity and frequency of exposure. Additionally, only adolescents who regularly frequent the school responded to the questionnaire, which may underestimate the prevalence of violence once adolescents who suffer physical abuse tend to fault more times than those who do not. Future studies should be conducted using a validated, reliable, and comprehensive instrument to measure family physical violence and its frequency and intensity. Another limitation is the small time-window of the questionnaire on physical activity (7 days prior to the interview date) and the impossibility of identifying the intensity of the exercise performed. Despite bringing more robustness to the information, such aspects can be minimized when considering the recommendation of the WHO9. Besides it guides 300 minutes of moderate-to-vigorous physical activity, it emphasizes that some physical activity is better than nothing. However, although the questionnaire is validated to estimate physical activity, a direct instrument has the most reliable and accurate measurements. It is worth noting that the data used in this research was gathered in 2015 and, investigation and analysis with current data would show more accurate information. Finally, future longitudinal studies are necessary to analyses the intensity of physical activities and their association with family physical violence and other violence forms and their possible directions.
Concluding, results suggest a distinct association between family physical violence and physical activity in adolescents. Adolescents exposed to family physical violence spend more time commuting physical activity in both sexes. Exposed boys spend less time in leisure-time physical activity, while for girls, there was a positive effect above the 80th percentile. The experience of family physical violence was associated with higher time spent in physical education classes in boys at the 80th percentile of activity. Finally, exposed girls spend more time in total physical activity per week than those not exposed.
The results of this study support the hypothesis that the association between family physical violence and physical activity differs by domain and sex. Nevertheless, it is worth highlighting the scarcity of studies focusing on this relationship. It reinforces the need for further studies to explore better the relationship between exposure to family physical violence in adolescents and physical activity (total and by domain). Recommend evaluating the association of other types of family violence, such as psychological, emotional, neglect, and sexual and physical activity in children and adolescents.

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