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Community and environment for physical activity among young people : a systematic review of the Report Card Brazil 2018 Ambiente comunitário para atividade física de jovens : uma revisão sistemática do Report Card Brasil 2018

The aim of this study was to identify evidence about the prevalence of the community and environment indicators related to physical activity (PA) among young Brazilian people. A systematic review was carried out using eight databases (PubMed, Scopus, Web of Science, LILACS, SPORTDiscus, BIREME, Scielo, and Google Scholar) with descriptors in Portuguese and English. Community and environment Indicators included access, presence, proximity, quality, safety and pollution of/in spaces, facilities, programs available for PA among young people (up to 18 years-old), which may be measured subjectively and/or objectively. A total of 23 documents were included, representing 15 different studies. There were more studies in the South region (n=8), followed by the Northeast (n=3) and Southeast (n=3). Self-reported instruments were more frequently used (n=15). The studies reported prevalence of perception (positive and/or barrier) for access to facilities, programs and/or parks (n=13); presence of sidewalks and bicycle lanes (n=4); proximity to residence (n=5); quality (n=5); safety from crime and traffic (n=14) and pollution (n=6); number of spaces and/or facilities around the residence (n=1); and observation of adolescents using public spaces for PA (n=3). The prevalence rates showed high variability according to environmental indicator. No studies are available for the North and Midwest of the country. Distinct environmental measures were used in selfreported studies, impairing data comparability. To date, no studies have been identified that provide information about the prevalence of combined environmental measures (perceived and objective).


INTRODUCTION
Increasing physical activity (PA) is a global health priority 1 . From an ecological perspective, multiple level factors (from individual to environmental aspects) may determine the levels of PA of the young population 2 . Thus, an attractive community environment provides benefits facilitating PA as well as a variety of additional benefits ranging from mental health to environmental sustainability and economics 3 . Consequently, identifying which community environment factors, being built or perceived, could support or suppress the engagement in PA and how they would do it is imperative in order to define health promoting strategies directed at the young population 4 .
Studies investigating the perception of the PA environment by adolescents have used different indicators, such as presence of places available for PA in the community [5][6][7][8] , as well as the quality, safety and cleanliness of these places 6,7,9 , which may play a role as facilities or barriers regarding engagement in PA. Systematic reviews have demonstrated that the most common methods for collecting data on building environmental characteristics are self-reports or objective measures such as the Geographic Information System (GIS) and systematic observation 10,11 .
Previous reviews have highlighted that most of the studies about the environment for PA with young people were conducted in high-income countries 11,12 . Also, studies from developing countries have similarly focused on the evaluation of macro (e.g. cities, rural/urban areas), meso (e.g. neighborhood) and micro (e.g. areas close to living places) environment scales, whereas studies measuring the meso environment are predominant in developed countries 11 . In Brazil, there is wide heterogeneity of culture, economy and natural environmental factors that could contribute to a distinct use or perception of the community environment for PA 6,7 .
Given the presented contextualization, this study aimed to compile evidence on the prevalence of indicators (e.g., infrastructure, accountability for policy implementation) in the community environment that can influence the PA opportunities and participation of Brazilian children and adolescents.

Measured Outcome
In this review, the environment outcome was defined by environmental attributes that are associated with PA in the community. We considered: spaces, facilities for PA or programs available, quality of spaces, facilities of the neighborhood, security (from crimes or traffic) and pollution (climate conditions or scattered garbage) 13,14 . These indicators can be evaluated with perceived or objective measures. Social indicators (socioeconomic income, schooling level or neighborhood inequality indexes) or indicators of social support (perceiving people using the spaces, support from friends or rela-tives for the use of spaces or seeing people of the same age performing PA) were not considered.

Study Search Strategies
A systematic search was conducted in the electronic databases Medline (PubMed), Scopus, Web of Science (Web of Knowledge), LILACS (Literatura Latino-Americana em Ciências da Saúde), SPORTDiscus, BI-REME (Biblioteca Regional de Medicina), Scielo, and Google Scholar in February 2018. The search strategy included three groups of descriptors: environment, PA and population (see Table 1 Supplementary Materials). The Boolean operator "AND" was used for combinations among descriptor groups. The truncation symbols ($, * or "") specific to each database were also used to increase the range of searches for the descriptor variations. Searches were conducted with the descriptors in English and Portuguese, when required. The search of the electronic databases was supplemented with a screening of the reference list of retrieved articles in order to find potentially relevant titles and the personal library, as well as searches in web sites to identify possible reports such as: The systematic search was conducted by VB (author) and searches in web sites and screening of the references were conducted by SV, GM, MV and GM.

• Selection Process
The initial analysis was performed based on the reading of the manuscripts titles and, when there were doubts regarding the inclusion of the study, a reading of the abstract was carried out. After this analysis, articles were obtained in full text version and subsequently analyzed according to established selection criteria. Subsequently, the screening of the reference list was carried out. The entire process was conducted by independent peers (SV/GM and MV/GM -authors), half of the references were read by each pair, and a third author (KS or VB) helped when there were disagreements.

• Selection Criteria
Studies were eligible for inclusion in this review when they: (I) were an original investigation published in a peer-reviewed journal; (II) included Brazilian children or adolescents aged 0-18 years (or a mean age within these ranges); (III) were observational studies using different methods for the evaluation of community/municipality PA indicators (e.g., self-report, proxy-report, structured interviews, objectively measured environment). These community/municipality PA indicators were considered whether they were measured by perceived (e.g., % of children and parents who perceive that their community/municipality is doing a good job promoting PA as facilities, programs, parks, and playgrounds; number of parks and other environments), or built (presence of structures for PA, quality, distance of structures for PA from school) methods.

Data Extraction
Data extracted included: study name, location of the study, aim, study design, sample type, sample size, percentage of girls, age range, instrument description, type of environmental indicators, and prevalence of each indicator. Data for the whole sample were extracted for all subpopulations presented. This process was conducted by independent peers (SW/GM and MV/GM -authors) and a third author (KS or VB) helped when there were disagreements.
The studies investigated were arranged in alphabetical and chronological order by author's name and year of publication, respectively. The findings were grouped using the following indicators: facilities, programs or spaces available for PA; presence of sidewalks or bicycle lanes; proximity to the residence; quality and PA attributes of public open spaces; safety; traffic safety and cleanliness or pollution in the neighborhood. The results were divided into the following groups: study description ( Table 1); prevalence of the perceptions (Table 2), and barriers (Table 3) of the built environment in the community context. Studies with objective measures (Table 4) were grouped into two categories: use of GIS and use of observational methods to evaluate public open spaces for PA in the community environment.

RESULTS
A total of 1,047 articles in databases and 21 in websites, contact authors, and reference lists were identified. About 376 duplicate references were found. The remaining 692 had titles and abstracts suitable for inclusion; 66 articles were further considered for full-text screening. Thus 21 full-text papers 5-9,15-30 and 2 national reports 31,32 were included in the systematic review, representing 15 different studies. Exclusion reasons are detailed in Figure 1.
The first included studies on the environment for PA among young people were started in 2006 in São Paulo 30 and Curitiba 6,9,21,26 . The most recent study was conducted in 2014 32 . However, the last evaluations of the subject's perception were conducted in 2012 5,15,16 (Table 1).
Reverdito 20 * Hortolândia, SP (n.a.) To investigate Public Leisure Policies, specifically the spaces and equipment, it is possible to endorse conjectures that the child is far from being a priority when it comes to their right to play in urban policies. Perception about facilities, programs, parks and playgrounds available for PA in the community ( Table 2) was reported by four studies in Note. Equal lowercase letters in parentheses at the right of the author's name refer to distinct articles from the same study; Undefined Questionnaire: Original instrument not identified by the authors, but questions were reported; (V): Undefined questionnaire with description of criterion, content and/or construct validity; *Studies that objectively evaluated the use of public areas for PA, with the sample unit being observation areas and not subjects; $National reports (grey literature); **Sample consisting of school managers; n.a.: Not available; PARA: Physical Activity Resource Assessment; NEWS-Y: Neighborhood Environment Walkability Scale for Youth; SOPARC: System for Observing Play and Recreation in Communities; CDC: Centers for Disease Control. eight publications [5][6][7][15][16][17][18]30 . The total the prevalence ranged from 37.2% 6 to 71.9% 30 . According to sex, the prevalence ranged from 50.6% 5 to 81.4% 16 among boys and from 40.4% 17 to 77.7% 16 for girls.
Results about the presence of sidewalks or bicycle lanes were found in two studies conducted in the Southern 6 and Northeastern 7,17 region. In the Northeast, both indicators were perceived by more than 60.0% of the adolescent sample, with a lower prevalence of perceived bicycle lanes by girls (42.4%) 17 . In the Southern region, less than 50% perceived the presence of bicycle lanes (48.0%, boys) 6 ( Table 2).
Perception of public open spaces or facilities for PA near the residence was reported in two studies of three publications 7,9,21 . Less than 50% of adolescents perceived some public open spaces for PA at a distance of up to 31 minutes from their home 7,9,21 . In the Southern region 21 , the perceived distance to the leisure facilities was more prevalent regarding the distance of 21-30 minutes for gymnasiums or sports courts in general (50.5%) and according to sex (boys: 46.9%, girls: 53.0%)( Table 2).
Regarding the quality of public open spaces and PA attestations in the neighborhood, reported in two studies 6,7,17,18 , more than 50% of the boys in the studied perceived the maintenance of the spaces as good (54.3% 6 and 69.8% 17 ), whereas this prevalence was lower among girls (34.1%) 6 ( Table 2).
The perceived safety of the neighborhoods for the practice of PA ( Table  2) varied from 57.5% 6 in the South to 67.8% in the Northeast region among the boys 17 . In the South region 6 , more than 90% of the boys perceived the environment as safe, with illuminated streets. In the Northeast region, less than 40% of the girls perceived the environment as safe walking or riding a bike (35.7%), and the prevalence among boys was lower (31.8% and 29.6%, respectively) 7 . The perception of traffic safety around the homes of adolescents ranged from 67.5% 17 to 79.8% 6 . Boys (82.6%) perceived greater safety in traffic than girls (77.9%) 6 ( Table 2).
Perception of cleanliness or absence of pollution in the neighborhood was reported in only one study, conducted in the Northeast region, and mentioned in two publications 7,17 . More than 60% of the sufficiently active boys perceived the residences as unpolluted (38.7% girls) 17 , while only 25.8% of the boys 7 of the general study sample reported this perception 7 ( Table 2).
Environment barriers for PA among Brazilian adolescents were investigated by seven studies 9,19,[23][24][25][26]29 (Table 3). Facilities, programs, parks and playgrounds available for PA in the community were reported in five studies 9,23-26 all conducted in the South region. The perception was more prevalent among girls, ranging from 35.8% 26 to 68.7% 9 , than among boys (27.8% 25 to 64.8% 9 ), among older adolescents (15-19 years: 43.6%) compared to younger ones (10-14 years: 24.1%) 25 , and among adolescents attending state schools (11.2%) than those attending Federal (2.4%) and Private (9.4%) 24 schools. Far distance from public open spaces and facilities was investigated as a barrier for PA in two studies in the South region 23,29 , and negative perception about the presence of sidewalks or bicycle lanes and quality of the neighborhood was investigated in another study 19 in the Southeast region. The prevalence of this barriers was low (highest: 16.7%) 29 (Table 3). …continue Low neighborhood and traffic safety as a barrier for PA (Table 3) was mostly reported in studies from the South region 9,23,24,29 , except one 19 . Safety indicators such as poor lighting (62.0%) of the neighborhoods, perceived insecurity (59.5%) for PA and dangerous traffic (58.3%) was more prevalent among girls than boys (54.4%, 54.2%, 57.8%, respectively) 9 . In a study with adolescents who were active in commuting the perception of insecurity in traffic was perceived by 61.7% of the sample 29 . Furthermore, adolescents from state schools perceived a greater proportion of crimes in the community environment (5.1%) 24 .
Information on cleanliness or pollution in the neighborhood as a PA barrier was reported by four studies 23,24,26,29 , all carried out in the South region. This negative perception was frequently reported by girls (49.0%) 26 , and by actively commuting adolescents (88.4%) 29 (Table 3).
The studies that investigated built environment indicators using different objective measures (Table 4) were conducted in the South 22,28 , Southeast 20 , and Northeast 27 regions. Only one study using GIS in more than 50% of the buffers around the residence of adolescents in Pelotas reported has some attributes for PA, with regular quality or public spaces 22 .
Systematic observation studies using SOPARC showed a higher prevalence of sports equipment in parks (56.4%) and in squares (51.4%) 28 . The frequency of the use of these spaces varies by children and adolescents varied according to sex, the period of the day, week and/or weekend, and the intensity of PA practiced 28 . Health Promotion Programs (Academia da Cidade Program) with assistance to adolescents are present in only 13.0% of the cities of Brazil 27 (Table 4).    Among the studies that reported the year of data collection, the first studies with Brazilian adolescents were conducted in 2006 in the South 6,9,21,26 and Southeast 30 regions, and most recent ones were conducted in 2012 in the Southern region. The region more investigated was the South 5, 6,9,15,16,21,23,26,28 followed by the Southeast 19,20,30 and Northeast 7,8,17,18,27,31 . The location of research groups or individual investigators that study the environment for the practice of PA may be one of the reasons explaining these results. Recent studies on environment perception for the practice of PA by adolescents may be in progress or are studies 19,20,23,24,31 that did not report this information or did not have this focus. Still, research groups and individual investigators of the subject may be focusing their studies on other age groups such adults and older adults. Anyway, this is an important gap of knowledge in view of the cultural and socioeconomic diversity of the regions.
The studies included in the review reported the prevalence of perception including facilities, programs, parks and playgrounds available for PA in the community [5][6][7][15][16][17][18]30 (barriers 9,23-26 ), the presence of sidewalks or bicycle lanes 6,7,17 (barriers 19 ), public open spaces or facilities for PA near the residence 7,9,21 (barriers 23,29 ), quality of public open spaces and PA attestations in the neighborhood 6,7,17,18 (barriers 19 ), safety of the neighborhoods for the practice of PA [6][7][8]17 (barriers 9,19,23,24,29 ), traffic safety around the homes 6,17 (barriers 9,19,29 ), and cleanliness or absence of pollution in the neighborhood 7,17 (barriers 23,24,26,29 ). This diversity of indicators analyzed shows the complexity and variability of the built environment items that are necessary to understand the practice of PA. The survey of an indicator does not reveal the use of space or existence of the physical and perceived structure of PA in the community environment. Thus, methods for evaluating the environment need to be combined (subjective and objective measures) for a better understanding of the complexity of the topic. Even studies that investigated the environment for PA by self-reported questionnaires used a variety of indicators based on different instruments, and only a few mentioned validation criteria for adolescents 8,[24][25][26] . A broad heterogeneity of the information collected was observed in some studies in which similar variables were questioned in different paths with various response options, thereby making it difficult to compare the data. Studies with objective measures of the environment were carried out only in the South and Southeast regions 20,22,27,28 . In the present review, no study was performed using objective and perceived measures for the built environment in combination, which makes it difficult to understand the analysis of the real environment with perceived and feasible use of space.
The perception of the presence of public open spaces and/or facilities for PA was the indicator more frequently investigated. Studies have shown that boys perceive a higher prevalence of the presence of some attribute for PA than girls 6,15,17,30 . Findings also indicate that boys accumulate more time in leisure PA than girls 15,33 . In general, perceiving the presence of spaces near one's home can facilitate engagement in PA 4,9 . In addition, studies have shown that low levels of PA may be influenced by the lack of opportunities for facilities close to the residence of Brazilian youth 17,29 . However, a community context with options for promotion of PA (i.e., security, maintenance, proximity, park features) may contribute to changes in the behavior of different age groups, as observed in highincome countries 13,14,34,35 .
Some gaps were identified. Although some studies reported prevalence data about the perception of spaces, facilities, program, quality or safety, the data were insufficient to determine their use by adolescents for PA 6,8,16,17,30 , except for one report 9 . A study carried out in Curitiba showed that more than 50% of the adolescents investigated did not attend the parks due to lack of equipment, very crowded conditions, and difficult access 9 . In this respect, it is important to investigate whether the fact that adolescents perceive an opportunity in the community causes it to be used for PA. In the studies using objective measures of the environment, the unit of analysis was the observed space or the quantity of these settings in a determined area or region. However, it is unknown if adolescents make use of these places by perceiving closeness to their residence, security, and quality or based on the facilities for PA 22,27,28 . Finally, it is also unknown whether the settings are frequented by adolescents for PA, when the indicators of the environment are perceived as non-barriers 25,26 .
Future studies could propose the standardization of instruments and their application to each indicator of the environment, considering its scope and unit of measurement. For systematic observational studies of the environment it is important to combine information at the individual and contextual levels in order to understand PA indicators. In addition, it is important to combine perceived and objective measures in order to understand the use of spaces or attributes for PA in the neighborhood.
Possibly, a collaborative network of researchers in the area could promote investigations in two of the five regions of the country that do not yet have information on this topic, thus yielding relevant national data.
Several limitations in this review need to be considered. The screening step was performed independently by two uncalibrated pairs, who may have made different decisions regarding the inclusion of certain studies. The bias risk was not analyzed because of the heterogeneity of the observational studies that investigated this outcome in adolescents. In addition, the lack of studies in all regions of the country and regarding the coverage of the indicators, standardized instruments and the representativeness of the samples investigated limited the discussion of the prevalence found in this review.
The strengths identified were the broad search of the studies as well as electronic databases in national reports. The systematic survey of the prevalence of the perception of indicators of the built environment for PA by adolescents provides subsidies for the creation of public health policies for the implementation of programs, actions or interventions to make urban environments friendly to PA in this population. By surveying the scientific literature, the review identified important gaps that can be considered in future research on the topic.
Thus, the review identified that perceived environment indicators of PA by adolescents has been investigated in the South, Southeast and Northeast regions of the country. The instruments used to measure environmental perception varied within the same indicator, which made it difficult to compared studies. The indicators of a community environmental were mostly the presence of public open spaces and facilities for PA and their proximity to the homes of the adolescents. The surveyed studies revealed a higher prevalence of boys who perceive the community environment for PA than girls in all the regions investigated. To date, no studies with the combined use of perceived and objective measures of the built environment have been identified.