ABSTRACT:

Introduction:

The complexity of urbanization processes across Latin American societies encourages investigating its implications in health conditions, especially during childhood. One of the possible links between them is recreation, a component of the daily life of children and, therefore, essential to produce health and life itself. The objective of this study was to examine the associations between neighborhood context and active public park use among school-aged children in Cordoba, Argentina.

Methods:

A cross-sectional study was conducted with 1466 children, aged 9 to 11, attending 19 schools and living in 110 neighborhoods. Multilevel models with Poisson distribution were used for the analyses, stratified by gender. Socio-demographic, behavioral, and physical covariates were included at the individual level, and socioeconomic neighborhood conditions at second level.

Results:

Girls residing in neighborhoods with a worse socioeconomic context were less likely to report frequent public park use for physical activity, while those from neighborhoods with better socioeconomic conditions were more likely to, regardless of individual characteristics.

Conclusion:

This study suggests that socioeconomic conditions of neighborhoods are associated with public park use for physical activity in school-aged girls, demonstrating gender inequality in the use and appropriation of public spaces.

Keywords:
Park’s recreational; Exercise; Residence characteristics; Child; Argentina

RESUMO:

Introdução:

O processo de urbanização das sociedades latino-americanas estimula investigar suas consequências nas condições de saúde. Um dos elos possíveis é a recreação, componente do cotidiano das crianças essencial para a produção da saúde e da própria vida. O objetivo foi examinar as relações entre o contexto do bairro e o uso ativo do parque público entre as crianças em idade escolar em Córdoba, Argentina.

Métodos:

Foi realizado um estudo transversal com 1466 crianças que frequentam 19 escolas e moram em 110 bairros. Modelos multinível com distribuição de Poisson foram utilizados para as análises, estratificados por sexo. Covariáveis sociodemográficas, comportamentais e físicas foram incluídas no nível individual e as condições socioeconômicas do bairro, no segundo nível.

Resultados:

As meninas que residem em bairros com pior contexto socioeconômico foram menos prováveis a relatar o uso frequente de parques públicos para atividades físicas, enquanto aquelas provenientes de bairros com melhores condições eram mais prováveis, independentemente das características individuais.

Conclusões:

Este estudo sugere que as condições socioeconômicas dos bairros estão associadas ao uso de parques públicos para atividade física em meninas unicamente, demonstrando uma desigualdade de gênero.

Palavras-chave:
Parques recreativos; Exercício físico; Características de residência; Criança; Argentina

INTRODUCTION

Within urban spaces, the social reproduction of different social classes develops in the neighborhood, crossed by ethnic and gender relations, so that each neighborhood entails a particular form of social organization¹1. Breilh J. La epidemiología crítica: una nueva forma de mirar la salud en el espacio urbano. Salud Colectiva 2010; 6(1): 83-101. https://doi.org/10.18294/sc.2010.359
https://doi.org/https://doi.org/10.18294... . Therefore, the recognition of this territory is a basic step for the characterization of distinct social groups and their difficulties²2. Alazraqui M, Diez Roux AV, Fleischer N, Spinelli H. Self-rated health and social inequalities, Buenos Aires, Argentina, 2005. Cad Saúde Pública 2009; 25(9): 1990-2000. http://dx.doi.org/10.1590/S0102-311X2009000900013
https://doi.org/http://dx.doi.org/10.159... ^,33. Monken M, Barcellos C. Vigilância em saúde e território utilizado: possibilidades teóricas e metodológicas. Cad Saúde Pública 2005; 21(3): 898-906. http://dx.doi.org/10.1590/S0102-311X2005000300024
https://doi.org/http://dx.doi.org/10.159... .

Approaches using neighborhoods as the main unit of analysis have been growing constantly in recent decades. In contrast, these are yet rarely used in Latin American countries, especially in Argentina. As research with a neighborhood approach grows, evidence confirming that health conditions are strongly related to community characteristics beyond individual ones is reinforced⁴4. Subramanian V. The relevance of multilevel statistical methods for identifying causal neighborhood effects. Soc Sci Med 2004; 58(10): 1961-7. https://doi.org/10.1016/s0277-9536(03)00415-5
https://doi.org/https://doi.org/10.1016/... .

Physical activity (PA) has been one of the most studied determinants of health in recent years in relation to environmental characteristics. Nevertheless, the majority of research has focused on the adult population in developed countries⁵5. Diez Roux AV, Evenson KR, McGinn AP, Brown DG, Moore L, Brines S, et al. Availability of Recreational Resources and Physical Activity in Adults. Am J Public Health 2007; 97(3): 493-9. https://dx.doi.org/10.2105%2FAJPH.2006.087734
https://doi.org/https://dx.doi.org/10.21... ^,66. Humpel N, Owen N, Leslie E. Environmental Factors Associated with Adults’ Participation in Physical Activity. Am J Prev Med 2002; 22(3): 188-99. https://doi.org/10.1016/s0749-3797(01)00426-3
https://doi.org/https://doi.org/10.1016/... ^,77. Ding D, Sallis JF, Kerr J, Lee S, Rosenberg DE. Neighborhood Environment and Physical Activity Among Youth. A Review. Am J Prev Med 2011; 41(4): 442-55. https://doi.org/10.1016/j.amepre.2011.06.036
https://doi.org/https://doi.org/10.1016/... ^,88. Ferreira I, van der Horst K, Wendel-Vos W, Kremers S, van Lenthe FJ, Brug J. Environmental correlates of physical activity in youth -a review and update. Obes Rev 2007; 8(2): 129-54. https://doi.org/10.1111/j.1467-789x.2006.00264.x
https://doi.org/https://doi.org/10.1111/... . Although a paradigm shift from individual to ecological conceptual models is observed, most of this turn has focused on the influence of neighborhood-built environment at the expense of neighborhood socioeconomic conditions (despite previous research showing that a favorable social environment was positively associated with several measures of PA and that built environment was not significantly related⁹9. Brownson RC, Hoehner CM, Day K, Forsyth A, Sallis JF. Measuring the Built Environment for Physical Activity State of the Science. Am J Prev Med 2009; 36(4 Suppl.): S99-S123.e12. https://dx.doi.org/10.1016%2Fj.amepre.2009.01.005
https://doi.org/https://dx.doi.org/10.10... ^,1010. Franzini L, Elliott MN, Cuccaro P, Schuster M, Gilliland MJ, Grunbaum JA, et al. Influences of Physical and Social Neighborhood Environments on Children’s Physical Activity and Obesity. Am J Public Health 2009; 99(2): 271-8. https://dx.doi.org/10.2105%2FAJPH.2007.128702
https://doi.org/https://dx.doi.org/10.21... ).

Consequently, the study of health-related behaviors such as PA requires a complex approach to address the potential effects of communities and neighborhood dimensions on the behavior of individuals⁸8. Ferreira I, van der Horst K, Wendel-Vos W, Kremers S, van Lenthe FJ, Brug J. Environmental correlates of physical activity in youth -a review and update. Obes Rev 2007; 8(2): 129-54. https://doi.org/10.1111/j.1467-789x.2006.00264.x
https://doi.org/https://doi.org/10.1111/... . At the individual level, children’s PA has been associated to categories such as age (as it increases, PA tends to decrease), gender (boys are more involved than girls), social support (family and peer support seems to be positively associated), screen activities (as they increase, the time for PA decreases), socioeconomic status (as it improves, it promotes PA)¹¹11. Sallis JF, Prochaska JJ, Taylor WC. A review of correlates of physical activity of children and adolescents. Med Sci Sports Exerc 2000; 32(5): 963-75. https://doi.org/10.1097/00005768-200005000-00014
https://doi.org/https://doi.org/10.1097/... ^,1212. Seabra AF, Mendonça DM, Thomis MA, Anjos LA, Maia JA. Biological and socio-cultural determinants of physical activity in adolescents. Cad Saúde Pública 2008; 24(4): 721-36. http://dx.doi.org/10.1590/S0102-311X2008000400002
https://doi.org/http://dx.doi.org/10.159... .

Despite the recognized benefits of PA and the growing evidence of environmental influence on it, a large proportion of the children population does not meet the recommendations of the World Health Organization (WHO). The lastest Global School-based Student Health Survey showed that the proportion of students who were physically active for a total of at least 60 minutes per day on five or more days a week was 28% in Cordoba and Argentina¹³13. World Health Organization. Global School-based Student Health Survey [Internet]. World Health Organization; 2012 [accessed on Nov. 9, 2017]. Available at: Available at: http://www.who.int/chp/gshs/Argentina_GSHS_FS_2012_National.pdf?ua=1
http://www.who.int/chp/gshs/Argentina_GS... .

Nowadays, more than 80% of the Latin American population lives in cities, constituting the most urbanized region of the planet. In Argentina, the urban population rises to 93%¹⁴14. Comissão Econômica para a América Latina e o Caribe. La matriz de la desigualdad social en América Latina. Santiago: Comissão Econômica para a América Latina e o Caribe; 2016.. In this country, the city of Córdoba is the second most populated and presents great economic and social contrasts¹⁵15. National Statistical and Census Institute. National Census on Population, Households and Homes [Internet]. National Statistical and Census Institute; 2010 [accessed on Dec. 9, 2017]. Available at: Available at: https://www.indec.gob.ar/nivel4_default.asp?id_tema_1=2&id_tema_2=41&id_tema_3=135
https://www.indec.gob.ar/nivel4_default.... . While some neighborhoods have high proportions of households with unsatisfied basic needs (UBN) (24%), others have values below the city average (5.8%)¹⁶16. Dirección General de Estadística y Censos. Censo 2010 [Internet] Córdoba, 2010 [accessed on Nov. 8, 2017]. Available at: Available at: https://datosestadistica.cba.gov.ar/dataset/censo-2010-barrios-asent-elect-capital
https://datosestadistica.cba.gov.ar/data... . Besides, there is an unequal distribution of green spaces in different areas of the city, correlated with socioeconomic indicators¹⁷17. Red Ciudadana Nuestra Córdoba. Indicadores Ciudadanos 2014 [Internet]. Nuestra Córdoba; 2014 [accessed on Mar. 10, 2018]. Available at: Available at: http://www.nuestracordoba.org.ar/node/759
http://www.nuestracordoba.org.ar/node/75... .

According to Almeida-Filho, inequalities are the quantitative variation in collectivities that can be expressed by demographic or epidemiological indicators. Instead, health inequalities determined by income, education, and social class are products of social injustice; as they acquire meaning in the political field as a product of conflicts related to the distribution of wealth in society. Thus, they should be considered health inequities¹⁸18. Almeida-Filho N. A problemática teórica da determinação social da saúde (nota breve sobre desigualdades em saúde como objeto de conhecimento). Saúde Debate 2009; 33(83): 349-70..

To date, little is known about how the socioeconomic characteristics of the neighborhood affect children’s PA in Latin American countries, and even less about children’s use of public spaces for PA. Therefore, studying the role of neighborhood public spaces in children’s PA opportunities is particularly relevant in a city characterized by persistent socio-territorial segregation and strong privatization of the public sphere¹⁹19. Marengo MC, Elorza AL. Social housing in Cordoba: consequences on residential segregation and urban growth (1991-2008). Revista iNVi 2016; 31(86): 119-44. http://dx.doi.org/10.4067/S0718-83582016000100005
https://doi.org/http://dx.doi.org/10.406... ^,2020. Murillo F. Ciudades primadas latinoamericanas: ¿hacia una nueva agenda urbana de mejoramiento y prevención de asentamientos informales? Cuaderno Urbano 2016; 21(21): 137-66. http://dx.doi.org/10.30972/crn.21211182
https://doi.org/http://dx.doi.org/10.309... ^,2121. Capdevielle J. Los grupos “desarrollistas” y su incidencia en el espacio urbano de la ciudad de Córdoba, Argentina (1990-2013). Terra Nueva Etapa 2014; 30(47): 129-52.^,2222. Molinatti F. Segregación residencial socioeconómica en la ciudad de Córdoba (Argentina): Tendencias y patrones espaciales. Revista iNVi 2013; 28(79): 61-94. http://dx.doi.org/10.4067/S0718-83582013000300003
https://doi.org/http://dx.doi.org/10.406... ^,2323. Boito ME, Espoz MB. Poder, territorio(s) y construcción de entorno: consideraciones políticas y metodológicas de los abordajes sobre cuerpos y emociones. Rev Bras Soc Emoç 2012; 11(33): 725-48.^,2424. Boito ME, Espoz MB. “Vaciar la calle, prometer la circulación”. Desplazamientos y construcción de entornos protegidos en el marco de las sociedades del espectáculo. In: Boito ME, Espoz MB (Eds.). Urbanismo estratégico y separación clasista. Instantáneas de la ciudad en conflicto. Rosario: Puño y Letra Editorialismo de Base; 2014. p. 387-421.. The objective of this study was to elucidate the associations between neighborhood context and the frequency of public parks (PP) use for PA among school-aged children in Cordoba.

METHODS

PARTICIPANTS

A cross-sectional study was carried out in a population of children from 4^th to 6^th grade - ages 9 to 11 years old - from municipal primary schools in Cordoba city, Argentina. The study was carried out between September and December 2011, during springtime.

Cordoba’s primary education system consists of four different types of schools: national, state, municipal, and private. The municipal school system was created to compensate for the lack of state education. Currently, there are 37 institutions and almost 12,500 children, which represent approximately 3% of total primary schoolchildren (366,424 in 2010)²⁵25. Álvarez MFS (Coord.). Educación en cifras: nivel inicial y primario en Córdoba: 2002-2010 [Internet]. Córdoba: CEPyD; 2013 [accessed on Feb. 20, 2018]. Available at: Available at: http://www.nuestracordoba.org.ar/sites/default/files/informe-educacion-Cepyd.pdf
http://www.nuestracordoba.org.ar/sites/d... . According to municipal reports, these schools attend to families living in urban poverty contexts²⁶26. Municipalidad de Córdoba. Escuelas Municipales [Internet]. Córdoba: Municipalidad de Córdoba; 2018 [accessed on Feb. 10, 2018]. Available at: Available at: https://educacion.cordoba.gob.ar/escuelas-municipales/#poblaciones
https://educacion.cordoba.gob.ar/escuela... .

The eligible sample consisted of 4,820 children enrolled from 4^th to 6^th grade in municipal schools in 2011, and their primary adult caregivers. A sample size of 1,349 students was estimated considering an expected prevalence of 50% (due to multiple outcomes), a sampling error of 3.5 percentage points, a 95% confidence interval, and a design effect of 2.0.

For the sampling process, all the primary municipal schools in 2011 (37 schools) were stratified in an attempt to design two groups with a similar number of schools, taking into account the available statistical data on parental illiteracy: schools with more than 25% of parents with, at least, complete elementary education level (20 schools) and those below this cutoff (17 schools). Then, 10 from the first group and nine from the second were randomly selected. The 19 schools selected yielded a potential pool of 2,424 students.

Parents were called to school for a meeting with the research team. An explanation of the study was given, and a written informed consent was obtained from those who agreed to participate and let their children participate. A note explaining the study and the informed consent was sent through children to parents who did not attend the meeting. Children were also asked to assent to participate, regardless of their parents’ consent.

When both agreed to participate, parents completed a self-administered questionnaire at school or at home. Children also completed a questionnaire read aloud by a research team member in the classroom, so that everybody could answer it at the same time and clear their doubts.

VARIABLES AND MEASURES

Parents’ questionnaire included the following dimensions: family sociodemographic conditions and health history; child’s health parameters and attention, PA, opportunities for PA in the neighborhood, eating habits at home and at school; and mother’s health conditions (150 questions).

Instead, the children’s questionnaire included dimensions of health-related quality of life: physical and psychological well-being, moods and emotions, self-perception, autonomy, domestic life, social and peer support, school environment, social acceptance and financial resources, screen behavior, eating habits and the Family Affluence Scale (80 questions).

Outcome

Frequency of PP used for PA. Parents were asked about the frequency with which the child used the different spaces (closest to their homes) for PA, in their neighborhood of residence: clubs, soccer fields, other sports courts, other recreational or exercise rooms, schools with recreational facilities, walking or cycling paths, parks or squares, wastelands and other outdoor spaces. The response options were: never, rarely (once a month or less), sometimes (once every fifteen days), and frequently (once a week or more). When modeling multivariate models, the frequent use (versus never, rarely or sometimes) was the expected outcome.

This question was obtained from the “Active Where?” survey of the Robert Wood Johnson Foundation’s Active Living Research from the United States and adapted to the local population²⁷27. Active Living Research. "Active Where?" surveys [Internet]. [accessed on Dec. 12, 2014]. Available at: Available at: http://activelivingresearch.org/active-where-surveys
http://activelivingresearch.org/active-w... . This set of questions taken from the US survey was cross-culturally adapted to be used in our population, showing good internal consistency (Cronbach's alpha of 0.86).

Individual covariates

Screen activities. These correspond to activities that could displace PA practice. Children were asked about the daily hours spent watching TV and/or using the computer during a usual week. Categories were constructed as follows: less than 2 hours per day, 2 to 3 hours per day, and more than 3 hours per day.

Social support. It refers to the quality of time shared with friends and other peers. It constitutes a dimension of the Health-Related Quality of Life measure inquired through the Argentinean version of KIDSCREEN-52 as follows: Were you with your friends during the last week? Did you share activities with other people? Did you have fun with your friends? Did your friends and you help each other? Could you talk about everything with your friends? Could you trust your friends? The response options were on a 5-point Likert-type scale: never, almost never, sometimes, almost always, and always. This domain is computed using Rash scores and transformed into T-values with a mean of 50 and a standard deviation of 10, based on the scores from the European reference data. The social support scale resulted in a Cronbach’s alpha = 0.81, and acceptable infit-outfit values from the Rasch analysis when the Argentinean version was tested²⁸28. Berra S, Tebé C, Esandi ME, Carignano C. Reliability and validity of the KIDSCREEN-52 questionnaire to measure health related quality of life in the 8 to 18 year-old Argentinean population. Arch Argent Pediatr 2013; 111(1): 29-35. https://doi.org/10.5546/aap.2013.29
https://doi.org/https://doi.org/10.5546/... . The variable was categorized into: low (score lower than 45), mean (from 45 to 55), and high (more than 55 points).

Mother’s educational level. The highest level achieved by mothers was considered, grouped into: mothers who completed at most primary education, those who completed secondary education, and those with tertiary or university studies or more.

Nutritional anthropometric status. Weight and height were measured with a digital weighing scale and a portable height rod by trained staff. Children wore light clothes during the procedure. Body mass index (BMI) z-scores were calculated according to the WHO 2006 standards using its AnthroPlus software. Three nutritional anthropometric status were established: not overweight, overweight, or obese.

The research team was trained to conduct both surveys and to perform measurements.

Neighborhood variables

Neighborhood of residence. Parents reported the name of the neighborhood where the child lived in order to cross-check information with secondary sources (e.g., National Census).

Socioeconomic context. It was obtained from the percentage of households with at least one UBN per neighborhood. The needs considered were:

The percentage of households with UBN varied between 0 and 24%. The variable was, therefore, ordinalized in three intervals: favorable context neighborhoods, when they had a low proportion of households with UBN (less than 8%); transitional context neighborhoods, those with an average proportion of households with UBN (from 8 to 16%); and critical context neighborhoods, those with a high percentage of households with UBN (more than 16%). This criterion was defined considering previous local studies, in order to compare results.

Information was obtained from the last National Census 2010 to determine the total number of households according to UBN condition by neighborhood¹⁵15. National Statistical and Census Institute. National Census on Population, Households and Homes [Internet]. National Statistical and Census Institute; 2010 [accessed on Dec. 9, 2017]. Available at: Available at: https://www.indec.gob.ar/nivel4_default.asp?id_tema_1=2&id_tema_2=41&id_tema_3=135
https://www.indec.gob.ar/nivel4_default.... . The cartographic conformation of the neighborhoods constitutes a census approximation made by the General Direction of Statistics and Census of the Province of Cordoba based on the official and unofficial neighborhoods of Cordoba city and the census division used in the Census¹⁶16. Dirección General de Estadística y Censos. Censo 2010 [Internet] Córdoba, 2010 [accessed on Nov. 8, 2017]. Available at: Available at: https://datosestadistica.cba.gov.ar/dataset/censo-2010-barrios-asent-elect-capital
https://datosestadistica.cba.gov.ar/data... . From that, the variable on neighborhood socioeconomic context was constructed.

All procedures performed were in accordance with the ethical standards of the Comité de Ética del Hospital Nacional de Clínicas (Ref. No. 066/10).

DATA ANALYSIS

Multilevel statistical models allow for the estimation of contextual effects of area-level factors by accounting for the spatial clustering of individuals within regions²⁹29. Subramanian SV, Jones K, Duncan C. Multilevel methods for public health research. In: Kawachi I, Berkman L (Eds.). Neighborhoods and health. New York: Oxford University Press; 2003. p. 65-111.. Three sets of multilevel models adjusted to Poisson distribution were carried out using STATA 14 software to estimate the association between individual and contextual characteristics, and high frequency of using PP for PA.

Girls and boys were modeled separately on the basis of previously found gender differences in PA and use of parks³⁰30. Lavin Fueyo J, García LMT, Mamondi V, Alencar GP, Florindo AA, Berra S. Neighborhood and family perceived environments associated with children's physical activity and body mass index. Prev Med 2016; 82: 35-41. https://doi.org/10.1016/j.ypmed.2015.11.005
https://doi.org/https://doi.org/10.1016/... (Table 1). The first set of models was adjusted only for individual covariates (models 1 and 3). The second set incorporated socioeconomic neighborhood context at the second level (models 2 and 4).

Boys models included a total of 384 children distributed in 77 neighborhoods; Girls models, 450 out of 81. The reason why the number of children varies from descriptive to multilevel results is related to the fact that, for the latter, data from the parents’ survey was necessary, and not all children had them. That is, 704 children did not have any of the data necessary for multilevel analysis, so the statistical system automatically excluded those cases.

Incidence rate ratios (IRR) with 95% confidence intervals (95%CI) were estimated in all models. Parameters were estimated by the full information maximum likelihood method.

In order to measure inequalities, a relative measure based on odds ratios was obtained from a logistic regression analysis. Also, the Slope Index of Inequalities (SII) was used. This index represents the absolute difference in the fitted value of the health indicator between the highest (score of 1) and the lowest (score of 0) values of the socioeconomic indicator rank. The SII is one of the most used measures of inequality in epidemiological literature, along with ratios and differences³¹31. Barros AJD, Victora CG. Measuring Coverage in MNCH: Determining and Interpreting Inequalities in Coverage of Maternal, Newborn, and Child Health Interventions. PLoS Med 2013; 10(5): e1001390. https://doi.org/10.1371/journal.pmed.1001390
https://doi.org/https://doi.org/10.1371/... .

All statistical tests were two-tailed and adopted a 5% significance level. Quantum GIS 3.2 software was used to create maps to help visualize neighborhood distribution.

RESULTS

The final sample consisted of 1,777 children and 1,313 adults (mothers in 86% of cases). The effective participation in the study was 64.3% of children, with a range of 29.8 to 82.5% in different schools; and 60.5% of adults, with a range of 37.5 to 84.2%. The difference between the participation of children and adults can be attributed to the lack of response in the parents’ survey. The strategy of sending the questionnaire through their children could have caused it to get lost along the way.

Children were evenly distributed throughout school grades and there were more girls (53%) than boys. Most mothers (62%) had only completed elementary school. Obesity was more frequent in boys than in girls, whereas overweight was more frequent in girls than in boys. Also, boys used parks for PA more frequently and spent more hours engaged in screen activities than girls. Less than half of the sample was classified as frequent users of neighborhood PP (Table 1).

Most neighborhoods were classified as favorable, although most children lived in those classified as transitional. No differences were found in the distribution of girls and boys.

Figure 1 shows geographical distribution according to the context of poverty. Differences were found between the context of neighborhood and geographical area (p < 0.005).

Regarding boys, the models observed in Table 2 show that individual and neighborhood variables were not related to the outcome of interest. Instead, girls’ models show that the critical socioeconomic neighborhood context was negatively associated with frequent use of PP for PA (IRR = 0.44; 95%CI 0.21 - 0.91).

Multilevel models without stratifying by gender showed that the neighborhood poverty context was also important in the use of PP for PA. As neighborhood context deteriorates, children’s use of PP for PA decreases considerably, regardless of individual variables. Furthermore, gender was associated with our outcome (IRR = 0.68; 95%CI 0.55 - 0.84).

The frequency of use of PP for PA in boys was 48%, or 1.48 times, higher in neighborhoods with better socioeconomic conditions than in those in worse conditions (95%CI 1.14 - 1.93). In girls, this percentage climbs to 60% (95%CI 1.24 - 2.06). Additionally, the SII equals 26.8, which represents the difference between frequently using the PP for PA and not using it frequently. This also indicates that this frequency in favorable context neighborhoods is 26.8 percentage points higher than in critical context ones (95%CI 0.16 - 0.37).

DISCUSSION

Multilevel models indicated the importance of neighborhood context in the use of PP for PA during childhood, especially for girls. As the neighborhood context deteriorates, the use of PP decreases considerably in the group of girls, regardless of individual variables. Also, inequality measures gave evidence of social and gender disparities in using PP to develop PA. This brings forward original evidence to the comprehension of social complexity in approaching leisure-time PA in a local context, focusing on childhood.

Critical neighborhoods would probably have streets and sidewalks in worse conditions, less lighting, and PP without care, compared to favorable ones. The poor quality of PP were problems regularly mentioned by children’s mothers in the previous studies³²32. Lavin J. Un acercamiento territorial a la práctica físico-deportiva de las infancias que habitan la ciudad de Córdoba, Argentina. Cad Saúde Pública 2019; 35(10): e00076518. https://doi.org/10.1590/0102-311x00076518
https://doi.org/https://doi.org/10.1590/... . Therefore, although there are PP in the neighborhood, their poor conditions could make children use them less and prefer to spend leisure time at home. Supporting this, half of the sample of children spent two hours or more on screen-based activities³³33. Lavin J, Bruzzone F, Mamondi V, González E, Berra S. Actividad física y comportamientos sedentarios de escolares de Córdoba en su tiempo libre y en clase de educación física. Rev Argent Salud Pública 2015; 6(24): 15-21.. In Portugal, adolescents living in neighborhoods with recreational facilities were more likely to be active³⁴34. Mota J, Almeida M, Santos P, Ribeiro JC. Perceived Neighborhood Environments and physical activity in adolescents. Prev Med 2005; 41(5-6): 834-6. https://doi.org/10.1016/j.ypmed.2005.07.012
https://doi.org/https://doi.org/10.1016/... .

In addition, feelings of unsafety are widely spread in the discourses of community members³²32. Lavin J. Un acercamiento territorial a la práctica físico-deportiva de las infancias que habitan la ciudad de Córdoba, Argentina. Cad Saúde Pública 2019; 35(10): e00076518. https://doi.org/10.1590/0102-311x00076518
https://doi.org/https://doi.org/10.1590/... . Neighborhood trust and social networks facilitate collective action³⁵35. Kawachi I, Berkman L. Social cohesion, social capital and health. In: Berkman L, Kawachi L (Eds.). Social Epidemiology. New York: Oxford University Press ; 2000. p. 174-190.. The lack of public space produced by perceived unsafety results in the impossibility to create community resources, intensifying the sensation of insecurity. This generates a circular and cumulative process in which the loss of places where citizenship and collective trust produces insecurity, promoting the reclusion into the private sphere³⁶36. Segovia O, Jordan R. Espacios públicos urbanos, pobreza y construcción social. CEPAL. Santiago de Chile: Naciones Unidas; 2005.. Related to this, lower neighborhood safety and social disorder were significantly associated with less PA in children from Chicago, Illinois³⁷37. Molnar BE, Gortmaker SL, Bull FC, Buka SL. Unsafe to Play? Neighborhood Disorder and Lack of Safety Predict Reduced Physical Activity among Urban Children and Adolescents. Am J Health Promot 2004; 18(5): 378-86. https://doi.org/10.4278/0890-1171-18.5.378
https://doi.org/https://doi.org/10.4278/... .

Focusing on gender inequality, we observed that neighborhood poverty has a stronger impact on girls’ PA. This pattern is verified (in an aged group) in a Brazilian study in which there is a greater presence of men compared to women in parks. The authors partially attribute this to the fact that many of these spaces are designed for predominantly male activities, such as football or basket, with fewer areas for walking, running, or cycling, usually preferred by women³⁸38. Hino AAF, Reis RS, Ribeiro IC, Parra DC, Brownson RC, Fermino RC. Using observational methods to evaluate public open spaces and physical activity in Brazil. J Phys Act Health 2010; 7(Suppl. 2): S146-54. https://doi.org/10.1123/jpah.7.s2.s146
https://doi.org/https://doi.org/10.1123/... . However, it should be noted that these assessments may also be incorporating a gender bias. Moreover, research developed in Spain also found a great absence of women in the public space which, according to the authors, shows the need for an urban design that considers the needs and interests of women³⁹39. Vilanova A, Soler S. Las mujeres, el deporte y los espacios públicos: ausencias y protagonismos. Apunts 2008; 91: 29-34..

PA and sports should be conceived as socially constructed phenomena that have been perpetuating male hegemony throughout history. Moreover, urban planning has mainly reflected the interests of adult men, while women and children appear merely as objects⁴⁰40. García-Ramón MD, Ortiz A, Prats M. Urban planning, gender and the use of public space in a peripherial neighbourhood of Barcelona. Cities 2004; 21(3): 215-23. https://doi.org/10.1016/j.cities.2004.03.006
https://doi.org/https://doi.org/10.1016/... . The use and perception of public space have clear gender connotations and are a sample of the hierarchical relationship between men and women. Women have been historically relegated to the private space, so their relationship with the public space and PA reflects and reinforces their place in society³⁹39. Vilanova A, Soler S. Las mujeres, el deporte y los espacios públicos: ausencias y protagonismos. Apunts 2008; 91: 29-34.. And this has been observed even since childhood.

CONCLUSIONS

This is an original study that focuses exclusively on children to determine whether the socioeconomic context of the neighborhood influences the PP used for PA. One of its main strengths is helping to understand socioeconomic and gender disparities in the opportunity children have to develop their right to use public spaces for being physically active.

The limitations of this study relate to the fact that the study population was that of children who attended only municipal schools. Therefore, results cannot be extrapolated to the entire school-aged population. Secondly, although the sample of schools was randomly selected and inclusion criteria were pragmatic, the response rate decreased mainly due to a lack of parents’ participation, compromising the external and internal validity. Data from non-participants could not be obtained, but it can be assumed that children from more vulnerable families were more likely not to participate. However, in the current analysis, the mother’s educational level was not associated to the dependent variable, and we cannot suspect a high risk of selection bias. What limited our conclusions was the precision of results and the statistical significance due to a lower sample size and stratified analysis. Another limitation was the use of self-reported information, since this type of data is subject to recall bias or social desirability issues. However, people’s perceptions of their use of neighborhood spaces contribute to how they use and recognize their environment⁴¹41. Boehmer TK, Hoehner CM, Wyrwich KW, Ramirez LKB, Brownson RC. Correspondence between perceived and observed measures of neighborhood environmental supports for physical activity. J Phys Act Health 2006; 3(1): 22-36. https://doi.org/10.1123/jpah.3.1.22
https://doi.org/https://doi.org/10.1123/... .

Health inequalities determined by socioeconomic and gender conditions should be considered as health inequities¹⁸18. Almeida-Filho N. A problemática teórica da determinação social da saúde (nota breve sobre desigualdades em saúde como objeto de conhecimento). Saúde Debate 2009; 33(83): 349-70.. PA is a fundamental way to promote an appropriation of the public space and to create shared spaces for the exercise of citizenship. This is crucial for understanding what policies are required in territories of greater social vulnerability.

ACKNOWLEDGMENTS

The authors are grateful to the staff from the Secretariat of Education of the Municipality of Cordoba; to the community of municipal schools, teachers, students and their families and to the staff of CIESS for their helpful contribution during fieldwork. Finally, thanks to scientific policy promoted by Argentinean government from 2003 to 2015.

REFERENCES

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