Promotion of physical activity among children through a community intervention - the case of the ciclovía of Bogotá

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Promotion of Physical Activity among Children through a Community Intervention: The Case of the Ciclovía of Bogotá

Carlos Grijalbaa MD; Alejandra Bravoa, MD; Olga L. Sarmientoa MD MPH Ph.D; M Bolívara Pablo Lemoineb M.Sc Ph.D; Silvia Gonzáleza ND MPH;

Affiliations: a School of Medicine, Universidad de los Andes, Bogotá, Colombia; and b School of Engineer, Universidad de los Andes, Bogotá, Colombia.

Address correspondence to: Olga Lucia Sarmiento; School of Medicine, Universidad de los Andes, Carrera 1 No 18 A - 10 Bloque Q Piso 8, telephone; osarmien@uniandes.edu.co.

Short title: (pending)

Source: No external funding for this manuscript.

Financial Disclosure: The authors have no financial relationships relevant to this article to disclose. Conflict of Interest: The authors have no conflicts of interest relevant to this article to disclose. Abbreviations:

BMI – Body mass index

ISCOLE - International Study of Childhood Obesity, Lifestyle and Environment MVPA – Moderate to vigorous physical activity

NEWS – Neighborhood Environment Walkability Scale OSP - Open street programs

PA - Physical activity

PAHO – Pan American Health Organization SB - Sedentary behaviors

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Promotion of Physical Activity among Children through a Community Intervention: The Case of the Ciclovía of Bogotá

Abstract

Background and Objectives: Only one in four children and youth, between 6 and 15 years, meet

international recommendations on physical activity (PA). The Ciclovía is a promising community-based intervention implemented in at least 24 countries to promote PA and to reduce sedentary behaviors (SB). Nonetheless, most of the studies have been conducted among adults and no studies have assessed PA and SB among children. The aim of this study is to assess the associations between levels of PA and SB among children who participate in the Bogotá’s Ciclovía compared to those who do not participate. Methods: The study sample included 769 children aged 9-11 years. PA and SB were measured using a standardized protocol of accelerometry and Ciclovía’s participation was self-reported. Analysis include multilevel generalized mixed models and generalized additive model (GAM).

Results: The prevalence of participating weekly and at least once a month in the Ciclovía was 5.46% and 31.21% respectively. Children who participated in the Ciclovía at least once a month were more likely to have higher mean of total minutes of moderate-to-vigorous physical activity (MVPA) on Sunday than non Ciclovía participants (67,3 vs. 59,8, p=0,001). In addition, Ciclovía participants were more likely to have lower mean of total minutes of SB on Sunday than non Ciclovía participants (429,7 vs. 453,8, p=0,0015).

Conclusions: The Ciclovía are a promising strategy to promote PA y and to reduce time spent in SB among children.

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Introduction

According to international guidelines children and adolescents should do at least 60 minutes of physical activity (PA) each day1; nevertheless globally, only one in four children and one in five adolescents meet these recommendations2,3. The available evidence suggests that children and adolescents who meet the recommended guidelines for daily PA have higher levels of cardiorespiratory and muscular fitness outcomes compared to those who are inactive. Moreover, there is strong evidence that PA improves bone health, controls levels of body adiposity and reduces anxiety and symptoms of depression4,1,5. Besides, it has been found in recent studies that sedentary behaviors (SB) occur in up to 68% of adolescents3. Currently, SB has received increasing attention as a modifiable determinant of cardiometabolic health6–9.

There is a worldwide call to build societies in which each individual could choice to be physically active and to reduce the amount of time of SB10. In order to achieve these objectives, the Plan of Action for the Prevention of Obesity in Children and Adolescents, developed by the Pan American Health

Organization (PAHO), intent to frame public health activities with strategies that previously shown to be effective11. One of this programs is the Ciclovía and it is considered as part of the multisectoral

strategies which have shown favorable results on enhancing PA.

Environment could shape PA levels among children and adolescents, therefore the design of cultural strategies is an increasingly approach to reduce the progressively frequent “obesogenic

environments”10,12. The Ciclovía is a community-based program that encourage PA using public space during leisure time through cycling, rolling, walking, running or engaging on activities hubs. This kind of program close streets off temporarily to automobiles, allowing exclusive space utilization to

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pedestrians, skaters and bicyclists. The Ciclovía, as other Open Street Programs (OSP), has shown promising results in terms of PA promotion, generating increases to overall PA behavior among participants13,14. Then, the Ciclovía program may provide a unique opportunity to engage planned and incidental PA in a regulated and safety setting.

So far, there is a body of literature that has shown promising results in PA promotion among adults who participate on Ciclovía15, but to our knowledge there is no studies that focus on children. Therefore, the purpose of the present study is to measure the associations between levels of PA and SB among

children, between 9 to 11 years, who participate in the Bogotá’s Ciclovía compared to those who do not participate.

Methods

Study population and study setting

Bogota is the capital city of Colombia with over 8 million inhabitants, around 20% of the total population of the country. The school-age population of Bogotá for the year 2014 is over 1,4 million children.

The Ciclovía program

The Ciclovía was established on late seventies and has over 113 km of extension that covers 17 of 20 localities of the city. It is estimated an average of participation around of 1,4 million persons per event. Events are held throughout the year on Sundays and holidays.

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This analysis is part of the International Study of Childhood Obesity, Lifestyle and Environment (ISCOLE), conducted in 12 countries. The full protocol has been previously reported16. Colombia’s sample included 919 students from 20 schools in Bogotá, that were selected according to the following inclusion criteria: 1) schools in urban area; 2) schools belonging to January-December calendar; 3) schools enrolling students from elementary, middle and high-school in the same facility; 4) schools including boys and girls; 5) schools with a morning schedule; and 6) not being a school mainly for disabled population (blind, deaf, etc.).

Data collection

The data was obtained through an administered questionnaire, which evaluated sociodemographic characteristics of children and their parents. The questions were based on the U.S Youth Risk Behavior Surveillance System, the questionnaire Health Behavior in School-aged children Survey and the U.S NHANES survey. Parents were informed about the study in school meetings; they signed an informed consent before entering the study. Parents and children were able to quit the study at any moment.

ISCOLE protocol was approved by the Pennington Biomedical Research Center Institutional Review Board and all the protocols and questionnaires were also reviewed and approved by the Institutional Review Board of the Universidad de los Andes in Bogotá.

Measures

Outcome variables: Moderate to vigorous physical activity and sedentary behavior

Actigraph GT3X + Accelerometer (ActiGraph LLC, Pensacola, FL, USA) was used to objectively measure moderate to vigorous physical activity (MVPA) and SB among children. Children were asked to use the

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accelerometer 24 hours per day for 7 days using an elasticized belt around the waist at the right mid-axillary line (Plus an initial familiarization day and the morning of the final day), in order to calculate the MVPA mean. The minimal amount of the accelerometer data that was considered acceptable for the study was 4 days a week with effective 10 hours per day, including at least one weekend day. In order to calculate MVPA the Evenson equation was used17, in which MVPA was defined as all activity greater or equal to 574 counts per 15 seconds and SB was defined as all activity less than 25 counts per 15

seconds. These measurements has been previously validated18. In order to use the accelerometer data, the number of valid days achieved was determined and the mean number of MVPA minutes per valid day was calculated.

Independent variables Ciclovía participation

A self-reported instrument was used in order to assess whether children attended to the Ciclovía. Parents were asked the following question: “How often does your child attend to the Ciclovía? The answers were dichotomized, 0 if parents reported that the children didn´t attend to the Ciclovía or that they attend only once a year and 1 if children attended once a month or more.

Co-variables: sociodemographic and anthropometric characteristics

For sociodemographic characteristics, a questionnaire addressed to children and administered by an interviewer was used to assess gender and age of participants. Anthropometric measures were performed by trained staff during in-school visit; detailed procedures have been published previously16. Also, an administered questionnaire completed by parents capture information about parent´s education (highest education level of the mother or the father), socioeconomic status and presence of motorized vehicles in

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the household. Finally, an adapted subscale based on Neighborhood Environment Walkability Scale (NEWS) was used to assess crime safety perception,. This subscale includes 5 questions with 4 possible answers (Likert type); an estimator was created with an average score.

Statistical Analysis

Statistical measures –means and standard deviations- were computed for variables with complete data for accelerometry and covariates. Associations between participation on the Ciclovía and PA or SB were estimated using multilevel generalized linear mixed models (SAS PROC MIXED). All these models were adjusted for age, sex, average body mass index (BMI) z-score, socioeconomic status, availability of motorized vehicles, highest level of parental education and criminality. The possible contextual effect of schools on MVPA and SB was assessed using an intra-class correlation (ICC). All data management were conducted with SAS 9.3 (SAS, Cary, 2007). The significance level was set at p<0.05.

It was also included an additional analysis assessing differences in hourly distribution of MVPA minutes throughout the day between Ciclovía users and nonusers. These comparisons were conducted using a generalized additive model (GAM) function of the MGCV package in R version 3.0.1 (R Foundation for Statistical Computing) with a smooth covariate function (time of day) for each group. GAM was fitted according to the data using a Poisson distribution with a log-link function and used thin-plate regression splines to estimate a smooth function. The model structure used for users and nonusers was:

𝐿𝑜𝑔{𝑢𝑖} = 𝑓(𝑥𝑖) + 𝜖𝑖,

Where 𝑢𝑖 = 𝐸(𝑦𝑖) and 𝑦𝑖~𝑃𝑜𝑖𝑠𝑠𝑜𝑛.

𝑦𝑖 is MVPA minutes throughout the day, 𝑥𝑖 is time of day, 𝑓 is a smooth function of the covariate 𝑥𝑖 represented using a thin-plate regression spline basis, and 𝜖𝑖 are i.i.d. 𝑁(0, 𝜎2) random variables.

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Results

The descriptive characteristics of the sample are summarized on table 1. Of the 919 children included in Iscole-Colombia, 769 remained in the analytic data due to validity of accelerometry information. The response rates of the twenty schools randomly selected was 75%. According to sex distribution 50,1% of participants were boys and the average age of participants was 9.90,6 years. Parents highest education was varied but the majority (69%) had high school diploma or more. The predominant socioeconomic status in this sample was low (1-2) with 76.5%; highest (5-6) socioeconomic status was the minority, with 5,4%. Only 24.9% of the families had 1 or more motorized vehicles, including cars, trucks or motorcycles in the household. Parental perception of criminality on average was 3,41 of 4 possible points in the subscale of NEWS, a higher score reflects greater perception of criminality.

The data about participation on Ciclovía is reported on table 2. It was found that 31,2% of children participate in the Ciclovía at least once per month. The preferred mean of transportation was the bicycle (47,6%), followed by walking (33,9%) and skates (9,1%); there were no wheelchairs reported. Also it was found that 50,78 of participants could find a route of the OSP in less than 1500 meters. Most of parents reported that their children engage on PA during Ciclovía participation at least 60 minutes (96,8%).

The results of accelerometry-based PA and SB (see Table 3) show that the mean of total minutes of MVPA on Sunday was 59,8 minutes for non-Ciclovía users and 67,3minutes for Ciclovía users

(Difference=-7,51; IC(95%)=-13,2 to -18,3, p=0,01). For SB on Sunday, the mean of total minutes for non-Ciclovía users was 453,8minutes vs. 429,7minutes for the Ciclovía users (Difference=24,1;

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IC(95%)=9,3 to 38,9, p=0.002). Furthermore, based on the generalized additive model hourly distribution of predicted MVPA was significantly higher in Ciclovía users between 16:00 to 17:00 (Figure 1) and SB was significantly lower between 10:00 to 11:00 (figure 2) during the event day.

Discussion

The data yielded by this study suggest that Ciclovía users, in this case children between 9 and 11 years old from Bogotá, have significant higher mean minutes of MVPA and lower mean minutes of SB on Sunday, compared to non-Ciclovía users. According to our results there is a predicted value of MVPA minutes higher and a lower predicted value of SB minutes in those who participate on Ciclovía at least once per month compare with those who do not attend. To date, there are no other studies that address these variables in children; however, we could make an analogy with other studies made in the adult population, reporting that the majority of Ciclovía participants are more likely to meet the PA recommendations in their leisure time than non-Ciclovía participants15. In addition, data from other studies involving children between 6 and 11 years old are similar to our results, showing that this age group spends 88 minutes/day doing MVPA and 351 minutes/day in SB19.

Nowadays, it is well known that policy and environmental conditions have an influence on the development of today´s major health problems and may have the potential to increase PA better than changes in individual attitudes and behaviors20,21. The Ciclovía may have the potential to increase the level of PA in children, which should be one of the main goals in public health as previously mentioned, as currently only 26% of Colombian youth meet the WHO guidelines for PA; nonetheless for children between 1-12 years of age there is a lack of national data22.

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As mentioned earlier, SB is emerging as an important and ndependent chronic disease risk factor. Our study suggests that the Ciclovía could potentially decrease SB in children. Currently, there is a lack of specific guidelines for overall sedentary behavior; therefore, the majority of studies rely on the

American Academy of Pediatrics recommendations, which claims that children should be limited to 2 hours or less screen time per day18. According to Colombia´s national data the prevalence of spending more than 2 hours in SB such as screen time in children aged 5-12 is 57.9% and for adolescents aged 13-17 is 67%21. These numbers indicate a similar prevalence compared to global data: in the United States, 59.1% and 47.8% of children aged 6-8 and 9-11 years old respectively do not meet the recommendations mentioned above2. Given the magnitude of this problem, efforts should be directed to decrease the time spent in SB among children; moreover, future studies should be directed to examine productive SB and leisure time SB independently23, in order to develop better recommendations on this matter. Also, the Ciclovía should be further studied to assess its potential to lower SB in children and adolescents.

We found that majority of participants lived mainly in low and middle SES areas. This is similar to the distribution of areas by SES of Bogotá city, where 51.19% of the population live in low SES (categories 1 and 2), 43.11% live in middle SES (categories 3 and 4), and the minority (4.17%) live in high SES (categories 5 and 6)24. Studies suggest that low income neighborhoods are about 4.5 times more likely not to have recreational facilities than high income areas, suggesting that recreational facilities and the resources they offer are not equitably distributed. Ciclovía are an opportunity to address this problem, since they are easier to install compared to parks, may have large covered areas and are able to connect different parts of the city25. In Colombia, these inequalities have also been acknowledged; in fact, Colombia is considered one of the countries with more socioeconomic inequity in Latin America26.

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The evidence presented here suggest that the Ciclovía may contribute to the equity problem related to PA by allowing the low SES groups, as well as the middle and high SES groups, to have access to free recreational spaces in the city of Bogotá. Furthermore, the Ciclovía is extensively distributed throughout the city, connecting socioeconomically diverse areas, which could contribute to the access inequalities of the city15. Then prioritizing closer proximity safe play areas programs as Ciclovía may improve children´s PA participation. Implementation of this kind of programs may reduce disparities in PA due to improvement on social cohesion that correlates with lower criminality perception.

Currently, more than three hundred cities in the Americas have established these programs, with the fastest expansion in the US and Canada during the last decades. This trend has been increasing

supported in recent publications highlighting gains in health, economic and public policy. The Ciclovía promote healthy recreation, social cohesion and enhance economic activities around a programmatic intervention 12,13,27,28. Moreover, this kind of programs stimulate inter-community organizational partnerships, community organization, safety perceptions and resident interaction aimed at promoting healthy activities. Thus is proposed that Ciclovía could increase MVPA and reduce SB between children, and also could serve as a buffer to social inequity29,30.

Limitations and implications of the study to the research field

The main limitations of this study are its cross-sectional design and the lack of control groups. In addition, part of this study relied on administered questionnaires adapted from validated instruments. Future studies on Ciclovía in children should address these limitations.

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The main contribution of this study to public health research is that, to date, it is the first study to objectively measure MPVA and SB on children who participate in the Ciclovía, comparing them to those who do not participate. Moreover, is the first study to address the importance of programs like the Ciclovía in children. For these reasons, this study represents a considerable effort to better understand OSP in this particular population, measuring important outcomes that could be the basis for future studies. Our results also show the importance of these programs for special populations, such as children who live in areas of low SES, which could have an impact on matters of public health, such as equity.

Conclusions

The Ciclovía represent a well stablished promising strategy to promote PA and to reduce time spent in SB among children. The Ciclovía as a health promotion strategy should be considered as a plausible community-level approach to encounter problems such as childhood overweight, obesity and sedentary lifestyles, in order to possibly decrease the burden of disease associated with these risk factors. For these reasons, policymakers should continue to support and promote creation of Ciclovías.

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Tables

Table 1. Sociodemographic variables from children included n=768

n %

Variables Gender

Male 385 50,1

Female 383 49,9

BMI*

Undernutrition / Normal 588 76,6

Overweight / Obesity 180 23,4

Socioeconomic status

Low (1-2) 588 76,6

Medium (3-4) 138 18,0

High (5-6) 42 5,5

Highest parental education

Less than secondary/high school 76 9,9

Some secondary/high school 159 20,7

High School Diploma 273 35,6

Technical degree or 1-3 years of college 126 16,4

Undergraduate degree 99 12,9

Postgraduate Degree 35 4,6

Number of functioning motorized vehicles at household

No automobiles at household 577 75,1

One or more than one automobile 191 24,9

Mean ED

Age 9,99 0,6

Criminality perception 3,4 0,7

* Z-Score: Undernutrion <-2; normal -2 to 1; overweight 1 to 2; obesity >2

Table 2. Participation on OSP (Ciclovía) characteristics n = 768

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Children´s participation on OSP (Ciclovía)

Never or once a year 528 68,75

Once a month or more 240 31,25

Distance to OSP (meters)

1 to 1500 390 50.78

1500 to 6000 378 49.22

Means of transportation*

Bicycle 163 47.66

Skates 31 9.06

Walking 116 33.92

Jogging 14 4.09

Scooter 1 0.29

Skateboard 17 4.97

Time spent in the Ciclovía by children**

Less than 60 minutes 3 0.87

60 minutes or more 341 99.13

Time spent in the Ciclovía doing PA by children**

Less than 60 minutes 11 3.20

60 minutes or more 333 96.80

* Missings = 4 ** Missings = 2

Table 3. Accelerometry-based physical activity and sedentary behaviors during

week and Sunday setting

Variables* Non-Ciclovía users Ciclovía users Estimate Lower IC Upper IC p value Mean of total minutes of MVPA on

Sunday 60,08 66,60 -6,51

-12,21 -0,82

0,03

Mean of total minutes of SB on Sunday 453,10 431,19 21,91 7,11 36,71 0,004

*Adjusted by age, sex, socioeconomic status, household automobile, highest parental education and criminality.

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Figure 1. Estimated values of the generalized additive model of predicted MVPA minutes comparing Ciclovía users with non users.

Figure 2. Estimated values of the generalized additive model of predicted SB minutes comparing Ciclovía users with non users

Figure

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Referencias

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