Assessing Physical Activity in Public Parks in Brazil UsingSystematic ObservationDiana C. Parra, MPH, Thomas L. McKenzie, PhD, MSc, Isabela C. Ribeiro, PhD, MSc, Adriano A. Ferreira Hino, BA, Mariah Dreisinger, MPH,Kathryn Coniglio, MPH, Marcia Munk, MSc, Ross C. Brownson, PhD, Michael Pratt, MD, PhD, Christine M. Hoehner, PhD, MSPH,and Eduardo J. Simoes, MD, MPH

Physical activity during leisure time has par-ticular relevance for public health practitionersbecause of its important role in preventingchronic disease and improving mental health,perceived health status, and quality of life.1,2

Leisure-time physical activity can also contributeto increased social interactions and social supportand promote a greater sense of communitycohesion.1 However, despite its well-known ben-efits, the prevalence of leisure-time physicalactivity continues to be low in many populations,particularly in low-income countries.3

Numerous studies have found that the builtenvironment plays an important role in pro-moting active living and its correspondinghealth benefits,4–6 and public parks have beenidentified as important environmental resourcesfor promoting leisure-time physical activity.7

Public health authorities have emphasized thataccess to and the promotion of parks, trails, andother public recreational facilities help commu-nity members reach recommended levels ofphysical activity.8,9 Systematic literature reviewshave also found that access to public recreationalfacilities promotes physical activity at the com-munity level.10,11 Specifically, the possibility ofbeing physically active is greater among thoseliving in areas with a larger proportion of landdedicated to public parks.12,13 Studies have alsorecommended promoting programs within thecommunity through the use of outreach activi-ties, some of which have been implemented byprograms in Latin America.14–16

A systematic review of community-basedphysical activity interventions in the LatinAmerican public health literature (in Spanishand Portuguese) was conducted in 2006 dur-ing the first phase of Project GUIA (Guide forUseful Interventions for Activity in Brazil andLatin America).17 The review identified 3 phys-ical activity intervention categories that had notpreviously been included in the US Guide toCommunity Preventive Service review.10 One of

these strategies was the offering of physicalactivity classes in community settings, includingpublic parks. This strategy has been employed bythe Academia da Cidade Program (ACP; inEnglish, ‘‘City Gyms’’), a municipal programsponsored by the Secretariat of Health in Recife,Brazil. This public policy strategy makes use ofenvironmental resources, such as parks, that arecurrently available in communities to deliverphysical activity classes and health and nutri-tional counseling free of charge.14 The secondphase of Project GUIA included the evaluation of2 ongoing community-based physical activitypromotion interventions in Brazil, with the ACPin Recife being one of the programs chosen fora comprehensive evaluation using both qualita-tive and quantitative methods.14

The use of systematic observation methodshas been promoted as a strategy suitable formonitoring levels of physical activity in thecommunity.18–20 One instrument, SOPARC(System for Observing Play and Recreation inCommunities), has been used to obtain reliable

information on physical activity and relatedvariables in parks in the United States. There isa need for alternative evaluation approaches tophysical activity at the population level, andmethods like SOPARC could be good alterna-tives.21,22 We used the SOPARC method tocompare physical activity levels, park use, andpark contextual characteristics in sites with andwithout the ACP.

METHODS

Recife, the capital in Pernambuco State innortheastern Brazil, is the country’s fifth largestcity, with over 1.5 million people. It has a trop-ical climate and warm temperatures that con-tribute to outdoor physical activity year round.Although mortality from cardiovascular dis-ease has been declining in Brazil, states in thenortheast region, including Pernambuco, haveshown reverse trends, with mortality rates in-creasing among both men and women.23 Ad-ditionally, a study by the Brazilian Ministry of

Objectives. We assessed park use in Recife, Brazil, and differences in physical

activity and occupation rates in public parks with and without the Academia da

Cidade Program (ACP), which provides cost-free, supervised physical activity

classes.

Methods. We used the System for Observing Play and Recreation in Commu-

nities (SOPARC) in 128 targeted areas in 10 park sites (5 ACP sites, 5 non-ACP

sites) to obtain data on the number of users and their physical activity levels and

estimated age. Each area was assessed 4 times a day for 11 days over a 4-week

period.

Results. A total of 32 974 people were observed during 5589 observation visits

to target areas. People using ACP parks were more likely to be seen engaging in

moderate-to-vigorous (64% vs 49%) and vigorous (25% vs 10%) physical activity.

Relatively more participants in ACP sites than in non-ACP sites were females

(45% vs 42% of park users) and older adults (14.7% vs 5.7% of park users).

Conclusions. On the basis of systematic observation, ACP appears to be

a useful strategy in promoting park use and physical activity among the

population in Recife. (Am J Public Health. 2010;100:1420–1426. doi:10.2105/

AJPH.2009.181230)

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Health in 2007 found 43% of Recife adults (‡18years) to be overweight (body mass index‡25kg/m2) and 11% to be obese, rates that areamong the highest of the country.24 Recife alsohas the fifth lowest prevalence of leisure-timephysical activity of all state capitals,3 and a recentsurvey found that only 19% of its population(26% of males, 14% of females) met recom-mended levels.14

The ACP, defined as a health promotionpolicy with a focus on physical activity, leisure,and healthy eating, was first implemented in2002 by the health secretary of Recife. Theprogram currently has approximately 30000participants in its 19 ‘‘polos’’ (i.e., settings wherethe intervention occurs, commonly publicparks). The program takes place daily from5:30 to 8:30 AM and from 5:00 to 8:00 PM; itincludes aerobic and dance classes and orga-nized jogging groups, as well as exercise anddiet orientation sessions for healthy people andalso those with hypertension, obesity, diabetes,and heart disease.25

Study Design

Our study, which was conducted in 2007,used the SOPARC methodology21 to objectivelyquantify levels of physical activity as well as userand park characteristics in 10 small to largeparks (2400–85926 m2) located in urbanneighborhoods in Recife. Table1gives the size ofACP and non-ACP parks selected for the study,as well as the socioeconomic status (SES) of theirneighborhoods. We used purposeful sampling toselect an equal number of ACP and non-ACPparks. We attempted to match ACP and non-ACP parks by neighborhood SES and type ofsetting (there were 6 inland parks and 4 beachsites that included both parks and trails, eachgroup divided equally between ACP and non-ACP sites), because previous literature showedevidence that these factors may affect leisure-time physical activity.26–28 In addition, we se-lected parks to represent each of the 6 politicaladministrative regions of the Municipality Office.These political administrative regions representa balanced distribution of Recife’s diversity inlocal (neighborhood) political representation andsocioeconomic stratification as identified by typeof residential developments (e.g., neighborhoodswith slums or poor dwellings) and the meanmonthly income of neighborhood residents.29,30

Taking practical considerations (such as safety)

into account, we distributed the final sample of10 sites throughout the city (Table 1).

Using specially designed coding forms,SOPARC observers classified park usersaccording to their physical activity level, sex,activity modes or types, and estimated agegroup. SOPARC also provided information onindividual park activity areas, such as theirlevels of accessibility, usability, supervision,and organization. Prior to data collection andthe SOPARC protocol, each site was mappedand divided into smaller target areas for mea-surement. A total of 128 target areas wereselected for observation (mean=12.8 areas perpark); these included green spaces and picnicareas, playgrounds, multipurpose fields, sport-specific fields or courts, and gymnastic orfitness areas (all of these were standard loca-tions for the ACP physical activity classes).Certified assessors then visited the target areasat specific times on randomly scheduled days,both weekdays and during weekends.

Observation Protocol

During each visit to a target area, assessorsused the SOPARC observation protocol to scanslowly from left to right (taking approximately1second per person) while using a mechanicalcounter to score each person in the area by sex,age group (child, adolescent, adult, or olderadult—that is, apparently older than 60 years),and physical activity–level code, which in-cluded sedentary (lying down, sitting, orstanding), walking, and vigorous (activitiesproducing a heart rate faster than duringordinary walking). Data were then transferredto prepared observation forms. During eachvisit, assessors also rated the contextual char-acteristics of target areas according to thefollowing categories, classifying them as yes orno: accessible (i.e., open to the general public),usable (i.e., suitable for physical activity), su-pervised (i.e., directly monitored by local per-sonnel such as park rangers, security guards,teachers), and equipped (i.e., had ‘‘loose’’equipment such as balls provided).

SOPARC has been used successfully andwith high reliability and validity21,22,31 in theUnited States; for our study, some physicalactivity categories were adapted for culturalrelevance to Brazil (e.g., American football wasomitted and dance was added). The observationprotocol and forms were translated by a native

Portuguese speaker, fluent in English, andchecked for accuracy.

Observation Schedule

Observations were conducted over a periodof 28 days in September 2007. Each targetarea (n=128) was scheduled to be observed on11 different days at each park during 4 one-hour observation periods (starting at 6:30 AM,9:30 AM, 2:30 PM, and 5:30 PM) on bothweekdays and weekends. Data were collectedduring 5589 visits to the target areas (i.e.,5632 scheduled visits minus 43 visits notmade [0.7%]). The observation times permit-ted comparisons to be made throughout theday and at times when ACP activities were inplace and when they were not. A set rotationensured that observations at each site includedeach day of the week twice (i.e., 2 Sundays, 2Mondays, and so on). Observations were con-ducted only during clement weather, and

TABLE 1—Characteristics of Parks

With and Without the Academia da

Cidade Program (ACP): Recife, Brazil,

2007

Site SESa Size, m2

ACP

Jaqueirab High 84 100.16

Hipodromob Middle 11 835.75

Sitio da Trinidadeb Low 79 497.15

Boa Viagemc High 3267.89

Brasilia Teimosac Low 2400

Non-ACP

Casa Forteb High 7891.78

Treze de Maiob Middle 85 926.31

Ypirangab Low 6783.73

Piedadec Middle 4325.78

Boa Viagemc High 2785.30

Note. SES = socioeconomic status.aSES was determined on the basis of the cityadministration’s classification, which uses the type ofresidential developments (e.g., neighborhoods withslums or poor dwellings) and monthly mean income ofthe residents. High SES was considered a monthlymean income of 4000 Brazilian reais, equivalent toUS $2300; middle SES was considered a monthlymean income of 1800 Brazilian reais, equivalent toUS $1035; low SES was considered a monthly meanincome of 500 Brazilian reais, equivalent to US $287.bInland location.cBeach location.

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missing observations were rescheduled to takeplace on the same day and hour during a laterweek.

Observer Training

Nine trained SOPARC observers conductedall observations under the supervision of 2field coordinators. Observer training was con-ducted by 4 core team members of the GUIAProject who had been trained by the creator ofthe SOPARC tool.21 Observer training consistedof a 2-day workshop. On day 1, trainees partic-ipated in interactive classroom sessions designedto familiarize them with operational definitions,instrument notation, and coding conventions,and to help them to discriminate among variousphysical activity and contextual characteristics.Trainees practiced coding and received feedbackon their scoring using examples contained in theSOPARC training DVD, which was translatedfrom English into Portuguese. On day 2, traineesreviewed the materials and practiced their skillsin diverse field exercises in local parks.

Data analysis. Descriptive statistics (SPSSversion14.0; SPSS Inc, Chicago, IL) were used toexamine differences in the frequencies andpercentages of park users by sex, age, physicalactivity level, park characteristics, and presenceor absence of ACP. Separate analyses of park usewere conducted by time of observation (e.g.,early morning) and ACP in operation as well aspark use patterns by neighborhood SES, ACPpresence, and type of setting (i.e., inland, beach).Statistical tests (c2) were calculated, and signifi-cance was set at a a £ .05.

Reliability. Reliability data were collectedduring 24 different 1-hour time periods bypairs of observers who made simultaneous andindependent observations. During reliabilityobservations, 28825 people were seen, anaverage of 3353 per park (range=792–5286). Reliability analyses were conducted toassess interobserver agreement on (1) charac-teristics of target areas (i.e., accessibility, us-ability, supervision, organization, and whetherthey were equipped), (2) number of femalesand males in target areas, and (3) age groupand physical activity levels of females andmales in target areas. Interobserver agreementscores on all area characteristics were high(Pearson product moment correlation=0.87).Agreement between assessors on the totalnumber of individuals, as well as their sex, age,

and physical activity levels, was also high,exceeding 90%.

RESULTS

A total of 5589 visits to target areas weremade and 32974 people were observed (meanusers per park=3297; range=935–9885).Table1shows use patterns by presence of ACP.Overall, more males than females were ob-served in the target areas (56% vs 44%;P<.001); adults (64%) were seen most fre-quently, followed by adolescents (13%), chil-dren (13%), and older adults (11%). Whenobserved, 43% of the people were sedentary,39% were walking (moderate physical activity),and 18% were engaged in vigorous activity(P<.001).

A significantly greater proportion of parkusers in ACP sites than in non-ACP sites werefemales (45% vs 42%; P<.001) and olderadults (15% vs 6%; P<.001). In addition,people in ACP sites were observed to besedentary less often (36% vs 51%; P<.001)and more likely to be engaged in vigorousphysical activity (25% vs 10%; P<.001)(Table 2).

Table 3, which describes the contextualcharacteristics of target areas, shows that bothACP and non-ACP sites were accessible, usable,and had organized activities nearly all the timesthey were visited. Target areas in ACP sites,however, were significantly more likely to be

equipped (9.0% vs 0.2% of the time; P<.001)and supervised (88% vs 46%; P<.001).

Park Use Patterns by Time of Observation

Overall, significantly more park users wereseen during the 2 afternoon periods than the 2morning periods (54% vs 46%; P<.001).Figure 1 shows that there was also variation inthe proportion of people engaged in the 3levels of physical activity (i.e., sedentary, walk-ing, and vigorous) by time of day in both ACPand non-ACP sites. A greater proportion ofpeople in ACP sites were engaged in vigorousphysical activity during all observation periods,but this was particularly evident at the specifictimes during which ACP activities were beingconducted; that is, at 6:30 AM (25.3% at ACPsites vs 16% at non-ACP sites; P<.001) and5:30 PM (28.2% at ACP sites vs 9.5% at non-ACP sites; P<.001). In addition, the proportionof people engaging in sedentary behaviors wassubstantially smaller in ACP sites during alltime periods, especially during the 5:30 PM

period (33.9% at ACP sites vs 59.7% at non-ACP sites; P<.001).

Park Use Patterns by Presence versus

Absence of Intervention

Taken together, Figures 2 and 3, whichillustrate physical activity levels at beach (parksand trails) and inland park locations by ACPpresence and neighborhood SES, show mod-erate-to-vigorous physical activity (walking plus

TABLE 2—Park Use Patterns, by Presence or Absence of the Academia da Cidade Program

(ACP): Recife, Brazil, 2007

All Sites, No. (%) ACP Sites, No. (%) Non-ACP Sites, No. (%)

Total users 32 974 (100) 18 007 (55) 14 967 (45)

Sex

Male 18 494 (56) 9889 (54.9) 8605 (57.5)

Female 14 480 (44) 8118 (45.1) 6362 (42.5)

Age group

Children 4147 (13) 2373 (13) 1774 (11.9)

Adolescents 4294 (13) 2388 (13.3) 1906 (12.7)

Adults 21 033 (64) 10 892 (60.5) 10 141 (67.8)

Older adults 3500 (11) 2644 (14.7) 856 (5.7)

Physical activity level

Sedentary 14 129 (43) 6532 (36.3) 7597 (50.8)

Moderate 12 862 (39) 7042 (39.1) 5820 (38.9)

Vigorous 5983 (18) 4433 (24.6) 1550 (10.4)

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vigorous activity) to be higher at beach loca-tions. Figure 2 shows that the proportion ofpeople engaged in moderate-to-vigorous phys-ical activity at beach locations was higher atnon-ACP sites than at ACP sites in both low-to-middle-SES neighborhoods (92.7% vs 71.3%;P<.001) and high-SES neighborhoods (98.9%vs 71.4%; P<.001).

Figure 3 shows that a greater proportion ofpeople in ACP parks were engaged in vigorousphysical activity in both low-to-middle-SESneighborhoods (20.8% vs 6.1%; P<.001) andhigh-SES neighborhoods (26.6% vs 10.3%;P<.001). Figure 3 also shows that a substantiallylarge proportion (64.7%) of people in inlandparks were sedentary, particularly in the non-ACPsites in the low-to-middle-SES neighborhoods.

DISCUSSION

To our knowledge, this investigation is thefirst to use direct observation on a large scaleto study physical activity levels in Latin

America. The results suggest that SOPARC isa reliable and feasible instrument for assess-ing physical activity and associated contex-tual variables (e.g., time of day, use ofequipment, park characteristics) in commu-nity settings in Latin America. In our study,the presence of the ACP was associated witha higher prevalence of vigorous physicalactivity, particularly at inland sites. Previousresearch showed that former and currentACP participants were more likely to meetphysical activity recommendations than non-ACP participants.16 The provision of locallyfunded programs may be an effective approachfor increasing levels of physical activity at thepopulation level, especially for lower-incomepopulations. Public parks are potential resourcesfor the promotion of physical activity duringleisure time, and they are especially relevant tolow-SES populations, which rely on cost-freefacilities.

A greater proportion of the park users inRecife were observed to be engaged in

moderate-to-vigorous physical activity thanwere users of 8 Los Angeles parks in a studyusing the same instrument (57% vs 34%).31

Our results, however, were similar to those ofMcKenzie et al.21 and Cohen et al.22 in that weobserved more males than females, more adultsthan any other age groups, and more users in theafternoon and evening periods than at othertimes. In addition, our results were similar tothose of Ferreira et al.,32 who used the SOPARCmethodology in the city of Curitiba, Brazil, a yearafter we conducted our study. They also ob-served more men than women, as well as moreadults and adolescents than older adults andchildren, which is similar to what we found in ourstudy.

According to a recent physical activity pop-ulation prevalence survey in the capitals of themain Brazilian states, walking is the mostcommon—and the preferred—physical activityfor both males and females.3 We observeda large proportion of the park users engaging inwalking, particularly in beach locations. It isimportant to mention that 3 of the 4 beach sitesincluded walking and running trails alongside thebeach; this could have contributed to our find-ings, since most of the people observed at theselocations were engaging in walking, jogging, orrunning. This helps to explain the large per-centage of people observed to be engaged inwalking and vigorous activity at beach sites ascompared with inland sites, particularly at non-ACP sites. A study conducted by Bauman et al.26

documented a coastal effect on physical activity;they found that proximity to the coast was

TABLE 3—Contextual Characteristics of the Target Areas in Parks With and Without the

Academia da Cidade Program (ACP): Recife, Brazil, 2007

Characteristic of Site All Sites (n = 5589), No. (%) ACP Sites (n = 2855), No. (%) Non-ACP Sites (n = 2734), No. (%)

Accessible 5395 (97) 2664 (93) 2731 (99)

Usable 5386 (96) 2655 (93) 2731 (99)

Equipped 262 (5) 255 (9) 7 (0.2)

Supervised 3775 (66) 2512 (88) 1263 (46)

Note. Numbers and percentages are based on total number of observation visits.

Note. ACP = Academia da Cidade Program

FIGURE 1—Patterns of park use in parks with and without the Academia da Cidade Program (ACP): Recife, Brazil, 2007.

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independently associated with higher levels ofphysical activity after adjusting for potentialconfounders.

We found that more people used ACP parksthan non-ACP parks, and that people in ACPparks were more active, particularly during thehours that program activities were in sessionand in sites away from the beach. Our resultssupport the findings of a randomized popula-tion phone survey,14 which reported that peoplewho heard about or participated in the ACPprogram were more likely to meet leisure-timephysical activity recommendations for health.Our results and an earlier evaluation of theprogram14 suggest the effectiveness of the ACP.Findings suggest that availability of cost-free and

open spaces, such as walking and running trails,could be a good public investment for the pro-motion of physical activity. This has implicationsfor governmental planning and policy in Braziland Latin America, suggesting that investmentsin programs like the ACP should be considered.

With large coverage at a relatively low cost,SOPARC provides an objective tool for assess-ing physical activity and numerous associatedcontextual characteristics. The results of thisstudy suggest that direct observation of se-lected public spaces may be useful in providingpopulation estimates of physical activity as wellas examining program effects in an urbandeveloping country where there are issuesof safety, low income, and limited options

for recreational physical activity. BecauseSOPARC can assess the number and demo-graphic characteristics of people using publicspaces, and the types and intensity of physicalactivity they engage in, it is a useful alternativeto traditional surveys.

Limitations of this study include the absenceof data on the condition of facilities and theiramenities, the proximity of people to theselected sites, and their perceptions of safety.The confounding effect of characteristics of thebuilt environment and social characteristicscannot be determined by the data gathered inthis study. As with most studies using directobservation methods, there was the potentialfor participants to react to the presence of

Note. ACP = Academia da Cidade Program; SES = socioeconomic status.

FIGURE 2—Physical activity levels in parks at beach locations (n=4), stratified by neighborhood socioeconomic status: Recife, Brazil, 2007.

Note. SES = socioeconomic status.

FIGURE 3—Physical activity levels in parks at inland locations (n=6), stratified by neighborhood socioeconomic status: Recife, Brazil, 2007.

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observers; however, the locations of the ob-servers were purposefully selected to guaran-tee the lowest visibility to the participants. Veryfew people responded with curiosity or ques-tioned observers about why they were there.Observers reported that they were typicallyignored, and none of them reported that anyof the people they observed displayed territo-riality.

Our findings show the promise of parks inpromoting physical activity. Nonetheless, al-though parks served many people, they wererarely filled to capacity, and individual targetareas were occupied during only 41% of theobservation visits. Assessing community feed-back relative to park features and programmingwould go a long way to determining how fundsfor public parks should be allocated. By usingfeedback, it might be possible to modify facilitiesand create programs to meet the specific needsof community members, thus attracting morepeople to engage in physical activity.

ACP programs may have been a contributorto vigorous physical activity, particularly inlow-income areas in sites away from the beach,where parks with an ACP program were likelyto have a greater proportion of users partici-pating in vigorous activity. Additionally, rec-ommendations for physical activity are fre-quently focused on leisure-time physicalactivity. However, this recommendation rarelyresonates with lower socioeconomic popula-tions, where cultural and economic conditionsrestrict leisure-time physical activity (i.e., theyhave less leisure time and fewer safe areas inwhich to exercise).31 Therefore, providing freeor low-cost physical activity programs at thecommunity level, such as the ACP, may bea good way to reduce disparities in physicalactivity rates. j

About the AuthorsDiana C. Parra, Mariah Dreisinger, and Ross C. Brownsonare with the George Warren Brown School of SocialWork, Washington University in St. Louis, St. Louis, MO.Thomas L. McKenzie is with the School of Exercise andNutritional Sciences, San Diego State University, SanDiego, CA. Isabela C. Ribeiro is with the Air Pollution andRespiratory Health Branch, Centers for Disease Controland Prevention, Atlanta, GA. Adriano A. Ferreira Hino iswith the Pontifıcia Universidade Catolica do Parana,Curitiba, Brazil. Marcia Munk is with the Department ofPreventive Medicine, Universidade Federal de Sao Paulo,Sao Paulo, Brazil. Kathryn Coniglio was with the School ofPublic Health, Saint Louis University, St. Louis, MO.

Michael Pratt is with the Physical Activity and HealthBranch, Division of Nutrition, Physical Activity andObesity, Centers for Disease Control and Prevention,Atlanta, GA. Christine M. Hoehner is with the School ofMedicine, Washington University in St. Louis, St. Louis,MO. Eduardo J. Simoes is with the National Center forChronic Disease Prevention and Health Promotion, Centersfor Disease Control and Prevention, Atlanta, GA.

Correspondence can be sent to Diana C. Parra, MPH,8150 Whitburn Dr 2 W, Clayton, MO 63105 (e-mail:dianacpp79@yahoo.com). Reprints can be ordered athttp://www.ajph.org by clicking on the ‘‘Reprints/Eprints’’link.

This article was accepted December 10, 2009.

ContributorsD. C. Parra supervised the study and led the analyses andwriting of the article. T. L. McKenzie contributed to thewriting of the article and the analyses. I. C. Ribeirocontributed to the writing of the article. A. A. FerreiraHino assisted with the analyses and contributed to thewriting of the article. M. Dreisinger, K. Coniglio, and M.Munk assisted with the study and analyses and contrib-uted to the writing of the article and the approval of thefinal version. R. C. Brownson, M. Pratt, and C. M.Hoehner contributed to the writing of the article and theapproval of the final version. E. J. Simoes providedimportant feedback in the study design and analyses andcontributed to the writing of the article and the approvalof the final version.

AcknowledgmentsThis study was funded by a grant from the Centers forDisease Control and Prevention through the PreventionResearch Center Program (grant U48/DP000060-02).

Special thanks go to the members of Project GUIA(Mario Bracco, Pedro Hallal, Branka Legetic, DeborahMalta, Victor Matsudo, Luiz Ramos, Rodrigo Reis, andJesus Soares) for their valuable input. Special thanksalso go to the Secretariat of Health of Recife and theAcademia da Cidade staff, particularly Wilson Damas-cena and Taciana Araujo, for their logistic support indata collection and study implementation. And finally,special thanks go to the SOPARC observers and the 2field coordinators, Maria Cecilia Tenorio and RafaelMiranda.

Note. The findings and conclusions in this report arethose of the authors and do not necessarily reflect theofficial position of the Centers for Disease Control andPrevention.

Human Participant ProtectionThe Saint Louis University institutional review board andthe Federal University of Sao Paulo human subjectsreview board approved all data collection procedures forthis study.

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