Social inequalities in leisure-time and transport-related physical activity through the lens of intersectionality:...

Social factors shape health behaviors and contribute to persistent inequalities, especially in the Global South. However, few studies have examined how intersecting social identities influence physical activity in low- and middle-income countries. This study explored social inequalities in leisure-time (LTPA) and transport physical activity (TRPA) through the lens of intersectionality among individuals living in São Paulo, Brazil.

Longitudinal data from 978 participants of the Health Survey of São Paulo: Physical Activity and Environment cohort were analyzed from three waves: 2014/2015, 2020/2021, and 2023/2024. Physical activity was measured using the long-form International Physical Activity Questionnaire (IPAQ). To capture intersectional social disadvantage, a Multiple Jeopardy Index was constructed by combining sex, race/skin color, and educational level, with scores ranging from 0 (lower vulnerability) to 4 (higher vulnerability). Associations between Jeopardy Index and physical activity in both domains were assessed using multilevel Poisson regression models, considering repeated measures nested within three hierarchical levels: observations, individuals, and census tracts.

Individuals in the highest vulnerability groups (female, belonging to racial or ethnic minority groups, and with low educational attainment) consistently reported lower levels of LTPA over time. In fully adjusted models, participants in higher vulnerability Jeopardy categories 3 and 4 showed significantly lower prevalence of LTPA compared to the lower vulnerability reference group (category 0: male, White, and highly educated), with prevalence ratios of 0.72 (95% CI: 0.57-0.91) and 0.62 (95% CI: 0.49-0.80), respectively. A clear inverse gradient and significant dose-response trend was observed (p < 0.001). Regarding TRPA, prevalence was higher among males and younger participants, and also more frequent among individuals from racialized or minority groups and those with a high school education. However, no significant associations were found between the Jeopardy Index and TRPA in any model.

Persistent and widening inequalities in LTPA were observed among Brazilians over a 10-year period, with intersections of sex, race/skin color, and education disproportionately affecting the most vulnerable groups, particularly women from racialized or minority groups with lower educational attainment. Public policies and programs should prioritize socially disadvantaged groups by promoting inclusive and sustained opportunities for leisure-time activity.