Biopsychosocial Inequality, Active Lifestyle and Chronic Health Conditions In Brazilians


 Background:A study estimated the biopsychosocial factors related to active physical behavior in the Brazilian population with and without chronic non-transmissible disease (CNCD).Methodology: Cross-sectional study of the National Health Survey (NHS) in Brazil, with 60,202 individuals. The outcome was physically active behavior. The independent variables were social characteristics, lifestyle and health. Cox regression was applied to estimate the prevalence ratio (PR).Results: 29,666 (48.3%; 95% CI: 47.0–50.0) reported having CNCD. Not being a smoker or alcoholic, living in an urban area, having informal social support, you are in class A, high schooling as well as paid work are more associated with active lifestyle in both groups. However, in the group without CNCD, the female sex, having some disability and not having private health insurance were more associated with sedentary behavior, while in the group with CNCD, being elderly, white and not having restful sleep are associated with sedentary lifestyle.Conclusion: People with and without CNCD in Brazil have very close active behavior, however, some biopsychosocial factors such as: sex, age, lifestyle, socioeconomic level are unevenly associated with the active lifestyle in the groups. Thus, therapeutic or preventive proposals as well as public policies for health promotion must observe these distinctions when elaborating their actions.

There is strong evidence that high socioeconomic levels are associated with a higher level of leisure-time physical activity and, therefore, it is associated with better health in general, whereas most physical activity is work-related among the population of lower socioeconomic levels. 12,13 Social determinants strongly in uence healthy behavior, maintaining or deepening social disparities regarding self-care in health, responsible for NCD control and their morbidity and mortality rates. Studies show that inequalities in education and race are related to the presence of chronic diseases [14][15][16] and may modulate active behavior together with other factors.
Strategies aimed at reducing these inequalities can impact NCD reduction in different populations, especially in the most vulnerable ones. 8 Paradoxically, as a result of the low investment in promoting physical activity, there may be an increase in the medium to long term in expenses with treatment for NCDs and early deaths. 17 Therefore, understanding the conditioning factors of active behavior in people without NCDs is as important as in those with NCDs in order to outline speci c actions for primary prevention in this population and manage previously installed conditions.
Hence, it is necessary to estimate the relationship that biopsychosocial factors establish in the physically active behavior of people with and without NCDs. We hypothesize that biopsychosocial conditions have different relationships between people with and without NCDs, which may possibly create a great vicious cycle of maintaining sedentary behavior in these subpopulations. Method This is a cross-sectional study from the Brazilian National Health Survey (NHS) database, developed in 2013 by the Brazilian Institute of Geography and Statistics (IBGE) in partnership with the Oswaldo Cruz Foundation. This research was approved by the National Committee for Ethics in Research under the number 10853812.7.0000.0008. The planning and conception of this research followed the criteria guided by STROBE guidelines.
NHS population includes permanent residents, grouped in census sections in state capitals, metropolitan regions and cities, and it excludes indigenous villages, military bases and barracks, camps, inns, boats, penitentiaries, penal colonies, prisons, jails, orphanages, convents and hospitals. The sample size was determined from the 2010 Demographic Census conducted by IBGE, the population groups of interest were selected and a sample size of 81,357 individuals aged over 18 years was estimated. Sampling took place by conglomerates, rst stage was the census sector, followed by households in the sector and then the resident by simple random sampling.
Participants were divided into two groups (non-NCD and NCD) and responded to a research instrument organized by thematic modules from A to W. The modules that involve individual characteristics of residents, such as demographic, social, lifestyle, health perception, chronic illnesses and household characteristics were analyzed. The independent variables were grouped according to the NHS modules and were listed in Table 1.
The outcome of the study was a minimal of 150 min of exercise per week, measured through self-report in the questioning: "In general, on the day you practice exercise or sports, how long does this activity last?", generating a continuous variable.
The independent variables were grouped according to the NHS modules. Demographic variables: sex (male or female), elderly (yes/no), living with spouse (yes/no), race (white or non-white), paid work (yes/no) and social class, (A, B, C and DE). The social class was generated from the Brazilian Economic Classi cation Criteria developed by the Brazilian Research Companies Association (ABEP) 11 .
The health variables were: NCD (yes/no), number of NCDs, self-reported presence of sleep complaints based on the question "In the past two weeks, how often did you have problems for not feeling rested and willing during the day, feeling tired, without energy?", which also generated an ordinal variable with the responses: "no day", "less than half the days" and "more than half the days/almost every day" that were transformed into a dichotomous variable (yes/no) for restful sleep; chronic disease patient (yes/no) and disability for activities of daily living (yes/no). Disability measured by the presence of physical, mental and/or sensory disability (yes/no); Body Mass Index (BMI) was measured in kg/m 2 .
The health perception variables were general health perception (good, regular or poor), depressive symptoms perception (yes/no), and behavioral lability perception (yes/no). Lifestyle variables were smoking (yes/no) and drinking (yes/no). Social network variables were based on the question "how many family members or relatives and friends you feel at ease and can talk about almost everything?". This variable was strati ed into less than 2 people, 3-5 people, 6-10 people, 11-15 people, 16-20 people and 21 or more people. Household variables were location of the household (urban or rural).
In complex sampling design, the data analysis is based on the weighted estimation of the sample units of the last stage. The data were described using estimates of prevalence and their 95% con dence intervals (CI95%). The association inferences between the outcome and the independent variables were analyzed by Cox Regression, with adjustment for complex design, and by Wald x 2 signi cance test. In addition, prevalence ratio (PR) estimation was determined as effect measurement and α ≤ 0,05. Models were strati ed for individuals with and without chronic non-communicable disease.

Results
In this study, 60,202 individuals were evaluated, 30,536 (51.7%; CI95%: 51.0-52.5) of these reported not having any NCDs, whereas 29.666 (48.3%; CI95%: 47.0-50.0) reported having at least one of them. We identi ed only 20.7% (CI95%: 19.8-21.6) active individuals without NCDs and 17.5% (CI95%: 16.7-18.3) with NCDs. More characteristics of these groups are shown in Table 1. The groups differ proportionally regarding sex, with more women (61.4%) in the NCD group and more men (51.6%) in the non-NCD group. The NCD group is also composed of older people (29.0%) as well as people who report more depressive symptoms, emotional lability, poor health perception and disabilities. People without NCD showed less restful sleep ( Table 1).
The associations between independent variables and active lifestyle for individuals with and without NCDs were analyzed and we identi ed that all of them were related to at least one of the groups or both in the crude model (p ≤ 0.05), with the exception of BMI (Table 1).
In the adjusted model (Table 2), it is evident that household location, education, having paid work, smoking, drinking and health perception are associated with an active lifestyle in both groups and are not factors that generate inequalities between people with and without NCDs, but inequalities in general population. In the non-NCD group, a discrepancy between genders is observed, with male being 42% more active than females (PR = 1.42). This is also seen among those who have health insurance (PR = 1.26) and those who are not physically or mentally disabled (PR = 1.31). In contrast, in the NCD group, it is possible to identify a distinction between elderly and non-elderly people (PR = 1.22), which are more active as well as non-white people (PRwhite = 0.85) and those who have restful sleep (PR = 1.23).
In addition, the variables of informal social support and social class are related to the active lifestyle differently in the analyzed groups. The active lifestyle is associated with people with NCDs only when they have a broader social support network than those without NCDs, that is, above 6-10 people (PR NCD =1.56). In contrast, active and non-NCD people are associated with active lifestyle mainly in social support networks below 6-10 people (PR nonNCD =1.26).
As for social class, all strata below class A are less associated with active lifestyle. The non-NCD group showed an increasing gradient of association with the active lifestyle between the strata DE up to A. On the other hand, in the NCD group, only strata DE (PR = 0.43) and C (PR = 0.56) differs from stratum A, which is similar to stratum B.
Living with/without a spouse, having perceptions of depressive symptoms and emotional lability as well as the number of NCDs in the group with these conditions were not associated with active style nor were they able to discriminate against them.

Discussion
It is necessary to understand the biopsychosocial inequalities that are related to the active lifestyle in the Brazilian population and that may potentiate the development of chronic diseases or worsen them. It is possible to state that in Brazil, among people with and without chronic health conditions, the proportion of physically active people is similar. However, there are biopsychosocial factors associated with the active lifestyle that sometimes are shared by both groups and some other factors are exclusively shown in only one of them.
One of these factors that revealed an association with active behavior in both groups was informal social support, however, with a different in uence potential in both groups. Concomitantly, the more involved in supporting people, the greater the engagement of those receiving this support, which can in uence the prevention/management of NCDs. 18 In this perspective, Wang et al. 2020 19 evaluated the effect of social support on the level of physical activity, nding that the greater the support from family, friends and partners, the greater the level of physical activity and the greater the self-e cacy. The speci c social support for physical activity is an important factor that helps mainly the elderly to be physically active, 20 which is the case of the NCD group in this study, which comprises a higher proportion of elderly people.
This is re ected in the gradient of social support related to active behavior, where Brazilians without NCDs are associated with the active lifestyle with less informal social support than those with NCDs. This greater need for contextual assistance for those with NCDs may be linked to social restrictions that other characteristics such as age may contribute to. Social restrictions, speci c to this population, consist of access to precarious professional support during the practice of supervised physical activity and limited access to essential medicines with/without prescription. Performing physical activity without monitoring makes this healthy behavior risky for the clinical safety of people with NCDs, especially those in advanced stages.
Other biopsychosocial conditions that are related to active behavior in both groups are smoking and alcohol consumption. Smoking and drinking are less associated with active lifestyle in our study, which also contributes to the decline in quality of life and health, with a higher prevalence of chronic diseases. 21 People who smoke are more likely to present respiratory symptoms and lower levels of physical activity than people who do not smoke. 22,23 Physical exercise is a strong ally in the process of smoking cessation, because the practice of physical exercises provides positive effects in reducing withdrawal symptoms and impulsivity, thus suggesting a double effect direction and the need to encourage adherence to an active lifestyle. 24 Similar to this situation, people who live in the urban area show higher prevalence in the practice of physical activity, when compared to the rural area, regardless of whether or not they have NCDs. Rural people inevitably have structural constraints, such as the absence of speci c environments for the practice of physical activity, and psychological constraints, such as the perception that human work is enough, which can interfere in the understanding of the importance of the practice of planned physical activity as a protective health measure. This context reinforces the idea that the intensity of work can in uence the practice of recreational physical activity 25 .
The individual's perception of feeling healthy or sick is not only due to physical sensations, but also to the social and psychological consequences of the disease, 26 and it is also a common condition for both groups. In this study, it was observed that a perception of health as good or regular is associated with a more active lifestyle. It is a positive feedback, in which the more active a person is, the better the self-perception of one's own health and vice versa. This is an indicator of vitality and it must be measured individually and collectively in order to estimate how healthy the person and the population are. Even with NCDs, individuals with a good perception of health are able to be more active, which may minimize their activity limitations and generate relevant social and economic impact. 27 The same occurs for those without NCDs, in this case the main idea is the prevention of these conditions.
Unlike the biopsychosocial characteristics discussed so far, the participant's sex also demonstrated in uence, but only in the group without NCDs, where the sedentary pattern is more common in female individuals. Considering the Brazilian adult population, 44.8% do not reach a satisfying level of physical activity, this percentage is higher among women than men. Women experience more barriers to the practice of physical activity, which is reduced according to the increase in the education level. [28][29][30][31] This was also one of our ndings, when we observed that those with higher education or graduate degrees are more active.
This inequality does not seem to be related to biological but to social issues, as there is no evidence that the anatomophysiological composition of female individuals prevents them from having physically active behavior.
Furthermore, women who perceive and receive little social support related to the practice of physical exercise have a negative impact on quality of life, emphasizing that social support should be perceived as a determinant of people's health, by health services, by the community, through the several social actors, including family members, friends, neighbors, religious groups and health professionals, 32,33 which supports the statement that it is a gender issue and not biological conditioning.
Our ndings indicate that age is only relevant in individuals with NCDs, and the elderly in this group are less active than adults. A practice of weekly physical activity of moderate intensity tends to decrease with age and increase with the presence of morbidities. The negative association between being elderly and active lifestyle in individuals with NCDs reported in this study is very worrying, considering that there is a great loss of physiological functions such as strength, balance and cognition that leads to the worsening of the progression stages of NCDs, 34,35 reinforced by the social stigmatization that elderly people suffer from the false assumptions of their potential fragility for physical exercise, the need for permanent rest and that their functional independence is minimal. 36,37 On the other hand, high levels of education and income seem to be related to active behavior in both groups and to minimize the effect of age and possibly other social indicators. This reinforces the idea of public stimulus actions, as there is good evidence that the practice of physical activity is related to a lower risk of chronic diseases as well as good quality of life, self-e cacy and better cognitive performance in the elderly. [38][39][40] As well as age, there is a negative association between white people and active lifestyle in the NCD group and some studies highlight that white elderly people had lower levels of commuting physical activity; and physical inactivity at work was higher in whites adults with higher education and higher income. 41 This is a paradoxical condition, as white people are more associated with better health status, but it might be explained by the interaction with the age, in which white elderly people have a higher life expectancy and, therefore, a greater chance of having NCDs.
Having private health insurance is more associated with active behavior in the non-NCD group, and people with private health insurance generally belong to a high socioeconomic level and generally have a higher level of education. However, high social status and education are commonly associated with an active lifestyle in both groups in this study. Probably, the highest proportion of elderly people in the NCDs group prevent them from having access to insurance due to the higher fees charged for this age group, which does not make the association in this group signi cant. Another plausible scenario is that a quick and wide access to the diversi ed option of health professionals in specialized health services made possible by private insurance may facilitate adherence to the physically active lifestyle, which results in higher levels of physical activity only in the group without NCDs . 31,42,43 On the other hand, people with paid work appear to be less active in both groups. This fact can be justi ed by having a more active life in the work aspect, which already promotes some type of physical effort, discarding the regular practice of physical activity prescribed as a preventive measure. Thus, it is essential to understand the barriers to the practice of physical activity in workers that could contribute to the elaboration of strategies for increasing the active lifestyle and improving quality of life in health promotion programs, mainly in primary health care, 44 addressing speci c skills of movement, control and self-regulation that come from the health and physical domains. 45 The negative association between people with physical or intellectual disabilities and active lifestyle was found in the non-NCD group. A study 46 showed that people with disabilities who have completed higher education or graduate school and were moderately active in childhood are more likely to be active than other adults with visual impairment. Another result shows signi cant increase in sedentary lifestyle, overweight and obesity in this population with disabilities, further increasing the chances of developing NCDs. 47 In the NCD group, physical or intellectual disabilities can have their effects mixed with chronic morbidities, not being an inequality factor, mainly because the number of NCDs was not associated with active style. However, several barriers stand out, such as problems with the sidewalks, lack of appropriate facilities/spaces, lack of support policies for public entities, need for a guide, lack of provision of activities by specialized institutions and lack of security conditions of the facilities to avoid accidents. More studies are needed in this population regarding the levels of physical activity.
Studies show that higher levels of physical activity are related to greater e ciency and quality of sleep, as well as low levels of physical activity are associated with worse quality of sleep. 48,49 However, restful sleep was positively associated with an active lifestyle only in the NCD group. Sleep plays a fundamental role in the physiological recovery and people with NCDs suffer extensively with symptoms of insomnia and excessive daytime sleepiness mediated by medications, pain and physiological changes in the sleep-wake cycle. 50 Despite inferences of great impact shown in this study, there are some limitations that must be highlighted. The rst one is due to the self-reported characteristic of NCDs, however it is already known in the literature that this information is reliable. The second limitation is related to the cross-sectional design, that makes it di cult to establish causality for temporally uncertain characteristics. Finally, the limitation of not identifying the intensity of physical activity between the groups, not knowing whether there is a distinction between the moderate or vigorous level of exercise, even though knowing that both intensities generate health bene ts.

Conclusion
It is evident that people with and without NCDs in Brazil have similar active behavior, however, the biological and psychosocial factors are unequally associated with this style in the analyzed groups. Thus, therapeutic or preventive proposals as well as public policies for health promotion must observe these characteristics when developing their guidelines and actions.
Treating these subpopulations equally may generate inequities for the active style and ine cacy of results, especially in individuals with NCDs, who tend to be more affected in the presence of social injustices than those without NCDs. Quali ed equitable approaches focusing on smoking and drinking cessation, on individuals from rural areas, low social strata and low education levels are essential for health promotion.