Exploring physical activity engagement in secondary school students in Montevideo, Uruguay: A qualitative study

Abstract

Physical activity provides multiple health and educational benefits to children and youth, yet the majority of young people across the globe, including adolescents in Uruguay, do not participate in sufficient physical activity. This study aims to further inform intervention efforts for promoting adolescent physical activity in Uruguay by exploring physical activity perceptions and practices as well as physical activity barriers and opportunities in a sample of public and private secondary school students living in and around Montevideo, Uruguay. A total of n=65 secondary school students, ranging in age from 11 to 15 years, participated in 12 focus groups. Despite generally favorable attitudes expressed by participants toward physical activity and identification of common physical activities, findings indicated several barriers for physical activity engagement in this sample of Uruguayan secondary school students -- which often vary by gender and SES, including: lack of access and availability of physical activity opportunities both within and outside of school time, lack of places as well as equipment and infrastructure for engagement in physical activity, and lack of time and competing activities such as video games. Key themes related to the importance of the social context for physical activity- especially for girls, as well as opportunities for physical activity, including the need for more afterschool programming, were also documented. These findings provide further context for understanding adolescent physical activity in Uruguay as well as direction for future intervention efforts.

Introduction

In Uruguay, non-communicable diseases that include cardiovascular disease, cancers, diabetes and other chronic diseases account for 85% of total deaths nationwide (1). As with their Southern Cone neighbors Argentina and Chile, obesity is one chronic disease condition that has become a pressing public health issue for Uruguay in recent years (2), with national prevalence estimates indicating that just over one in five adult males (21.1%) and just over one in four adult females (28.1%) are obese (1). In Uruguayan children between the ages of 6 and 15 years, estimates based on national data indicate that between 18.8% and 26.6% are obese (3). As children who are obese have a greater risk of overweight or obesity in adulthood (4), increased public health attention and interventions are warranted to prevent the onset of obesity in Uruguayan children.

Physical activity is a key behavior for the prevention of childhood obesity (4) and also provides multiple additional health benefits, including the prevention of hypertension, type 2 diabetes, cardiovascular disease, and some types of cancer (5). Beyond physical health benefits, physical activity has been found to positively impact young people’s academic achievement and cognitive performance, including their time-on-task, concentration and performance on standardized tests (6). Despite the multiple benefits of physical activity, less than one third of adolescents (28.8%) in Uruguay have been found to meet World Health Organization (WHO) physical activity recommendations of 60 minutes of daily physical activity (7) -- a prevalence rate that reflects global trends of low physical activity engagement in young people (8).

In exploring approaches to support physical activity engagement in Uruguayan adolescents, research is needed to identify individual risk and protective factors related to physical activity as well as opportunities and barriers in young people’s contexts that are amenable to intervention. To the authors’ knowledge, no such research from Uruguay has been published to date, specific to young people, and qualitative research on adolescent physical activity from Latin America is sparse. As previous research has found disparities in leisure time physical activity by gender in Uruguayan adolescents, with boys being more active than girls (7), and with documentation of lower physical activity among adolescents of lower socioeconomic status (SES) based on internationally diverse adolescent studies (9), research is also needed on the roles that gender and SES may play in shaping physical activity behaviors in Uruguayan adolescents.

This study aims to address current gaps in the literature and further inform intervention efforts for promoting adolescent physical activity in Uruguay by exploring physical activity perceptions and practices as well as physical activity barriers and opportunities in a sample of public and private secondary school students living in and around Montevideo, Uruguay. Based on data collected via a series of focus group discussions, we specifically explore these factors by gender and school socioeconomic status among urban and semi-urban Uruguayan adolescents.

Methods

The study was conducted as part of a health needs assessment for the ¡Activate Ya! project, a National Institute of Health-funded study of tobacco use and physical activity in Uruguayan secondary school students being led by a partnership between the [name removed for blinded review], Uruguay, and the [name removed for blinded review], a public university in the United States. In contributing to a better understanding of adolescent physical activity engagement, focus group discussions were conducted in 2013 with students in Ciclo Básico 1 and 2 (equivalent to 7^th and 8^th grades in the U.S. and representing students between the ages of 12 and 15 years of age) attending public and private schools in and adjacent to Montevideo, Uruguay. A total of 12 focus groups stratified by gender and grade level (Ciclo Básico 1 and 2) were conducted at three schools: one private school that serves higher income students (“middle-high SES school”), one public school that serves middle income students (“middle SES school’), and one public school that serves middle-low income students (“middle-low SES school”).

Study measures and procedures

A 14-item focus group discussion guide was developed by the research team aimed at eliciting input from adolescents about intrapersonal factors related to physical activity engagement (e.g., knowledge, attitudes, and perceived barriers), physical activity practices and preferences, and environmental factors such as opportunities for physical activity engagement. The development of the focus group interview guide was informed in part by constructs from the Health Belief Model (e.g., perceived barriers) (10), the Theory of Reasoned Action/Planned Behavior (e.g., subjective norms; attitudes) (11), and the Ecological Model of Active Living (e.g., opportunities and environments) (12).

Students were invited to participate in the focus group discussions via verbal and written invitations delivered in their school. Participation in the focus groups was voluntary, and both student assent and parental informed consent were required for participation. Privacy and confidentiality were made clear as conditions for participating in the focus groups via written and verbal informed consent procedures. Permission to conduct the focus groups was granted by the school directors, and the study protocols were reviewed and approved by the Committee for the Protection of Human Subjects of the University of Texas Health Science Center’s School of Public Health and the Comité de Ética de la Facultad de Medicina (UDELAR) in Uruguay.

The focus groups were conducted in Spanish between April and May of 2013 by two trained Uruguayan research staff members from [Uruguayan partner organization. Name removed for blinded review]. Focus group discussions were digitally recorded, and notes were taken by the interviewers. Transcripts were stored in a password-protected computer upon the completion of focus groups. Focus groups were conducted by posing a question and allowing open discussion, using probes whenever necessary. Each session was approximately one hour in duration and took place at school. Research staff transcribed all focus group discussions. Once focus group discussions were transcribed, two research staff (a primary English speaker and primary Spanish speaker) translated the transcriptions to English.

Data analysis

Analysis of the focus group data was conducted separately by two independent analysts from our research team, which included an initial phase of coding by the two analysts, and then a centering phase in which the analysts -- with input from the broader research team -- discussed and confirmed the specific codes. Content analysis (13) guided the analysis of the data and was conducted to identify and compare common themes using the NVivo qualitative data analysis software (QSR International Pty Ltd. Version 10, 2012). Specifically, data were analyzed by attaching a descriptor, grouping into categories, and then developing themes to describe these categories. Themes were explored by gender and school SES, with gender coded based on the stratified research design, and school SES coded based on the primary income status of the student’s school, as defined by the school principal.

Results

A total of n=65 secondary school students participated in the 12 focus groups conducted, which included 34 girls (18 girls from 1˚ Ciclo Básico and 16 girls from 2˚ Ciclo Básico) and 31 boys (14 boys from 1˚ Ciclo Básico and 17 boys from 2˚ Ciclo Básico), ranging in age from 11 to 15 years. The participants from the middle-high income school included 12 boys and 11 girls; participants from the middle-low income school included 10 boys and 11 girls; and participants from middle income schools included 11 boys and 12 girls. Below, we share the key findings from the focus groups as organized by the following thematic content areas: physical activity norms and types of activities; perceived benefits of physical activity; perceived barriers for physical activity; and physical activity engagement inside and outside of school. Where relevant, differences observed by gender and school SES are noted. If not noted, no differences by these factors were observed.

Physical activity norms and types of activities

Girls and boys across middle-low, middle, and middle-high SES schools shared that leisure-time physical activity tends to be common among adolescents their age, yet important differences were noted by gender. While most girls said that they themselves were active, they also reported that girls generally should do more physical activity, mentioning physical appearance and a changing body as important reasons to engage in physical activity. Reasons for lower engagement in physical activity among girls included that they find other activities more important for girls of their age, such as taking care of younger family members and studying. Girls shared that boys are generally more active than girls, but expressed that some boys need to be more active because men are more likely to be obese than women. While boys seemed to agree that physical activity was common for boys their age, they did note that not all boys like physical activity, with some preferring to play video games and spend time on the computer. Findings were mixed when boys were asked about how common physical activity engagement was for girls, with some boys noting that girls are sedentary and need to be active, and others noting that girls are active and do not need to be more active.

Across both girl and boy groups, participants noted gender-specific differences in types of physical activities. For example, a male student (middle-high SES school) remarked:

“En el liceo tenés hándbol, fútbol y básquetbol. A hándbol solo…los profesores dicen ‘Solo pueden ir niñas…’ Fútbol y básquetbol que yo sepa no va ninguna niña [In school there is handball, soccer and basketball. For handball only, teachers say ‘Only girls can go (participate)’… Soccer and basketball, as far as I know, not one girl goes (participates)].”

In addition, it was also mentioned by a female student (middle-high SES school) that:

“Está dicho ‘los varones juegan al fútbol, las chiquilinas juegan hándbol,’ que el hecho de que a todos los varones les gusta más el fútbol que el hándbol…” [It is said that ‘boys play soccer, girls play handball,’ which makes all the boys like soccer more than handball].

Despite these differences, both girls and boys commented that there were activities that they engaged in together, which included soccer, tag, tennis, and volleyball. An emerging theme common to both boys and girls regarding joint participation in physical activity was safety. Females commented that boys play rough (“bruto”) and throw and push (“pechar”), with boys sharing the same concerns about girls: “Pero es peligroso jugar con ellas [But it is dangerous to play with them (girls)]” (Male student, middle-low SES school). Boys also mentioned that sports clubs have clear distinctions between “masculine” and “feminine” sports, and that there are boys or girls that cannot participate in certain sports at clubs.

An important theme that emerged among girls was the importance of doing physical activity with others, particularly for girls with other girls, and that being alone or not having friends in the neighborhood influenced their activity levels. One female participant from a middle-low SES school stated: “Y yo, por ejemplo, soy más tímida y en el barrio no tengo ningún amigo [I, for example, am more timid and do not have a single friend in the neighborhood].” Another girl (middle-high SES school) said: “Las niñas prefieren ir como juntas [Girls prefer to go together]” and that for boys: “No les importa mucho estar tanto solos o sea…solos con el ejercicio y eso.[It doesn’t matter much to boys to be alone with exercise and things like this].”

Perceived benefits of physical activity

When asked about the benefits of physical activity, girls and boys cited social and health related reasons. For both boys and girls, participants thought that participating in physical activity helped them make new friends, socialize, and work as a team. Several middle school girls also cited that extracurricular activities outside of school provided opportunities to meet with friends and do activities they like. Regarding health, boys and girls across all social classes indicated that physical activity takes care of the body by promoting physical and mental health, although some gender-specific reasons were noted. For example, boys shared that physical activity is important for mobility and building strength (“fortaleciendo”). They also noted that physical activity contributes to one’s character development. As shared by one boy from a middle-high SES school: “Yo creo que los deportes te dan más valores; también te ayudan a crecer [I think that sports give you more values; they also help you grow].” Girls mentioned more frequently than boys that physical activity helps to prevent obesity. In addition, girls more commonly cited mental health as an important reason for engaging in physical activity, as reflected in quotes from middle-high and middle SES school participants: “Te distraes [You entertain yourself]” and “Estás como libre, como que te tranquilizas cuando haces un deporte que te gusta [You are free, it is like you calm yourself when you are playing a sport that you like].”

Perceived barriers for physical activity

Time, competing activities & transportation

Boys and girls across all social classes mentioned time (or lack thereof) as a reason some may not engage in physical activity, which included insufficient time during the day outside of school as well as limited time during school, such as recess time. Common reasons also given by middle-high income students were that other activities compete with physical activity, such as hanging out with friends or studying. In addition, boys and girls across school SES levels agreed that transportation can be a barrier to physical activity, as some activities and places for physical activity were not located in their neighborhoods. In response to this barrier, some middle-low SES school students mentioned biking as an accessible means of transportation. Middle-low SES school students said that feeling tired was also a barrier more frequently than participants from the higher SES schools.

Availability and access to opportunities

While boys and girls identified opportunities for physical activity, important SES and gender-related barriers were noted in relation to the availability and accessibility of these opportunities. The inability to pay for opportunities for physical activity (e.g., health clubs or gyms), for example, was brought up among boys and girls from across school SES levels. It was also common among middle-low income students to say that places to participate in physical activity are expensive, and that there are no free options in their neighborhood. Middle-low SES school students were also more likely to cite barriers such as no space, dirty space, no equipment, broken equipment, or few places in the neighborhood to be physically active. In addition, not enough space or equipment at school were obstacles cited by mostly middle-low income students. One girl from a middle-low SES school noted: “[Los areas de juego del liceo] [s]on muy chicos y no tienen espacio [The school play areas are very small and do not have space]”.

Gender-specific barriers

While barriers to access and availability were cited by both girls and boys, across the sample more girls than boys reported that either there are not very many places near them to be physically active, or if there are, they do not know about them. Girls, mostly from the middle SES schools, also mentioned embarrassment or shame as a barrier (“verguenza”) for girls to participate in physical activity. On the other hand, more boys mentioned preference for electronics (i.e. video games, computers) over physical activity as a barrier, although some male participants said that boys play on the computer but also engage in sports. More middle and middle-high income students tended to note electronics as a barrier. Boys and girls also identified dislike for physical activity as a barrier for some, and more girls than boys mentioned having friends that do not like physical activity. Lastly, middle-high SES school boys and girls both cited parents not allowing them to engage in sports as a barrier to physical activity.

Physical activity engagement during and outside of school time

Although recess (break time) and PE were cited as opportunities for physical activity during school, both boys and girls and participants across all school SES groups emphasized that it is difficult to engage in physical activity in school due to limited time and lack of equipment. Below we explore some of the opportunities and barriers cited for physical activity during school.

Recess time

Although boys mentioned physical activities that they engaged in during recess, such as ping pong, soccer and basketball, lack of equipment was cited as a barrier for engaging in physical activity during recess. Boys also reported that recess is short, usually 10–15 minutes long, and is often a time to eat. Similarly, girls also said that they do not have equipment such as soccer balls to play with during this time, that there is not enough time to engage in activity, and that they usually use this time to eat as well. Something that was mentioned by girls more than boys was their enjoyment with taking time to talk to their friends during recess. Although limited time was cited as a barrier by students of all social classes, middle-low and middle income students cited lack of equipment as a more common barrier to active play during recess. Example quotes illustrating these themes include:

“Como que me parece que el año pasado en el colegio teníamos más tiempo como para hacer deporte. [It seems to me that last year in school we had more time to play sports].” (Girl, middle-high SES school).

“Pero un día queríamos jugar al fútbol y no podíamos porque no había pelotas; las pelotas que teníamos estaban todas pinchadas, ta y son cosas así [But one day we wanted to play soccer and we could not because there were no balls; the balls that we had were flat…as such, there are things like this].” (Boy, middle SES school).

Physical Education class

Boys and girls across all social classes specified physical education (PE) class as an important opportunity for physical activity in school. Overall, participants discussed more likes than dislikes for their PE class. Positive aspects expressed by boys for their PE class included the opportunity to play sports and engage in competition, with appealing activities that included soccer, basketball, and tag. Girls also liked activities that included sports as well, such as volleyball, gymnastics, handball, soccer, and tag, as well as racing games (“carreras”). However, it should be noted that some girls expressed that they did not like anything about PE class. Middle-low and middle income students said playing together more was an attraction for them, while middle-high income students mostly highlighted engagement in sports as an attraction. Both boys and girls expressed the importance of having variety in sports as attractive, which was more often cited by middle-high SES school students. A main dislike of PE class noted by participants was ‘theoretical classes’, which require being inside a classroom and completing written exercises. Male and female students across all three school SES levels said these classes were boring and involved no activity: “La clase teórica porque es muy aburrida y no te moves [Theoretical class (is an aversion) because it is very boring and you do not move]” (Female student, middle-low SES school).

Activity breaks during class time

Activity breaks during class time, which may include short bouts of movement or activity, were not commonly practiced as reported by students. One exception was a student who reported that they have an activity break in Spanish class, although others said that those breaks do not involve activity but rather an activity that involved resting/taking time to close their eyes, such as a meditation break.

Walking and biking to/from school

Participants were asked about active transportation to and from school by biking or walking. Overall, riding bikes to school was generally reported as uncommon, with many comments noting confusion about where to leave bikes and the possibility of getting bikes stolen. However, more middle and middle-low students tended to say riding bikes was more common than middle-high students, with boys in these social classes being more likely to cite riding bikes. Some girls highlighted the dangers associated with biking: “A mi me gustaría eh, venir en bici, pero es medio peligroso el cruce de acá [I like to come on my bike, but the crossing is a bit dangerous over here]” (Female student, middle-high SES school). When considering walking as a method of active transport, more girls than boys reported that it is common for the majority of students to walk to school. Both middle-low and middle-high income students acknowledged that it is common for students to walk to school if they live close. However, middle-high income students more frequently said that they take the bus or are dropped off at school by their parents.

Outside of school time

Physical activity outside of school time

Across all social classes, both boys and girls commonly identified swimming, playing soccer, and bicycling as common activities they do outside of school. Boys and girls also mentioned going to “La Rambla”, or the boardwalk, to walk, go to the park, or bike. Boys talked more about activities such as basketball, skating, and karate as primary activities they engaged in outside of school, while girls talked more about other activities such as volleyball, dance, handball, and artistic gymnastics. A common activity mentioned by middle-high income girls specifically was “ritmos,” also known as rhythms or dance, which is commonly done at gyms, as well as basketball and swimming.. Middle-high and middle SES school boys and girls also communicated that they often go to sports clubs to play sports outside of school time; students from middle-low SES school students noted that this was common for some students, but not for them. While not specific to physical activity, middle-low SES school students specifically mentioned the occasional opportunity to attend “talleres,” or after school workshops, yet these talleres were stated to not always be available for public schools.

Discussion

Given national estimates that indicate that more than half of Uruguayan adolescents do not meet recommendations for daily physical activity (7), research is needed to provide further context into both the barriers and potential facilitating factors for PA engagement in young people living in Uruguay. Despite important limitations of the current study -- which include the small sample of adolescents from three secondary schools, as well as a limited geographic representation of urban students from Montevideo and surrounding area, this qualitative study contributes to the literature by exploring physical activity perceptions, practices, barriers, and opportunities for physical activity engagement among Uruguayan secondary school students, including boys and girls attending socioeconomically diverse schools. While the Uruguayan adolescents who participated in this study identified a range of physical activities as common to young people their age and expressed various physical, mental and social health benefits of physical activity- as previously documents with adolescents in Brazil (14), important gender-specific and SES-specific barriers for physical activity emerged that offer potential areas for future study and intervention.

In exploring previously documented gender disparities in physical activity behaviors among Uruguayan adolescents (7), we identified several gender-specific factors that may inhibit physical activity participation in Uruguayan girls and boys. Both girls and boys in this study identified some sports activities as being more a “girl sport” or more a “boy sport”, with some participants indicating that these beliefs are reinforced by their teachers as well as by sports clubs that do not allow some gender groups to play a given sport. These gender-biased perceptions of physical activity and sports have been previously cited by groups that include la Red Para la Actividad Física and underscore an ongoing need to respond to calls to “desexuar” (“de-sex/de-gender”) physical activity in order to ensure an equitable teaching and promotion of sports and games to both girls and boys (15).

While girls and boys in this study generally expressed that physical activity was something their peers engage in, some female participants felt that girls should do more physical activity for their appearance and changing bodies, and that boys should do more physical activity as men are more likely to be obese than women. As obesity affects both males and females in Uruguay, with lower rates for Uruguayan girls (3) yet higher rates for Uruguayan women (1), continued efforts are needed to raise awareness about the importance of physical activity for promoting a healthy weight for both boys and girls in Uruguay. Girls in this study were also more likely to report general feelings of embarrassment as a reason for not engaging in physical activity. Research on adolescent girls from the U.S. (16) and Canada (17) has found that body image concerns are important barriers to physical activity participation; further research is needed to understand the role of embarrassment and the potential role of body-related concerns as barriers for physical activity participation in Uruguayan girls.

Other key barriers cited by girls included the need to take care of siblings after school or on the weekend, the lack of places and opportunities near them to participate in physical activity, the importance of engaging in physical activity with other girls, and concerns about joint participation in sports with boys due to rough play. Taking care of siblings is a barrier that has been previously cited by Hispanic middle school girls in the U.S. who report child care as a more common activity compared to their white and African American counterparts (16). A large body of research has documented the important role social support plays in physical activity engagement among young people, which includes evidence from South America (18). Our findings suggest that fostering social support may be especially important in supporting girls’ physical activity. The potential lack of places and opportunities for girl participation in sports and physical activity, the importance of engaging in physical activity with other girls, as well as concerns about joint participation in sports with boys merit further confirmation and present potential targets for intervention efforts.

For boys, video game playing was cited across focus groups as a potential reason why some boys their age did not participate in physical activity or sports. While research on screen time use, which includes TV watching and video game playing, and physical activity engagement is either mixed or shows small negative associations (19), findings from a recent qualitative research review of diverse international studies underscore the important role that video games and computers play as part of daily life for adolescents of this generation, which may include serving as a vehicle for social interaction (20). Further research on the functional meaning of screen time and video games within the adolescent context in Uruguay as well as how to incorporate more physical activity in a way that delivers similar benefits of screen time, such as positive adolescent social interaction and entertainment, holds potential to further inform intervention efforts.

In the current study, middle-low SES school students cited various barriers to physical activity that included the financial cost of physical activity opportunities, lack of free options in their neighborhood, and a lack of space, dirty spaces, and/or lack of equipment or broken equipment in school. Previous research based on internationally diverse samples of adolescents indicates an inverse association between physical activity and SES (9), and research from the U.S. has found that lower SES populations may have less access to PA supportive environments and resources (21). Our findings suggest a need for enhanced investments to create safe and accessible spaces and program opportunities for physical activity for adolescents in Uruguay, with specific focus on lower SES adolescents and girls.

While physical education class was cited as an important time for physical activity during school – with generally positive comments for PE from students in this study, Uruguayan secondary school students often receive PE class on only two days a week (for 80 minutes and 40 minutes at each time, respectively). As such, other opportunities to help students meet daily physical activity recommendations merit exploration. Recess presents an important opportunity for unstructured active play, yet participants in this study indicated that time for recess was limited, with usually only 10–15 minutes scheduled, which was time also used for eating. Beyond time, students also cited lack of equipment and space as key barriers. Although classroom activity breaks were not a common practice cited by this sample of students, classroom activity breaks have been found to provide meaningful opportunities for physical activity engagement (22) and merit further exploration for supporting adolescent PA in Uruguay. Outside of school, “talleres” (afterschool workshops), which may provide opportunity for physical activity, were noted by some students, yet these workshops were not always offered at public schools. Further research on strategies for increasing adolescent physical activity both within and outside of school is warranted such as exploration of community-school partnerships, which have been found to enhance physical activity opportunities and engagement among students (23).

In recent years, Uruguay has taken several important steps toward increasing physical activity (PA) in young people, including passage of legislation to make PE a requirement for all primary school students in 2007 (24), implementation of ‘open-air gyms’ (25), and awareness raising and mobilization of social networks around PA via efforts led by groups such as la Red de Actividad Física del Uruguay, among other efforts. In our work with the ¡Activate Ya! study, a school-based intervention study taking place in 16 schools in and around Montevideo, qualitative findings from the current study have informed several of our intervention strategies, which are designed to decrease barriers noted by study participants and increase PA opportunities while enhancing intrapersonal factors such as PA knowledge, attitudes, self-efficacy, and a healthy and active self-concept. Key components of the ¡Activate Ya! program include the creation of a university student-led afterschool component (“Espacio Adolescente”) that provides games and activities, a classroom component that incorporates student-centered activities aimed at promoting PA social norms, social support and positive intrapersonal factors, a classroom activity break component to enhance PA opportunities during the school day, and student-led action to promote social norms and awareness for PA via a community-wide final event in partnership with community organizations. The ¡Activate Ya! study will conclude in 2017, and we look forward to sharing our lessons learned and recommendations based on our findings.

Physical activity is a key health promoting behavior that provides multiple benefits for adolescents (5). Despite generally favorable attitudes expressed by adolescents in this study toward physical activity, our findings indicate several barriers for adolescent engagement in PA in Uruguay -- which often vary by gender and SES, including: lack of access and availability of PA opportunities both within and outside of school time, lack of places for engagement in PA as well as equipment and infrastructure for PA, limited time, and competing activities such as video games. These findings provide further context for understanding adolescent physical activity engagement in Uruguay and provide a foundation for the design and implementation of efforts aimed at promoting physical activity with Uruguayan adolescents.