The Effect of Built Environment on Older People Leisure-Time Walking and Physical Activity in Different Sex Groups in the City of Ningbo, China

Abstract

The aim of this study was to examine the effect of built environment (BE) elements on older people’s (OP) leisure-time physical activity (LTPA) and leisure-time walking (LTW) level in the city of Ningbo. Older participants numbering 312 were randomly recruited using cross-sectional survey in 2019. International Physical Activity Questionnaire-short version (IPAQ-S) and Neighborhood Environment Walkability Scale—abbreviated (NEWS-A)—were used to gather LTPA data and the perceive scores of BE, respectively. Liner regression analysis was performed to investigate the association relationship between the perceived scores of BE and OP’s LTW and LTPA. The study’s results showed that, when not considering different sex groups, OP’s LTW was significantly related with the perceived scores of access to services (AE, p = 0.045), walking/cycling facilities (W/CF, p = 0.007), aesthetics, and land use mix diversity (LUMD, p = 0.04). OP’s LTPA was significantly related with AE (p = 0.04) and aesthetics (p < 0.001). The association relationships of BE with LTW and LTPA varied in different sex groups. Three elements (AE, W/CF, and LUMD) and one element (pedestrian/traffic safety and P/TS) of BE were found be related with older male and older female’s LTW, respectively. One element (aesthetics) and two elements (aesthetics, LUMD) of BE were found be related with older male and older female’s LTPA, respectively. The results indicated that the effects of BE on OP’s LTW and the effects of BE on OP’s LTPA were different. The effect also varied in different sex groups. More studies are needed to confirm the effect of BE on OP’s LTW and LTPA in different sex groups to globally enrich the scientific data base.

1. Introduction

The world, especially for China, is facing a population aging problem. By the end of 2050, the percentage of people over 65 years old will be 16% [1]. The number will be more terrible in China. Only by the end of 2040, 24% of people in China will be 60 years old [2]. Due to body functional losses increasing with aging, medical expenditure of older people (OP) will be a big economic burden for most countries in the world, especially for China. Keeping OP healthy with all possible methods is key to reducing medical burden for all countries. Exercise, as a non-medical method, has been testified to be a useful tool for improving body functions and keeping OP healthy. Numerous previous studies and also the world health organization (WHO) have indicated that many health benefits can be obtained through physical activity (PA), including decreasing risks of coronary heart disease, enhanced cardiorespiratory and muscular fitness, improved cognition ability, and so on [3,4,5,6,7]. As the most common exercise for older people, walking is helpful for reducing blood pressure and blood glucose and the risk of falls for older people [8,9]. Furthermore, more health benefits will be obtained by OP from leisure time physical activity (LTPA) due to larger energy consumption [10].

The OP’s PA is mainly influenced by three components including internal factors, social support and environmental factors according to a socioecological model [11]. For social support, Andrea et al. proposed that the OP who were accompanied by people to walk had a 2.45-times greater possibility of receiving the recommendations of LTPA than those who did not [12]. For internal factors, deficiency of motivation, deficiency of interest, and deficiency of time were identified as intrapersonal barriers of OP’s PA in a systematic review [13]. For built environment (BE), numerous studies have indicated that it would induce effects on OP’s PA [12,14,15,16,17,18,19,20,21,22,23]. In a systematic review, Barnett et al. suggested that positive environmental factors significantly related with OP’s PA, ranked by strength of evidence, were as follows: walkability, safety from crime, overall access to destinations and services, recreational facilities, and so on. Additionally, they also indicated that more high quality relative studies are needed in future [14].

There were also some Chinese studies surveying the relationship between BE and resident’s PA [7,17,24,25,26,27,28,29,30,31,32,33,34], and part of them particularly focused on the participants of OP [17,24,25,28,29,30,31,33]. Zhang et al. suggested that ample green land space, easily accessible commercial establishments, dense bus stops, and abundant sidewalks are potentially useful to motivate OP in participating in more walking PA in the city of Zhongshan, which is located in the southern region of China [33]. Some previous studies investigated the effect of BE on OP’s LTPA in some eastern cities of China [29,30,31]. The study in the city of Jinhua suggested that OP’s LTPA was influenced by various BE factors in different sex groups. Women’s LTPA was usually more sensitive to BE [30]. Another study in the city of Yiwu suggested that higher street connectivity (SC), lower residential density (RD), and better aesthetics environment would prompt OP to be involved more in LTW and LTPA. The better access to services (AE) promotes only LTW and not LTPA [31]. According to the finding of the three above studies, we can find that the influence of BE on OP’s PA would vary between diverse cities, and the association relationship would also change in different sex groups and different parts of LTPA. Therefore, more relative studies are needed to expand the scientific data base.

To our knowledge, no study explored the relationship of BE with OP’s LTPA in Ningbo. As the second largest city of Zhejiang province and a globally famous port city, the research data of Ningbo are important for enriching the scientific data base of Chinese relative studies. The purpose of the current study was to investigate the correlation relationship between OP’s LTW, LTPA, and BE in all participants. We also wanted to confirm whether the association relationship would be different in men and women groups. The hypothesis of current study was that the correlation relationship would be different between LTW and LTPA, and it would also be different between men and women groups.

2. Materials and Methods

2.1. Sample and Study Design

The current study was carried out in the city of Ningbo, which is located in the Zhejiang province in the eastern region of China. Ningbo is also one of the most conducive environments toward wellbeing in China mainly due to its beautiful environment, convenient public traffic system, and high resident income levels. The OP participants were recruited in the university of OP that is located in the downtown area of Ningbo in June, 2019. The sample size was 312 OP. The sample size in this study was comparable with previous relative studies [26,27]. A cross-sectional survey of random samples was performed in the university of OP. The participants inclusion principles were (a) OP over the age of 60 years old, (b) be a resident of Ningbo and have lived in their living communities for no less than 6 months, and (c) have no cognitive impairment and possess normal communication abilities. The study was approved by the ethics committee of Research Academy of Grand Health, Ningbo University (RAGH20190600021; June, 2019). All team members were trained to make sure they understand the questionnaires and data-collecting process precisely. All questionaries were filled by one-to-one interview between OP and team members. All older people participants involved in this study have signed written consents to participate before data collection.

2.2. Measures

Three questionaries were involved in this study. The demographic features of OP participants were collected using a self-made individual characteristics questionnaire. The collected demographic features of OP include age, education level, income situation, travel mode choice, and motion sickness. The LTW and LTPA levels of OP were collected using IPAQ-S. The metabolic equivalent (MET) scores were calculated based on IPAQ data using the IPAQ scoring procedure to represent LTW and LTPA levels. The perceived scores of BE elements were collected using the Chinese version of NEWS-A. The reliability and validity of NEWS-A have been testified by previous study [35], so NEWS-A is suitable for OP surveys in China. The detailed explanation of NEWS-A is present in our previous study [29]. To summarize, eight BE elements including RD, LUMD, AE, SC, W/CF, aesthetics, P/TS, and crime safety (CS) were evaluated in NEWS-A. All questions of this questionnaire were designed relative to the style of Likert Scales. The RD was measured on a 5-point Likert Scale (1—one; 5—all), and the perceived score of RD was calculated based on the method provided in a prior study [35]. The LUMD is measured on a 5-point Likert Scale (1—1 to 5 min; 5—more than 30 min), and the other six built environment elements were measured on a 4-point Likert Scale (1—totally disagree; 4—totally agree). The perceived score of other seven BE elements was represented by the mean score of questions in the corresponding element.

2.3. Statistical Analysis

The demographic features of Ningbo in different gender groups were described using descriptive statistical analyses. The variances in demographic features between gender groups were analyzed by the Chi-square test. An independent t-test was used to find discrepancies of LTW, LTPA, and the perceived scores of BE elements in different gender groups. The multivariate linear regression was performed to examine the association of perceived score of BE with OP’s LTPA and LTW in men and women separately and then in all participants together. Statistical significance level was p < 0.05. All analyses were performed in SPSS 19.0 software (SPSS Inc., Chicago, IL, USA).

3. Results

Table 1. Demographic characteristics of participants in Ningbo (n = 312).

Variable	Men (n = 93) n	%	Women (n = 219) n	%	X2	p
Age					7.50	0.02 *
60–69 years	60	64.5	138	63
70–79 years	30	32.3	81	37
≥80 years	3	3.2	0	0
Education level					17.14	<0.001 *
Lower secondary	6	6.5	51	23.3
Upper secondary	33	35.5	87	39.7
Tertiary and above	54	58.0	81	37.0
Income situation (RMB)					29.10	<0.001 *
1501–2500	3	3.2	3	1.4
2501–3500	6	6.5	57	26.0
3501–4500	15	16.1	63	28.8
≥4501	69	74.2	96	43.8
Travel mode choice					5.89	0.053
Car or bus	60	64.5	132	60.3
Bicycle	27	29.0	51	23.3
Walking	6	6.5	36	16.4
Motion sickness					5.14	0.02 *
Yes	39	41.9	63	28.8
No	54	58.1	156	71.2

Note: * represents significantly different between sexes in Ningbo. The unit of income situation is yuan.

reveals the demographic characteristics of participants in Ningbo. Significant differences were observed in education level, age, income situation, and motion sickness between men and women. Men’s education level was significantly higher than that of women (X² = 17.14, p < 0.001). Fifty-eight percent of men’s education level were tertiary and above, but only 37% of women were at this education level. The percentage of upper secondary was higher than that of tertiary and above in women (39.7% vs. 37.0%), but the situation was opposite in men. This finding is coherent with our earlier study in the city of Jinhua [30] and also consistent with another previous study [36]. Zhang discovered that the education level of women was significantly lower than that of men on the nationwide level. The same was observed with education level, and the income condition of women was also significantly lower than that of men (X² = 29.10, p < 0.001). The percentage of income larger than 4501 yuan was 74.2% in men but only 43.8% in women. This result is also uniform with our former study in the city of Jinhua [30] and an earlier study [37]. Yang et al. found that the income situation of women was significantly lower than that of men at a nation level. Additionally, more men had motion sickness than women in this study.

Table 2. Comparison of OP’s LTW, LTPA, and perceived BE scores in different gender groups.

Variable	Men	Women	Differences of 95%CI	t	p	Effect Size
LTW (MET. min/week)	1637.65 ± 932.97	1390.67 ± 988.46	10.19–483.78	2.05	0.04 *	0.13
LTPA (MET. min/week)	3244.10 ± 2370.16	2311.34 ± 2158.87	391.21–1474.30	3.39	0.001 *	0.20
RD	817.94 ± 162.94	804.33 ± 172.38	−27.71–54.92	0.65	0.52	0.04
AE	2.83 ± 0.50	2.70 ± 0.52	0.01–0.26	2.05	0.04 *	0.13
SC	3.13± 0.67	3.09 ± 0.75	−0.13–0.22	0.48	0.63	0.03
W/CF	3.23 ± 0.75	2.98 ± 0.56	0.09–0.40	3.19	0.002 *	0.19
Aesthetics	2.61 ± 0.63	2.71 ± 0.71	−0.26–0.07	−1.11	0.27	−0.07
P/TS	2.56 ± 0.69	2.29 ± 0.68	0.10–0.44	3.22	0.001 *	0.19
CS	2.37 ± 0.76	2.23 ± 0.77	−0.05–0.32	1.45	0.15	0.09
LUMD	2.71 ± 0.52	2.72 ± 0.71	−0.17–0.15	−0.16	0.88	−0.01

Note: * represents significantly different between sexes in Ningbo MET stands for metabolic equivalent score. Differences of 95% CI indicates the differences between men and women of 95% confidence interval values. OP: older people; LTW: leisure time walking; LTPA: leisure time physical activity; BE: built environment; RD: residential density; AE: access to services; SC: street connectivity; W/CF: walking/cycling facilities; P/TS: pedestrian/traffic safety; CS: crime safety; LUMD: land use mix diversity.

demonstrations the comparison results of LTW level, LTPA level, and perceived BE scores in different gender groups. LTW and LTPA level between men and women were significantly different. Both LTW and LTPA level of men were significantly higher than those of women. In the perceived scores of BE, three elements were found significantly different between men and women, including AE, W/CF, and P/TS. All the three elements’ scores were significantly higher in men that those of women. No significant differences were obtained in other BE elements between different sex groups.

Table 3. Association of the BE with OP’s LTW in different gender groups.

Variable	B	Men SE	p	B	Women SE	p
RD	0.47	0.52	0.37	0.03	0.37	0.93
AE	425.95	203.46	0.04 *	184.30	135.13	0.17
SC	−307.15	177.20	0.09	−106.85	104.60	0.31
W/CF	430.49	142.50	0.003 *	117.06	152.76	0.44
Aesthetics	418.71	217.99	0.058	166.41	104.46	0.11
P/TS	−89.40	152.61	0.56	273.78	104.35	0.009 *
CS	−68.41	119.45	0.57	73.95	89.27	0.41
LUMD	−392.07	188.80	0.04 *	−144.21	105.06	0.17

Note: Depend variable: OP’s total LTW score, B represents regression coefficient, SE is stand error, and * denotes significant association (p < 0.05). OP: older people; LTW: leisure time walking; BE: built environment; RD: residential density; AE: access to services’ SC: street connectivity; W/CF: walking/cycling facilities; P/TS: pedestrian/traffic safety; CS: crime safety; LUMD: land use mix diversity.

displays the results of association of BE with OP’s LTW level in different gender groups. The results show that more BE elements induced effects on men’s LTW level compared with women’s LTW level. Three BE elements were significantly related with men’s LTW level, including AE, W/CF, and LUMD. The perceived scores of AE and W/CF were positively related with men’s LTW and the perceived score of LUMD was negatively related with men’s LTW. Compared with men’s LTW, women’ LTW was much less effected by BE, and only one BE element was significantly related with women’s LTW. The perceived score of P/TS was positively correlated with women’s LTW. No other BE elements were significantly related with men and women’s LTW level.

Table 4. Association of the BE with OP’s LTPA in different gender groups.

Variable	B	Men SE	p	B	Women SE	p
RD	−0.08	1.28	0.95	−0.56	0.77	0.47
AE	−533.55	499.97	0.29	−437.59	285.69	0.13
SC	38.07	435.43	0.93	257.56	221.14	0.25
W/CF	196.13	350.17	0.58	−228.74	322.95	0.48
Aesthetics	1701.60	535.66	0.002 *	708.70	220.83	0.002 *
P/TS	41.20	375.01	0.91	120.40	220.60	0.59
CS	66.83	293.52	0.82	111.43	118.73	0.56
LUMD	−209.08	463.95	0.65	521.55	222.11	0.02 *

Note: Depend variable: OP’s total LTW score, B represents regression coefficient, SE is stand error, and * denotes significant association (p < 0.05). OP: older people; LTPA: leisure time physical activity; BE: built environment; RD: residential density; AE: access to services; SC: street connectivity; W/CF: walking/cycling facilities; P/TS: pedestrian/traffic safety; CS: crime safety; LUMD: land use mix diversity.

shows the results of association of BE with OP’s LTPA level in different sex groups. The results showed that when considering LTW and moderate to vigorous PA together, the effect of BE on OP’s LTPA became different compared with the effect only on LTW. The perceived scores of one BE element and two BE elements were found significantly related with men and women’s LTPA, respectively. Aesthetics was positively correlated with men’s LTPA. Aesthetics and LUMD were positively correlated with women’s LTPA. No other BE elements were found to be significantly corelated with men and women’s LTPA level.

Table 5. Association of BE with OP’s LTW and LTPA in Ningbo.

BE Element	B	LTW SE	p	B	LTPA SE	p
RD	0.002	0.293	0.99	−0.73	0.66	0.27
AE	212.62	105.47	0.045 *	−496.89	237.51	0.04 *
SC	−150.66	85.72	0.08	222.43	193.03	0.25
W/CF	268.04	98.03	0.007 *	139.43	220.75	0.53
Aesthetics	217.66	87.53	0.01 *	770.73	197.10	<0.001 *
P/TS	146.39	81.74	0.07	87.25	184.06	0.64
CS	43.32	71.49	0.55	183.49	160.99	0.26
LUMD	−180.06	88.25	0.04 *	291.39	198.73	0.14

Note: Depend variable: OP’s total LTW score, B represents regression coefficient, SE is stand error, and * denotes significant association (p < 0.05). OP: older people; LTW: leisure time walking; LTPA: leisure time physical activity; BE: built environment; RD: residential density; AE: access to services; SC: street connectivity; W/CF: walking/cycling facilities; P/TS: pedestrian/traffic safety; CS: crime safety; LUMD: land use mix diversity.

displays the results of association of BE with OP’s LTPA level in the city of Ningbo when not considering different sex groups. For LTW, the perceived scores of four BE elements were significantly correlated with it. AE, W/CF, and aesthetics were positively correlated with OP’s LTW, and LUMD was negatively related with OP’s LTW. For LTPA, the perceived scores of two BE elements were significantly related with OP’s LTPA. AE and aesthetics were positively related with OP’s LTPA.

Table 5 displays the results of the association of BE with OP’s LTPA level in the city of Ningbo when not considering different sex groups. For LTW, the perceived scores of four BE elements were significantly correlated with it. AE, W/CF, and aesthetics were positively correlated with OP’s LTW, and LUMD was negatively related with OP’s LTW. For LTPA, the perceived scores of two BE elements were significantly related with OP’s LTPA. AE and aesthetics were positively related with OP’s LTPA.

4. Discussion

The aim of this study was to investigate the effect of BE on OP’s LTW and LTPA in different gender groups in the city of Ningbo. We particularly would like to confirm whether the association relationship would differ between LTW and LTPA. We also would like to figure out whether the association relationship would be different between male and female groups.

Our results showed that the associations of BE with OP’s LTW and LTPA were different. When not considering different sex groups, OP’s LTW was influenced by four BE elements, including AE, W/CF, aesthetics, and LUMD. However, OP’s LTPA was only influenced by two BE elements, including AE and aesthetics. W/CF and LUMD were not related with OP’s LTPA. This discovery is coherent with our former study in the city of Yiwu. Yu et al. presented that, except RD and aesthetics as the common BE influence factor, OP’s LTW was influenced by AE, and OP’s LTPA was affected by SC in the city of Yiwu [31]. Another study also found similar results. Yu et al. observed that five BE factors were related with adult’s LTW, but only four BE variables were correlated with adult’s leisure time with moderate to vigorous PA in Shenzhen [32]. The outcomes of this study and the two former studies might indicate that although LTPA included LTW, the BE factors related with LTPA and LTW might be different. Therefore, it is essential to locate the BE impact factors of LTW and LTPA.

Our results also showed that the BE influence factors of male and female’s PA were different. For LTPA, only aesthetics was related with men’s LTPA, but both aesthetics and LUMD were related with women’s LTPA. This result is in agreement with our preceding study in the city of Jinhua. The results of Jinhua showed that only two BE factors were related with men’s LTPA, but four BE factors were correlated with women’s LTPA [30]. It seems that women’s LTPA was more easily influenced by BE based on the findings of the two studies. However, when considering LTW, the association relationship changed. Men’s LTW was influenced by more BE factors. Our results showed that AE, W/CF, and LUMD were related with men’s LTW, but only P/TS was correlated with women’s LTW. All those findings suggested that no matter with investigating the association of BE with LTW or LTPA, different sex groups should be considered into the study design.

AE is a critical BE influence factor of OP’s LTW and LTPA. Our outcomes indicated that OP’s LTW and LTPA level were related with the perceived score of AE when no considering different gender groups. Additionally, men’s LTW was also correlated with the perceived score of AE. The results indicated that better AE would motive OP to engage in LTW and LTPA, particularly for men’s OP. This discovery is in agreement with previous studies. In a systematic review study, Barnett et al. suggested that overall access to destinations and services (p < 0.001), recreational facilities (p < 0.001), park/public open space (p = 0.002), and shops/commercial destinations (p = 0.006) was significantly correlated with OP’s total PA [14]. In another study, Jefferis et al. found a positive association of men’s LTPA with AE, but they did not find the association relationship between women’s LTPA and AE [38]. This result is in line with our observation of a positive association of AE with only men’s LTW. Just as the earlier study suggested, a good AE would offer OP satisfying accessibility to open places such as recreational facilities and other public open spaces and would encourage OP to walk to these destinations in place of using other travel methods [31].

Aesthetics is another important BE influence factor for both LTW and LTPA of OP in Ningbo. The results exhibited that the perceived score of aesthetics was associated with OP’s LTW and LTPA level when not considering different sex groups. Furthermore, the score of aesthetics was related with both men’s and women’s LTPA as well. A better aesthetics would provide OP a satisfying environment that is useful for OP to maintain a good mood and overcome fears such as falling risk and traffic dangers. Therefore, a good aesthetics would motive OP to participate more LTPA. This discovery is in agreement with former studies. For example, Jauregui et al. suggested that participation in LTW and moderate to vigorous PA was positively correlated with highly perceived aesthetics [39]. In other four review studies, aesthetics was testified to be a positive influence factor of OP’s PA [14,40,41,42].

The associations of LUMD with OP’s PA were different between LTW and LTPA. In this study, the perceived score of LUMD represents the walking distance from home to diverse destinations and a greater score means farther distances. Our results showed that only LTW was found to be significantly related with the perceived score of LUMD when not considering sex groups. This is mainly because men’s LTW was significantly correlated with the perceived score of LUMD. No significant associations were located between women’s LTW and the score of LUMD. However, women’s LTPA was significantly related with the score of LUMD. We also noticed that the association of LTW with LUMD was negative, but the association of LTPA with LUMD was positive. The possible explanation of this result might be that when OP take part in LTW, they always walk near home. A closer distance from home to diverse destinations might help them in making the decision to walk outside. However, when OP engage in moderate to vigorous PA such as square dancing, they always need to walk a little farther from home. The women’s perceived score of LUMD was 2.72, which implies women need about ten minutes for walking to destinations. This distance is an acceptable and friendly for OP. Therefore, in order to take part in their favorite square dance activity, women have to walk a little farther but still within an acceptable distance.

The strength of the current study is the location of the association of BE with OP’s LTW and LTPA. We particularly investigated whether the association relationship would vary in different sex groups. Our results showed that, for OP’s LTW, better AE, WC/F conditions, and shorter distances from home to destinations would motivate older males to take part in LTW, but only a better P/TS condition would motivate older female to engage in LTW. For OP’s LTPA, a better aesthetics environment would encourage older males to take part in LTW. However, not only a better aesthetics environment but also shorter distances from home to destinations would motive older female to take part in LTPA. All these findings might provide suggestions for policy makers of Ningbo government in the urban construction process. The limitations of this study were as follows: Firstly, the questionnaire survey method can cause bias inevitably. Secondly, this sample size of men’s OP was a little small, and this might cause some effects on the association relationship between BE with men’s LTW and LTPA. Whether the association relationship can change after enlarging the sample size requires more future studies.

5. Conclusions

The BE influence factors of OP’s LTW and LTPA were different in the city of Ningbo. Except AE, aesthetics as a common factor of LTW and LTPA, W/CF, and LUMD would only induce effects on OP’s LTW. The BE influence factors of OP’s LTW and LTPA varied in different sex groups. For men, three BE elements and one BE element induced effects on men’s LTW and LTPA, respectively. For women, one BE element and two BE elements induced effects on women’s LTW and LTPA, respectively. All these findings might provide suggestions for policy makers in the process of urban construction.