Improvement of the EHIS module: PHYSICAL ACTIVITY Leila Oja, Ardo Matsi

1. Improvement of the EHIS module: PHYSICAL ACTIVITY Leila Oja, Ardo Matsi National Institute for Health Development Estonia www.tai.ee

2. National Institute for Health Development (NIHD)is a governmental organisation under the Ministry of Social Affairs of Estonia. The main activities of the NIHD are the research, development and implementation of activities in the health and social sectors

3. Content of the presentation • Description of the problems • Definitions of the concept • Final suggestion for the instrument • Presentation of the instrument

4. 1. Description of the problems EHIS first wave modified International Physical Activity Questionnaire (IPAQ) was used to evaluate population based PA PE.1 During the past 7 days, on how many days did you do vigorous physical activities? PE.2 During the past 7 days, how much time did you spend doing vigorous physical activities? PE.3 During the past 7 days, on how many days did you do moderate physical activities? PE.4 During the past 7 days, how much time did you spend doing moderate physical activities? PE.5 During the past 7 days, on how many days did you walk for at least 10 minutes at a time? PE.6 During the past 7 days, how much time did you usually spend walking? It was decided to remove the question about sedentary behaviour: PE.7 During the last 7 days, how much time did you spend sitting on a week day?

5. EUROPEAN HEALTH DETERMINANTS MODULE Introduction 21 Now I'm going to ask you about your height and weight. BMI.1 How tall are you without shoes? └─┴─┴─┘ cm · don't know 998 · refusal 999 BMI.2 How much do you weigh without clothes and shoes? └─┴─┴─┘ kg · don't know 998 · refusal 999 Introduction 22 Now I am going to ask you about the time you spent being physically active in the past 7 days. Please answer each question even if you do not consider yourself to be an active person. Think about the activities you do at work, as part of your house and yard work, to get from place to place, and in your spare time for recreation, exercise or sport. Think about all the vigorous activities which take hard physical effort that you did in the last 7 days. Vigorous activities make you breathe much harder than normal and may include heavy lifting, digging, aerobics, or fast bicycling. Think only about those physical activities that you did for at least 10 minutes at a time. PE.1 During the past 7 days, on how many days did you do vigorous physical activities? └─┘ Days per week · don't know 8 · refusal 9 INTERVIEWER CLARIFICATION: THINK ONLY ABOUT THOSE PHYSICAL ACTIVITIES THAT YOU DO FOR AT LEAST 10 MINUTES AT A TIME. INTERVIEWER NOTE: IF RESPONDENT ANSWERS ZERO, REFUSES OR DOES NOT KNOW, SKIP TO QUESTION PE.3. OTHERWISE ASK PE.2. EN EN 37 PE.2 During the past 7 days, how much time did you spend doing vigorous physical activities? INTERVIEWER PROMPT ONLY IF NECESSARY "AN ESTIMATE IS ACCEPTABLE". └─┴─┘hours └─┴─┘minutes · don't know 98 98 · refusal 99 99 Now think about activities which take moderate physical effort that you did in the past 7 days. Moderate physical activities make you breathe somewhat harder than normal and may include carrying light loads, bicycling at a regular pace, or doubles tennis. Do not include walking. Again, think about only those physical activities that you did for at least 10 minutes at a time. PE.3 During the past 7 days, on how many days did you do moderate physical activities? └─┘ Days per week · don't know 8 · refusal 9 INTERVIEWER CLARIFICATION: THINK ONLY ABOUT THOSE PHYSICAL ACTIVITIES THAT YOU DO FOR AT LEAST 10 MINUTES AT A TIME. INTERVIEWER NOTE: IF RESPONDENT ANSWERS ZERO, REFUSES OR DOES NOT KNOW, SKIP TO QUESTION PE.5. OTHERWISE ASK PE.4. PE.4 During the past 7 days, how much time did you spend doing moderate physical activities? INTERVIEWER PROMPT ONLY IF NECESSARY "AN ESTIMATE IS ACCEPTABLE". └─┴─┘hours └─┴─┘minutes · don't know 98 98 · refusal 99 99 Now think about the time you spent walking in the past 7 days. This includes at work and at home, walking to travel from place to place, and any other walking that you might do solely for recreation, sport, exercise, or leisure. EN EN 38 PE.5 During the past 7 days, on how many days did you walk for at least 10 minutes at a time? └─┘ Days per week · don't know 8 · refusal 9 INTERVIEWER CLARIFICATION: THINK ONLY ABOUT THE WALKING THAT YOU DO FOR AT LEAST 10 MINUTES AT A TIME. INTERVIEWER NOTE: IF RESPONDENT ANSWERS ZERO, REFUSES OR DOES NOT KNOW, SKIP TO INTRODUCTION 23. OTHERWISE ASK PE.6. PE.6 During the past 7 days, how much time did you spend walking? INTERVIEWER PROMPT ONLY IF NECESSARY "AN ESTIMATE IS ACCEPTABLE". └─┴─┘hours └─┴─┘minutes · don't know 98 98 · refusal 99 99 1. Description of the problems: responses of MS According to the feedback based on MS experience, certain weaknesses in using the PA module were brought out. The problems reported most often were the following: Problems concerning analysing the data Problems concerning respondents • Difficulties to distinguish between moderate and vigorous PA • Questions are difficult to understand, examples are not suitable, explanations are too long, and not clear enough. • The same activity could be understood differently by respondents of different age, health status and living conditions. • Respondents had serious problems to report not only the number of days but also to calculate the amount of time used for different levels of PA • There is no information about sedentary activity, which is still important concerning health. • It is difficult to clean the dataand assess given answers according to the whole amount of daily PA. • It would be better to ask PA in different domain (leasure time, domestic work, occupational PA) separately

6. 1. Description of the problems • Some of the mentioned problems have clear reasons or explanations: • Different MS have made their own modifications, that makes it difficult to compare the results. • Too much freedom has been left to translators. • Given examples are not relavant across EU

7. 1. Description of the problems: evaluation of PA module Responses of MS about PA Module

8. 2. Definitions of the concept: The terms used in module Physical activity Occupational physical activity Leisure time Sleeping time EHIS takes into account all PA during a day. From the proposals of MS it became evident that it would be good to make difference between occupational and leisure time PA, and add also a question about sleeping time.

9. 2. Definition of the concepts Physical activity PA is any body movement that works your muscles and uses more energy than you use when you're resting.Public health surveys focuses more on health enhancing physical activity (HEPA). Occupational physical activity Occupational PA explains physical effort of the respondent's everyday work Leisure time PA Leisure time PA includes different versions of physical fitness, such as improving aerobic capacity and muscle strength. Sleeping time Insufficient sleep is associated with a number of chronic diseases and conditions — such as diabetes, cardiovascular disease, obesity, and depression, also it may complicate daily activities and productivity. .

10. 2. Definition of the concepts/ standardizedinstruments Several instruments that have been used for the population based assessment of physical activity have not been validated and therefore they cannot be used for EHIS II. Two widely used standardized short self-report or interview-based instruments for physical activity surveillance are available: . • IPAQ- was developed in 1997 as result of various research projects. The short IPAQ form about last 7 days. • GPAQ (Global PA Questionnaire) was developed in 2001 as part of the WHO Stepwise approach to HCD risk factor surveillance (STEPS) program.

11. 2. Definitions of the concept. Pros and cons . IPAQ • IPAQ requires respondents to recall PA on the past 7 days compared to a “typical week” in GPAQ. • IPAQ measurement provides information about the patterns of total physical activity and inactivity. • IPAQ - for the respondents it is hard to assess the whole amount of daily PA • IPAQ is the most tested and used in the European context (Eurobarometer (EU), N=15; World Health Survey (WHO), N=50; Int Prevalence Study (IPS), N=19; Eurobarometer 2 (EU), N=25). • Short IPAQ form is recommended for national monitoring, the shortest instrument available • Developed formula to estimate PA levels based MET-s (metabolic units) GPAQ • GPAQ is very similar to the long version of IPAQ. Both assess frequency, duration and intensity of PA. • GPAQ has been used in 58 countries across five WHO regions. • GPAQ questionnaire is not prevalent in the EU countries • GPAQ has 15 questions in three domains (work, travel, recreation) and is validated for use 16-84 years old compared to 7 questions of short IPAQ which is validated for use among 15-69 years old.

12. Expert meeting in Tallinn, Sept 7-8, 2010

13. 3. Final suggestion for the instrument IPAQ short version has some limitations, but it is the best instrument available at the moment to measure PA at the population level. NB! Itwas the origin of the questions used in EHIS I. Unfortunately many different modifications derived from IPAQ which makes it difficult to compare the results. The question about sitting should be included again, and the questions about time in different intensity levels should be modified back to the original version. Our recommendation is to use the whole package of the original short version IPAQ, which deals with the whole dimension of PA.

14. 3. Final suggestion for the instrument • Attention should be paid: • Translation of the Questionnaire, including back-translation and testing • Interviewers training • The detailed development of the manual, etc are important to ensure optimal compliance with the aims and data comparability • Data cleaning and handling must be carried out centrally. • To those who would like to separate occupational and leisure time PA and estimate about sleeping time we recommend the same additional question for all MS in order to have comparable data • In conclusion : • To use the original IPAQ short version, but explain better different levels of PA and use better explanations in interviewer`s manual • add an optional question about (1) occupational PA • (2) leisure time PA • (3) sleeping time

15. 4. Presentation of the instrument: IPAQ short version 1. During the last 7 days, on how many days did you do vigorous physical activitieslike heavy lifting, digging, aerobics, or fast bicycling? _____ days per week No vigorous physical activities Skip to question 3 2. How much time did you usually spend doing vigorous physical activities on one of those days? _____ hours per day _____ minutes per day Don’t know/Not sure 3. During the last 7 days, on how many days did you do moderate physical activitieslike carrying light loads, bicycling at a regular pace, or doubles tennis? Do not include walking. _____ days per week No moderate physical activities Skip to question 5 4. How much time did you usually spend doing moderate physical activities on one of those days? _____ hours per day _____ minutes per day Don’t know/Not sure 5. During the last 7 days, on how many days did you walk for at least 10 minutes at a time? _____ days per week No walking Skip to question 7 6. How much time did you usually spend walking on one of those days? _____ hours per day _____ minutes per day Don’t know/Not sure 7. During the last 7 days, how much time did you spend sitting on a week day? _____ hours per day _____ minutes per day Don’t know/Not sure

16. 4. Presentation of the instrument: optional questions

17. Remarks for optional questions By the questionnaire structure the occupational PA questions may be part of the occupational background variables and locate separate from health determinants module. The question about sleeping time might give extra information to other modules, such as mental health, and therefore in the structure of the questionnaire, it may also be located separately from the PA issues.

18. References Abu-Omar K, Rütten A. (2008) Relation of leisure time, occupational, domestic, and commuting physical activity to health indicators in Europe. Prev Med;47:319-23. Bauman A, Ainsworth BE, Bull F, Craig CL, Hagströmer M, Sallis JF, Pratt M, Sjöström M (2009). Progress and pitfalls in the use of the International Physical Activity Questionnaire (IPAQ) for adult physical activity surveillance. J Phys Act Health; 6 Suppl 1:S5-8. Caspersen CJ, Powell KE, Christensen GM. Physical activity, exercise and physical fitness: definitions and distinctions for health-related research. Public Health Reports, 1985; 100: 126-131. Craig C, Marshall A, Sjöström M, Bauman A, Booth M, Ainsworth B, Pratt M, Ekelund U, Yngve A, Sallis J, Oja P, and the IPAQ Consensus Group and the IPAQ Reliability and Validity Study Group. (2003) International Physical Activity Questionnaire (IPAQ): a comprehensive reliability and validity study in twelve countries. Med Sci Sports Exerc; 35:1381-1395. Dewar A, Woodgate-Jones G, Wilmot A, Betts P, Hand C. (2005) Evaluation of Modules for the European Healt Interview Survey (EHIS), Workpackage 4: Formal Qualitative Field Testing, Data Collection Methodology. Office for National Statistics, UK, December 2005:112-124. http://www.statistics.gov.uk/about/services/dcm/downloads/EHIS_Report_FINALDRAFT_20.12.2005.pdf, accessed 13 Sept 2010 Dugdill L,Crone D, Murphy R. (2009) Physical activity and health promotion. Evidence based approach to practice. Blackwell Publishing Ltd Guidelines for Data Processing and Analysis of the International Physical Activity Questionnaire (IPAQ) - Short Form. http://www.ipaq.ki.se/downloads.htm, accessed 13 Sept 2010 Global Physical Activity Surveillance. www.who.int/chp/steps/GPAQ/en/index.html, accessed 13 Sept 2010 Kilpeläinen K, Aromaa A, ECHIM project (Eds.) (2008) European health indicators development and initial implementation. Report of the ECHIM project. Helsinki University Press, Helsinki 2008:114. Meusel D. (2008) Physical activity - Relevant databases, organisations and projects. In: EUPHIX, EUphact. Bilthoven: RIVM. http://www.euphix.org> EUphact\ Determinants of health\ Health behaviours\ Physical activity, 29 May 2008. Pate R, Yancey A, Kraus W. (2010) The physical activity guidelines for Americans: Implications for clinical and public health practice. American Journal of lifestyle medicine, 4, 209-217. Physical Activity Guidelines for Americans. Be Active, Healthy, and Happy! (2008) www.health.gov/paguidelines, accessed 13 Sept 2010 Sjöström M, Oja P, Hagströmer M, Smith BJ, Bauman A. (2006) Health enhancing physical activity across the European Union countries: The Eurobarometer Study. J Public Health (Springer); 14:291-300. Sleep and Sleep Disorders. Centers for Disease Control and Prevention. http://www.cdc.gov/features/sleep/, accessed 13 Sept 2010 WHO, (2009) Workshop on integration of data on physical activity patterns, Zurich, Switzerland, 25–26 February 2009. Meeting report.

19. Thank you! Be Active!