Journal of Public Health

, Volume 14, Issue 2, pp 66–70

Development of the World Health Organization Global Physical Activity Questionnaire (GPAQ)

Authors

    • Surveillance and Population-based Prevention, Department of Chronic Diseases and Health PromotionWorld Health Organization
  • Fiona Bull
    • BHF National Centre for Physical Activity and Health, School of Sport & Exercise SciencesLoughborough University
Review Article

DOI: 10.1007/s10389-006-0024-x

Cite this article as:
Armstrong, T. & Bull, F. J Public Health (2006) 14: 66. doi:10.1007/s10389-006-0024-x

Abstract

The aim of developing the World Health Organization (WHO) Global Physical Activity Questionnaire (GPAQ) was to have a tool that would produce valid and reliable estimates of physical activity, especially relevant to developing countries where patterns of energy expenditure differ from developed countries because people experience diverse ways of life. The development of a standardized tool to measure physical activity that enables comparisons across culturally diverse populations is a challenging task. Comparable, valid, and reliable information on physical activity enables countries to follow trends over time, understand regional and global comparisons, and better inform physical activity policy decisions. A WHO expert working group on physical activity measurement provided a draft GPAQ for global consultation. The draft instrument was validated in nine countries. Validation studies and qualitative feedback on GPAQ were presented at an Expert Meeting on Global Physical Activity Surveillance held jointly by WHO and the US Centers for Disease Control and Prevention. A second round of global consultation led to minor revisions and preparation of a final GPAQ version 2 instrument (GPAQv2). Around 50 developing countries are now using GPAQ for physical activity data collection. GPAQv2 is a suitable physical activity surveillance instrument for developing countries.

Keywords

Physical activityMeasurementSurveillanceEpidemiology

Introduction

Rapid changes in urbanization are leading to rapid health transitions and resultant increases in chronic disease burden, especially in economically developing countries (World Health Organization 2005a). Physical activity is a major independent, modifiable risk factor that has a protective effect for cardiovascular disease, ischaemic stroke, type 2 diabetes, colon cancer, and breast cancer (Bull et al. 2004) and is also associated with other important health outcomes, including mental health (Saxena et al. 2005), injuries, falls, and obesity (Bauman 2004).

Surveillance of population levels of physical activity levels using a standardized protocol is an important and necessary part of a public health response to current concerns regarding physical activity levels. Surveillance of physical activity in population groups is most often undertaken using a self-reported questionnaire, as these are relatively inexpensive and relatively easy to administer compared with objective measurement techniques. However, until recently, less than a handful of countries regularly collected robust data on physical activity to monitor trends over time (Bull et al. 2004). This is at least partly due to the lack of consensus on what measurement instrument should be used.

The development of an appropriate, valid, and reliable tool to measure physical activity is a challenging task. Physical activity for health benefit comprises several components (e.g. intensity, frequency, duration, and type) that can be performed in different domains (e.g. occupational physical activity, transport physical activity, and/or physical activity during discretionary or leisure time) (Armstrong et al. 2000). Further, the validity, and, to a lesser extent, the reliability of physical activity questionnaires has been questioned by some authors (Jakes and Wareham 2003).

Given the increased global interest in the role of physical activity to prevent chronic disease and the lack of data that is useful both to inform within-country public health efforts and for intercountry comparisons, there is an urgent need for standardized measurement of physical activity. These measures must be valid, reliable, and adaptable to incorporate cultural and other differences across countries. This paper describes the process of the development of a WHO-recommended tool for physical activity surveillance in developing countries.

Development of the Global Physical Activity Questionnaire (GPAQ): phase 1

The development of GPAQ as an instrument to assess physical activity patterns, especially in developing country contexts, has been undertaken by the WHO as part of the WHO STEPwise approach to chronic disease risk-factor surveillance (STEPS) (WHO 2005b). The STEPS approach to risk-factor surveillance enables countries to build and strengthen their capacity to conduct chronic disease risk-factor surveillance within the framework of an integrated, systematic approach aimed at a sustainable collection of data (Armstrong and Bonita 2003).

In February 2002, the WHO convened a Workshop on Physical Activity Measurement and Surveillance, which was held in Hobart, Australia. At that meeting, existing physical activity questionnaires were reviewed for their usefulness in developing country settings. The processes and discussions from that Workshop are described elsewhere (de Courten 2002) and will not be revisited here. However, it is important to note that both the long and short forms of the International Physical Activity Questionnaire (IPAQ 2002) were discussed in detail due to their recent development (Craig et al. 2003) and similarity in their intended purpose as instruments suitable for international comparisons of physical activity. The long form of IPAQ, however, was deemed ‘‘too long’’ and ‘‘too complex’’ to be used in a general chronic disease risk-factor survey such as STEPS or in other national health surveys. One perceived limitation of the short-form IPAQ was that the instrument does not allow the differentiation of data from the different domains in which physical activity can be performed. The capture of information on patterns of physical activity in the key domains (or settings) of life common to people in developing countries who experience diverse lifestyles is important. In developing countries, occupational-, domestic-, and transport-related activities may contribute more to overall energy expenditure than does leisure-time or recreational activity (Bull et al. 2004). For surveillance of physical activity over time and for the planning and delivery of targeted population interventions a multidomain approach was deemed essential. In this regard, the development of GPAQ can be viewed as a ‘‘compromise’’ between the nine-question short-form IPAQ and the 31-question long-form IPAQ instruments.

The resulting draft questionnaire from the Hobart workshop was distributed to WHO regional offices for comment and was also presented for review at several WHO regional- and national-level STEPS workshops and other risk factor surveillance and physical activity scientific meetings held throughout 2003. Comments on the instrument were reviewed, and a draft questionnaire, an ‘‘Interviewers Guide,’’ and analysis protocol were prepared for field testing.

The GPAQ version 1 (GPAQv1) comprised 19 questions that were grouped to collect information on physical activity in three domains: work (paid and unpaid), transport (i.e., walking and cycling to get to and from places), and discretionary time (leisure, recreation, etc.). A single question to assess sedentary behavior is a feature of both the GPAQ and IPAQ. Within the work and discretionary domains, information on frequency and duration of vigorous-intensity and, separately, moderate-intensity physical activities are collected. For the transport domain, information on all walking and cycling are collected; however, there is no attempt to differentiate between these types of activity or the intensity at which they are performed.

Validation and reliability of GPAQ version 1

During 2002–2004, WHO commissioned a coordinated program of research to test the reliability and validity of GPAQ in a diverse set of countries, and particularly in populations with lower education levels. The specific areas of research were to assess the concurrent and criterion validity of GPAQ, along with the test-retest reliability of the instrument. Testing was undertaken among populations in nine countries (Bangladesh, Brazil, China, Ethiopia, India, Indonesia, Japan, Portugal, and South Africa). Detailed methods and results of this program of research will be described elsewhere (article in preparation at the time of writing: Bull F, Maslin T, Armstrong T, Global Physical Activity Questionnaire: 9-country reliability and validity), and only a brief summary will be presented here.

The test-retest reliability of GPAQ was examined to assess the repeatability of the instrument over multiple applications using a 3- to 7-day time gap for time 1 and time 2. Concurrent validity (intermethod comparison) was undertaken by comparing GPAQ with IPAQ, an instrument with known acceptable-to-good validity and reliability properties (Craig et al. 2003). Assessing the correlation between selected variables from both GPAQ and IPAQ enabled the relative ability of GPAQ to measure those parameters to be assessed. The criterion validity of GPAQ was assessed using objective motion monitors, either a pedometer or accelerometer. Objective measurement of physical activity by motion sensors enables the collection of more accurate information on activity patterns than do questionnaires (Shephard 2003). However, as motion sensors are not usually practical for population surveillance of physical activities, their use as a measure for determining the criterion validity of questionnaires is important.

Pooled summary results for total activity show that the concurrent validity between GPAQv1 and IPAQ produced a moderate-to-good correlation coefficient (r=0.54). The concurrent validity of the sedentary question was good (r=0.65). Pooled criterion validity (from pedometer studies) for total physical activity was fair (r=0.31) and for time spent in sedentary activities produced a fair negative correlation (r=0.26). Test-retest reliability data produced good-to-excellent results, indicating a high level of repeatability between administrations of GPAQ (0.67–0.81). Overall, these results indicate that GPAQ performed well and at least as well as the IPAQ short-form in terms of its measurement properties.

The initial results of the GPAQ research program informed the continued development and refinement of the GPAQ instrument and signified the beginning of the second and final phase of GPAQ development.

Development of the Global Physical Activity Questionnaire (GPAQ): phase 2

Preliminary results of the validity and reliability of GPAQv1, along with qualitative feedback from field testing, were presented at the February 2005 Expert Workshop on Surveillance of Physical Activity held in Portugal and jointly hosted by WHO and the US Centers for Disease Control and Prevention (US CDC).

In addition to the quantitative analysis of GPAQ research, qualitative feedback from both interviewers and interviewees provided a valuable source of information. Feedback from both country research sites and from countries that have started to use the GPAQ within the context of STEPS implementation reinforced that the “domain approach” of the GPAQ was one of the strengths of the instrument and also the importance of using show cards to introduce the relatively new concepts, such as intensity of activities. There were, however, concerns about the length of the questionnaire and the importance of interviewer training.

A WHO GPAQ drafting group reviewed all submissions—both of a qualitative and a quantitative nature. Revisions to GPAQv1 were made and circulated to the expert participants of the Portugal workshop and STEPS focal points in WHO regional offices. Comments from this final round of consultation led to a majority consensus view and the formulation of GPAQ version 2 (GPAQv2) (see Table 1). GPAQv2 is only slightly modified from GPAQv1, and the same structure and domain approach has been retained. GPAQv2, with 16 questions, is slightly shorter than GPAQv1, as the screening questions of the original were deemed redundant and were removed. Wording was improved for ease of understanding and, in several instances, to bring into alignment with wording from the IPAQ questions.
Table 1

Global Physical Activity Questionnaire version 2 (GPAQv2)

GPAQ V2

Next I am going to ask you about the time you spend doing different types of physical activity in a typical week. Please answer these questions even if you do not consider yourself to be a physically active person. Think first about the time you spend doing work. Think of work as the things that you have to do such as paid or unpaid work, study/training, household chores, harvesting food/crops, fishing or hunting for food, seeking employment. [Insert other examples if needed]. In answering the following questions ‘vigorous-intensity activities’ are activities that require hard physical effort and cause large increases in breathing or heart rate, ‘moderate-intensity activities’ are activities that require moderate physical effort and cause small increases in breathing or heart rate

 

 

Response

Coding Column

 

P 1

Does your work involve vigorous-intensity activity that causes large increases in breathing or heart rate like [carrying or lifting heavy loads, digging or construction work] for at least 10 minutes continuously? INSERT EXAMPLES &USE SHOWCARD

Yes

1

If No, go to P3

No

2

  

P2a

In a typical week, on how many days do you do vigorous-intensity activities as part of your work?

Days a week

□□

 

P2b

How much time do you spend doing vigorous-intensity activities at work on a typical day?

In hours and minutes

hrs□□ : mins□□

P3

Does your work involve moderate-intensity activity, that causes small increases in breathing or heart rate such as brisk walking [or carrying light loads] for at least 10 minutes continuously? INSERT EXAMPLES &USE SHOWCARD

Yes

1

If No, go to P5

No

2

  

P4a

In a typical week, on how many days do you do moderate-intensity activities as part of your work?

Days a week

□□

 

P 4b

How much time do you spend doing moderate-intensity activities at work on a typical day?

In hours and minutes

hrs□□ : mins□□

 

The next questions exclude the physical activities at work that you have already mentioned. Now I would like to ask you about the usual way you travel to and from places. For example to work, for shopping, to market, to place of worship. [insert other examples if needed]

P 5

Do you walk or use a bicycle (pedal cycle) for at least 10 minutes continuously to get to and from places?

Yes

1

If No, go to P7

No

2

  

P 6a

In a typical week, on how many days do you walk or bicycle for at least 10 minutes continuously to get to and from places?

Days a week

□□

 

P 6b

How much time do you spend walking or bicycling for travel on a typical day?

In hours and minutes

hrs□□ : mins□□

 

The next questions exclude the work and transport activities that you have already mentioned. Now I would like to ask you about sports, fitness and recreational activities (leisure),[insert relevant terms]

P 7

Do you do any vigorous-intensity sports, fitness or recreational (leisure) activities that cause large increases in breathing or heart rate like [running or football,] for at least 10 minutes continuously? INSERT EXAMPLES &USE SHOWCARD

Yes

1

If No, go to P9

No

2

  

P 8a

In a typical week, on how many days do you do vigorous-intensity sports, fitness or recreational (leisure) activities?

Days a week

□□

 

P 8b

How much time do you spend doing vigorous-intensity sports, fitness or recreational activities on a typical day?

In hours and minutes

In hours and minutes hrs□□ : mins□□

 

P 9

Do you do any moderate-intensity sports, fitness or recreational (leisure) activities that causes a small increase in breathing or heart rate such as brisk walking,[cycling, swimming, volleyball] for at least 10 minutes continuously? INSERT EXAMPLES &USE SHOWCARD

Yes

1

If No, go to P 11

No

2

  

P10a

In a typical week, on how many days do you do moderate-intensity sports, fitness or recreational (leisure) activities?

Days a week

□□

 

P 10b

How much time do you spend doing moderate-intensity sports, fitness or recreational (leisure) activities on a typical day?

In hours and minutes

hrs□□ : mins□□

 

The following question is about sitting or reclining at work, at home, getting to and from places, or with friends including time spent [sitting at a desk, sitting with friends, travelling in car, bus, train, reading, playing cards or watching television], but do not include time spent sleeping. INSERT EXAMPLES & USE SHOWCARD

P 11

How much time do you usually spend sitting or reclining on a typical day?

In hours and minutes

hrs□□ : mins□□

 

Ongoing global physical activity surveillance

Research, feedback from field use, and current practice within countries using STEPS and countries using the GPAQ in other health surveys indicates that GPAQ is suitable for collection of physical-activity prevalence data in both developing and developed countries. The GPAQv2 instrument is currently the physical activity data collection instrument within STEPS. Further, the instrument may be appropriate for use in other physical activity or population-based health surveys, especially in developing countries with no or little physical activity data. Some 49 countries (see Table 2) have, or are in the process of, collecting physical activity data using GPAQ within their STEPS chronic disease risk factor surveillance activities. It is worth noting that the performance of GPAQ in reporting national-level prevalence estimates has yet to be examined and reported.
Table 2

Countries that have used or are using the Global Physical Activity Questionnaire (GPAQ) within the World Health Organization’s (WHO) Stepwise Approach to Surveillance

Algeria

Cook Islands

Ghana

Kiribati

Myanmar

Saudi Arabia

Tokelau

American Samoa

Côte d’Ivoire

India

Lebanon

Namibia

Solomon Islands

Tonga

Angola

Democratic Republic of the Congo

Indonesia

Madagascar

Nauru

South Africa

Tunisia

Bangladesh

Egypt

Iran

Maldives

Nepal

Sri Lanka

Tuvalu

Botswana

Eritrea

Iraq

Marshall Islands

Nigeria

Syria

Uganda

Cameroon

Ethiopia

Jordan

Micronesia

Palau

Tanzania

Vanuatu

Congo (Brazzaville)

Fiji

Kenya

Mozambique

Samoa

Thailand

Zimbabwe

GPAQ scoring protocols have been developed and are available from the authors (TA). The main outcome variables from GPAQ analysis are: a categorical variable of total physical activity (high, moderate and low); continuous variable of total physical activity within each domain—work, transport, leisure (reported as Median METmin/week). The measure of total physical activity should, in theory, be comparable with the outcome measure of total physical activity obtained from IPAQ because both instruments aim to capture physical activity undertaken across the same multiple domains. The IPAQ and GPAQ are therefore conceptually comparable but structurally different. It is not yet known how this difference will affect estimates obtained from IPAQ and GPAQ; however, this warrants further investigation.

In conclusion, the reliability and validity of the GPAQ instrument has been found to be comparable with that of the IPAQ. Moreover, the GPAQ has a perceived added advantage that information in specific domains is collected. Further, testing of the GPAQ will be conducted by the WHO in order to provide more information on how the instrument performs in a wider range of cultural and country settings, including sites in Eastern Europe.

The WHO and the US CDC will convene a second WHO–CDC Physical Activity Surveillance Workshop in late 2006 to examine the latest GPAQ and IPAQ data. At this meeting, the relationship between the two instruments will be examined further, and their use in population and other surveys on physical activity will be discussed, along with the identification of research questions for future physical activity surveillance.

Copyright information

© Springer-Verlag 2006