Preliminary evaluation of a video questionnaire to assess activity levels of children

Development and validation of the Global Adolescent and Child Physical Activity Questionnaire (GAC-PAQ) in 14 countries: study protocol

INTRODUCTION

Global surveillance of physical activity (PA) of children and adolescents with questionnaires is limited by the use of instruments developed in high-income countries (HICs) lacking sociocultural adaptation, especially in low- and middle-income countries (LMICs); under-representation of some PA domains; and omission of active play, an important source of PA. Addressing these limitations would help improve international comparisons, and facilitate the cross-fertilisation of ideas to promote PA. We aim to develop and assess the reliability and validity of the app-based Global Adolescent and Child Physical Activity Questionnaire (GAC-PAQ) among 8-17 years old in 14 LMICs and HICs representing all continents; and generate the 'first available data' on active play in most participating countries.

METHODS AND ANALYSIS

Our study involves eight stages: (1) systematic review of psychometric properties of existing PA questionnaires for children and adolescents; (2) development of the GAC-PAQ (first version); (3) content validity assessment with global experts; (4) cognitive interviews with children/adolescents and parents in all 14 countries; (5) development of a revised GAC-PAQ; (6) development and adaptation of the questionnaire app (application); (7) pilot-test of the app-based GAC-PAQ; and, (8) main study with a stratified, sex-balanced and urban/rural-balanced sample of 500 children/adolescents and one of their parents/guardians per country. Participants will complete the GAC-PAQ twice to assess 1-week test-retest reliability and wear an ActiGraph wGT3X-BT accelerometer for 9 days to test concurrent validity. To assess convergent validity, subsamples (50 adolescents/country) will simultaneously complete the PA module from existing international surveys.

ETHICS AND DISSEMINATION

Approvals from research ethics boards and relevant organisations will be obtained in all participating countries. We anticipate that the GAC-PAQ will facilitate global surveillance of PA in children/adolescents. Our project includes a robust knowledge translation strategy sensitive to social determinants of health to inform inclusive surveillance and PA interventions globally.

Development and Content Validity of the Physical Activity Questionnaire-Young Children (PAQ-YC) to Assess Physical Activity in Children between 5 and 7 Years

Childhood is a critical period in the development and consolidation of healthy habits, such as the practice of physical activity (PA). It is essential to have valid instruments to measure PA from an early age. The aim of this study was to design and evaluate the content validity of the Physical Activity Questionnaire-Young Children (PAQ-YC) to measure the PA level in children aged 5-7 years. The first version of the questionnaire was tested by a 2-round Delphi study. It was established as a consensus criterion that the relative interquartile range (RIR) and/or the coefficient of variation (CV) were ≤20%. The most significant discrepancies in the Delphi survey (n = 11-13) were observed for items about hours of Physical Education or similar activities at school (item 7: RIR = 20, CV = 38.73) and for items about participation in Physical Education (item 8: RIR = 25, CV = 15.45). The cognitive interviews (n = 5) confirmed the version agreed by the experts. The results show that the PAQ-YC presents adequate content validity in terms of relevance, comprehensiveness and comprehensibility.

The effect of a video-supported assessment to increase the accuracy of self-reported physical activity

Self-reported physical activity differs from activity levels measured by device. We tested the effect of a video that visualizes the intensity levels of physical activity to increase the agreement between self-reported and accelerometer-based moderate-to-vigorous physical activity (MVPA) within a single-blinded, randomized study. Participants (N = 378, 40-75 years) wore an accelerometer for seven days. Prior to the collection of self-reported data by the IPAQ-SF, participants were randomly assigned (1:1) to a control group (CG) or a video group (VG). The outcome was the absolute difference between self-reported and accelerometer-based time spent in MVPA (Δ MVPA_{IPAQ-Accelerometry} ). To examine the agreement, we used Spearman correlation coefficients and Bland-Altman analysis. To test the video effect, we used Wilcoxon signed-rank test, Bayes factor, and simultaneous-quantile regression. In total, 302 participants fulfilled the accelerometer wear time criteria (≥10 hours/day; ≥6 days) and completed self-reports within three days after the wearing period. The median of Δ MVPA_{IPAQ-Accelerometry} was -9.0 min/day (IQR: -32.0 to 66.6) for CG and -11.5 min/day (IQR: -29.9 to 14.3) for VG. Wilcoxon signed-rank test revealed no differences in Δ MVPA_{IPAQ-Accelerometry} between study groups whereas Bayes factor indicated insensitivity of the data. Simultaneous-quantile regression revealed no relationship between video presentation and Δ MVPA_{IPAQ-Accelerometry} in the 25th percentile. In the 50th (b = -12.4 [95% CI = -23.2 to -1.5] and 75th percentile (b = -45.7 [95% CI = -70.5 to -20.9]), Δ MVPA_{IPAQ-Accelerometry} was negatively associated with video presentation. To conclude, video-supported assessment may increase the accuracy of self-reported MVPA among individuals who slightly underestimated and those who overestimated their MVPA.

An Updated Systematic Review of Childhood Physical Activity Questionnaires

Background and Objective

This review is an update of a previous review published in 2010, and aims to summarize the available studies on the measurement properties of physical activity questionnaires for young people under the age of 18 years.

Methods

Systematic literature searches were carried out using the online PubMed, EMBASE, and SPORTDiscus databases up to 2018. Articles had to evaluate at least one of the measurement properties of a questionnaire measuring at least the duration or frequency of children’s physical activity, and be published in the English language. The standardized COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist was used for the quality assessment of the studies.

Results

This review yielded 87 articles on 89 different questionnaires. Within the 87 articles, 162 studies were conducted: 103 studies assessed construct validity, 50 assessed test–retest reliability, and nine assessed measurement error. Of these studies, 38% were of poor methodological quality and 49% of fair methodological quality. A questionnaire with acceptable validity was found only for adolescents, i.e., the Greek version of the 3-Day Physical Activity Record. Questionnaires with acceptable test–retest reliability were found in all age categories, i.e., preschoolers, children, and adolescents.

Conclusion

Unfortunately, no questionnaires were identified with conclusive evidence for both acceptable validity and reliability, partly due to the low methodological quality of the studies. This evidence is urgently needed, as current research and practice are using physical activity questionnaires of unknown validity and reliability. Therefore, recommendations for high-quality studies on measurement properties of physical activity questionnaires were formulated in the discussion.

PROSPERO Registration Number

CRD42016038695.

Electronic supplementary material

The online version of this article (10.1007/s40279-018-0987-0) contains supplementary material, which is available to authorized users.

An evaluation of questionnaires assessing physical activity levels in youth populations

The aim of this study was to revise and organize according to recall time based criteria, questionnaires created and validated to assess the level of physical activity in children and adolescents, with the intention of enabling their proper understanding and subsequent use by nurses and health care professionals. In order to determine the questionnaires' quality, their degree of reliability and validity was the main feature to be taken into account. Thirty-eight papers were retrieved and analyzed, 31 of which were aimed at designing and validating a questionnaire intended for physical activity (PA) level assessment in youth populations (four to 19 year olds). The most widely used questionnaires were those whose recall time spans from one to seven days. In general, all questionnaires were characterized by the use of pen-and-paper format and scarce utilization of new technologies. Based upon validity and reliability criteria, in order to assess PA level in children and adolescents, nurses should use the "Children's Leisure Activities Study Survey" and the "Flemish Physical Activity Computer Questionnaire", respectively. There is a need for the validation of these tools in other languages and cultures.

Mediators of the effect of the JUMP-in intervention on physical activity and sedentary behavior in Dutch primary schoolchildren from disadvantaged neighborhoods

Background

Important health benefits can be achieved when physical activity in children from low socio-economic status is promoted and sedentariness is limited. By specifying the mediating mechanisms of existing interventions one can improve future physical activity interventions. This study explored potential mediators of the long-term effect of the school-based multicomponent JUMP-in intervention on sport participation, outdoor play and screen time in Dutch primary schoolchildren from disadvantaged neighborhoods.

Methods

In total, 600 primary schoolchildren (aged 9.8 ± 0.7, 51% girls, 13% Dutch ethnicity, 35% overweight) from 9 intervention and 10 control schools were included in the analyses. JUMP-in was developed using Intervention Mapping, and targeted psychological and environmental determinants of physical activity. Outcome behaviors were self-reported sport participation, outdoor play, TV-viewing behavior and computer use. Potential mediators were self-reported psychological, social and physical environmental factors.

Results

JUMP-in was effective in improving sport participation after 20 months, but not in improving outdoor play, or reducing TV-viewing or computer time. JUMP-in was not effective in changing hypothesized mediators so no significant mediated effects could be identified. However, changes in self-efficacy, social support and habit strength were positively associated with changes in sport participation, and changes in social support, self-efficacy, perceived planning skills, enjoyment and habit strength were positively associated with changes in outdoor play. Changes in enjoyment was positively associated with changes in TV-viewing while parental rules were negatively associated. Having a computer in the bedroom and enjoyment were positively associated with changes in computer use, while changes in parental rules were negatively associated.

Conclusions

Besides a significant positive effect on sports participation, no significant intervention effect on outdoor play, screen time or any of the potential mediators was found. This suggest that other (unmeasured) factors operated as mediating mechanisms of the intervention, that we used unsuccessful intervention strategies, that the strategies were inappropriately implemented, or that children are unable to accurately recall past activities and cognitions. Additionally, the school setting might not be the sole channel to influence leisure time activities. Still, several personal and environmental constructs were found to be relevant in predicting change in sport participation, outdoor play and screen behavior and seem to be potential mediators. Future interventions are recommended including more effective strategies targeting these relevant constructs, addressing different constructs (e.g. pedagogic skills of parents), and focusing on different implementation settings.

Trail registration

ISRCTN17489378

The development of a unique physical activity self-report for young children: challenges and lessons learned

The number of overweight and obese children in the Western world is alarming. Efforts to impact this problem at an individual level have had little effect. Interventions that focus on the whole population may prove more successful. This study reports the development of a unique self-report picture questionnaire designed to assess playground physical activity preferences in young children (4-9 years, N = 1,881) at 14 regional Australian primary schools. Children's picture preferences were compared with observational data using the Children's Activity Scanning tool (CAST2). Results indicate that 62% to 89% of children preferred activities that were moderate or highly active; however, CAST2 data indicated that children spent only 50% to 70% of play time being active. The findings confirm that young children are able to indicate their preferences for physical activity. Important considerations in future attempts to develop a measure of physical activity in young children are discussed.

Can accelerometry be used to discriminate levels of activity?

The aims of this study were to investigate the associations between an activity logbook and the RT3 accelerometer and to assess whether the RT3 can discriminate activity levels in healthy adults. Ten participants completed two trials wearing an RT3 accelerometer over a 4-6 h period and completed a detailed activity log. Results showed a poor correlation between the RT3 in moderate activities (r = 0.22) in comparison to low (r = 0.52) and hard (r = 0.70) from the logbook. A significant difference was found in average RT3 vector magnitude (VM) counts/min in each activity level (p < 0.0001). Discriminant analysis demonstrated that an RT3VM counts/min value of approximately 500 was found to have high sensitivity (88%), and specificity (88%) for discriminating between low and moderate activity levels from the logbook. This study found that accelerometry has the potential to discriminate activity levels in free living. This study is the first to investigate whether tri-axial accelerometry can discriminate different levels of free-living activity recorded in an activity logbook. The RT3 accelerometer can discriminate between low and moderate physical activities and offers a methodology that may be applicable to future research in occupational settings.

Assessment of physical activity in youth

Despite much progress with physical activity assessment, the limitations concerning the accurate measurement of physical activity are often amplified in young people due to the cognitive, physiological, and biomechanical changes that occur during natural growth as well as a more intermittent pattern of habitual physical activity in youth compared with adults. This mini-review describes and compares methods to assess habitual physical activity in youth and discusses main issues regarding the use and interpretation of data collected with these techniques. Self-report instruments and movement sensing are currently the most frequently used methods for the assessment of physical activity in epidemiological research; others include heart rate monitoring and multisensor systems. Habitual energy expenditure can be estimated from these input measures with varying degree of uncertainty. Nonlinear modeling techniques, using accelerometry perhaps in combination with physiological parameters like heart rate or temperature, have the greatest potential for increasing the prediction accuracy of habitual physical activity energy expenditure. Although multisensor systems may be more accurate, this must be balanced against feasibility, a balance that shifts with technological and scientific advances and should be considered at the beginning of every new study.

The Multimedia Activity Recall for Children and Adolescents (MARCA): development and evaluation

BACKGROUND

Self-report recall questionnaires are commonly used to measure physical activity, energy expenditure and time use in children and adolescents. However, self-report questionnaires show low to moderate validity, mainly due to inaccuracies in recalling activity in terms of duration and intensity. Aside from recall errors, inaccuracies in estimating energy expenditure from self-report questionnaires are compounded by a lack of data on the energy cost of everyday activities in children and adolescents. This article describes the development of the Multimedia Activity Recall for Children and Adolescents (MARCA), a computer-delivered use-of-time instrument designed to address both the limitations of self-report recall questionnaires in children, and the lack of energy cost data in children.

METHODS

The test-retest reliability of the MARCA was assessed using a sample of 32 children (aged 11.8 +/- 0.7 y) who undertook the MARCA twice within 24-h. Criterion validity was assessed by comparing self-reports with accelerometer counts collected on a sample of 66 children (aged 11.6 +/- 0.8 y). Content and construct validity were assessed by establishing whether data collected using the MARCA on 1429 children (aged 11.9 +/- 0.8 y) exhibited relationships and trends in children's physical activity consistent with established findings from a number of previous research studies.

RESULTS

Test-retest reliability was high with intra-class coefficients ranging from 0.88 to 0.94. The MARCA demonstrated criterion validity comparable to other self-report instruments with Spearman coefficients ranging from rho = 0.36 to 0.45, and provided evidence of good content and construct validity.

CONCLUSION

The MARCA is a valid and reliable self-report questionnaire, capable of a wide variety of flexible use-of-time analyses related to both physical activity and sedentary behaviour, and offers advantages over existing pen-and-paper questionnaires.

Sex differences in habitual physical activity and lung function decline in children with cystic fibrosis

OBJECTIVES

To evaluate the feasibility of measuring habitual physical activity (HPA) in children with cystic fibrosis (CF) and to assess the relation between HPA and the rate of decline in FEV1 over a period of 2 years.

STUDY DESIGN

At regular clinic visits, 109 patients (7 to 17 years; 56 girls) performed pulmonary function testing and completed the Habitual Activity Estimation Scale (HAES). Patients were divided into quartiles, based on activity levels derived from the HAES.

RESULTS

Girls in the two lowest activity quartiles had a more rapid rate of decline FEV1 (-3.40% and -3.05% predicted, respectively) than girls in the two highest activity quartiles (-0.93% and +1.17% predicted, respectively) (P = .02). In boys, the rate of decline of FEV1 was similar in all activity quartiles (-1.95% predicted). Patients reported significantly more activity in summer compared with spring, winter, and fall (P < .0001), and boys reported greater activity than girls (6.5 +/- 2.9 vs 5.4 +/- 2.5 h/d, P < .05).

CONCLUSIONS

The annual rate of change of FEV1 was related to activity quartile in girls but not in boys. This research suggests that an inactive lifestyle may partially explain the poorer survival of female patients with CF. The HAES is a feasible tool for routine follow-up of HPA in our CF clinic.

Development of the Physical Activity Interactive Recall (PAIR) for Aboriginal children

BACKGROUND: Aboriginal children in Canada are at increased risk for type 2 diabetes. Given that physical inactivity is an important modifiable risk factor for type 2 diabetes, prevention efforts targeting Aboriginal children include interventions to enhance physical activity involvement. These types of interventions require adequate assessment of physical activity patterns to identify determinants, detect trends, and evaluate progress towards intervention goals. The purpose of this study was to develop a culturally appropriate interactive computer program to self-report physical activity for Kanien'kehá:ka (Mohawk) children that could be administered in a group setting. This was an ancillary study of the ongoing Kahnawake Schools Diabetes Prevention Project (KSDPP). METHODS: During Phase I, focus groups were conducted to understand how children describe and graphically depict type, intensity and duration of physical activity. Sixty-six students (40 girls, 26 boys, mean age = 8.8 years, SD = 1.8) from four elementary schools in three eastern Canadian Kanien'kehá:ka communities participated in 15 focus groups. Children were asked to discuss and draw about physical activity. Content analysis of focus groups informed the development of a school-day and non-school-day version of the physical activity interactive recall (PAIR). In Phase II, pilot-tests were conducted in two waves with 17 and 28 children respectively to assess the content validity of PAIR. Observation, videotaping, and interviews were conducted to obtain children's feedback on PAIR content and format. RESULTS: Children's representations of activity type and activity intensity were used to compile a total of 30 different physical activity and 14 non-physical activity response choices with accompanying intensity options. Findings from the pilot tests revealed that Kanien'kehá:ka children between nine and 13 years old could answer PAIR without assistance. Content validity of PAIR was judged to be adequate. PAIR was judged to be comprehensive, acceptable, and enjoyable by the children. CONCLUSIONS: Results indicate that PAIR may be acceptable to children between nine and 13 years old, with most in this age range able to complete PAIR without assistance. The flexibility of its programming makes PAIR an easily adaptable tool to accommodate diverse populations, different seasons, and changing trends in physical activity involvement.

Growth retardation is associated with changes in the stress response system and behavior in school-aged jamaican children

In the developing world, 39% of children <5 y old are short for their age (stunted, defined as height-for-age less than -2 SD of National Center for Health Statistics references), and many have poor levels of mental development along with behavioral problems. We showed previously that 8- to 10-y-old children from a longitudinal cohort who experienced early childhood stunting had altered hypothalamic-pituitary-adrenocortical (HPA) and sympathetic-adrenomedullary (SAM) system activity. We repeated the study with 31 newly recruited, stunted Jamaican school children (less than -2.0 SD height-for-age) and nonstunted controls (n = 31, more than -1.0 SD height-for-age) matched for sex, age and school. All children were tested in a 1.5-h session, including psychological and physiologic stressors, in which their behaviors, salivary cortisol concentrations and heart rates were measured. In addition, we measured urinary catecholamine (epinephrine, norepinephrine, dopamine) concentrations, which were not reported for the children in the longitudinal cohort. After controlling for covariates that differed between groups (child intelligence quotient, body mass index and birth weight), stunted children had faster resting heart rates while lying and sitting (P < 0.05) and also during psychological testing (P < 0.05), as well as higher concentrations of urinary epinephrine (P < 0.05) and norepinephrine (P < 0.05), compared with nonstunted children. In addition, the stunted children were less happy (P < 0.01), more inhibited (P < 0.01) and more frustrated (P < 0.05) during the psychological tests than nonstunted children. These results suggest that growth retardation is associated with alterations in stress-sensitive systems, particularly the SAM system, and that this connection may contribute to the poor levels of development observed in stunted children.