RESEARCH ARTICLE
Validity and responsiveness of the Global Physical Activity Questionnaire (GPAQ) in assessing physical activity during pregnancy Estelle D. Watson1,2*, Lisa K. Micklesfield2, Mireille N. M. van Poppel3,4, Shane A. Norris2, Matteo C. Sattler3, Pavel Dietz3
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1 Centre for Exercise Science and Sports Medicine, School of Therapeutic Sciences, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa, 2 MRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa, 3 Institute of Sports Science, University of Graz, Graz, Austria, 4 Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, the Netherlands * [email protected]
Abstract OPEN ACCESS Citation: Watson ED, Micklesfield LK, van Poppel MNM, Norris SA, Sattler MC, Dietz P (2017) Validity and responsiveness of the Global Physical Activity Questionnaire (GPAQ) in assessing physical activity during pregnancy. PLoS ONE 12 (5): e0177996. https://doi.org/10.1371/journal. pone.0177996 Editor: Pedro Tauler, Universitat de les Illes Balears, SPAIN Received: January 9, 2017 Accepted: May 5, 2017 Published: May 26, 2017 Copyright: © 2017 Watson et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
The physiological and biomechanical changes that occur during pregnancy make accurate measurement of physical activity (PA) a challenge during this unique period. The Global Physical Activity Questionnaire (GPAQ) has been used extensively in low-to-middle income countries, but has never been validated in a pregnant population. In this longitudinal study, 95 pregnant women (mean age: 29.5±5.7 years; BMI: 26.9±5.0 kg/m2) completed the GPAQ and were asked to wear an accelerometer for 7 days at two time points during pregnancy (14–18 and 29–33 weeks gestation). There was a significant difference between accelerometry and GPAQ when measuring moderate-to-vigorous physical activity (MVPA) at 29–33 weeks gestation (16.6 vs 21.4 min/day; p = 0.02) as well as sedentary behaviour (SB) at both 14–18 weeks (457.0 vs 300 min/day; p < 0.01) and 29–33 weeks gestation (431.5 vs 300 min/day; p < 0.01). There was poor agreement between the GPAQ and accelerometry for both PA and SB at both time points (ICC: -0.05–0.08). Bland Altman plots indicated that the GPAQ overestimates PA by 14.8 min/day at 14–18 weeks and by 15.8 min/ day at 29–33 weeks gestation. It underestimates SB by 127.5 min/day at 14–18 weeks and by 89.2 min/day at 29–33 weeks gestation. When compared to accelerometry, the GPAQ shows poor agreement and appears to overestimate PA and underestimate SB during pregnancy.
Data Availability Statement: The authors confirm that all data underlying the findings are fully available without restriction. All relevant data are within the Supporting Information files.
Introduction
Funding: This work is based on the research supported in part by the National Research Foundation of South Africa (grant no. 87944 to EDW). Any opinion, finding and conclusion or recommendation expressed in this material is that of the authors and the NRF does not accept any
It is now generally accepted that regular physical activity (PA) has a fundamental role to play in positive health outcomes during pregnancy. Participating in 20–30 minutes of moderate intensity PA on most days of the week (approximately 150 minutes per week) [1], as recommended by the American College of Obstetricians and Gynecologists (ACOG) [2], provides various benefits such as reduced risk of excessive gestational weight gain, gestational diabetes
PLOS ONE | https://doi.org/10.1371/journal.pone.0177996 May 26, 2017
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Validation and responsiveness of the GPAQ during pregnancy
liability in this regard. The study was funded by the Wellcome Trust (UK), Medical Research Council of South Africa. SAN is supported by the MRC/DFID African Research Leader Scheme (UK). This submission also received support from the DSTNRF Centre of Excellence in Human Development at the University of the Witwatersrand, Johannesburg in the Republic of South Africa LKM would like to acknowledge funding from the Academy of Medical Sciences-Newton Advanced Fellowship. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist.
mellitus [3,4] and preeclampsia [5]. In addition, women who are physically active during pregnancy benefit from increased cardiovascular fitness and muscular strength [6], as well as psychological benefits and improved mental health [7]. Although the evidence for the role of PA in birth outcomes is contradictory [8], some studies suggest that PA may have a protective effect on outcomes such as low birth weight, preterm birth and intrauterine growth restriction [9]. There is a general consensus that moderate intensity PA is safe to perform and does not place the fetus at any unnecessary risk [2,10]. The accurate measurement of PA is essential to monitor PA patterns, as well as to determine dose-response relationships and its associations with health outcomes in pregnancy [11]. Clarity on each of these aspects is critical for effective public health interventions, especially during pregnancy, but relies heavily on accurate measurement instruments. Self-reported questionnaires are simple, cost effective methods of assessing levels and patterns of PA in large samples [12, 13]. They are potentially useful to categorize participants as “active” or “inactive” within a population, and can provide useful information on activity domains such as occupational, transport or recreational PA [12]. However, the reliability and validity of questionnaires to measure PA have been called into question [13], and few appear to correlate well with the more objective measures of PA, such as accelerometry [14]. There are various questionnaires which have been used to assess PA during pregnancy, and the validity and reliability of many of these have been assessed [15, 16, 17]. Chasen-Taber et al. [17] developed the Pregnancy Physical Activity Questionnaire (PPAQ), which has been shown to be a moderately reliable measure of PA during this pregnancy. Correlations between the PPAQ and accelerometry cut points have varied between 0.08–0.58 for total PA, 0.20–0.49 for moderate intensity PA and 0.25–0.39 for vigorous intensity PA [18, 19]. In contrast, the International Physical Activity Questionnaire (IPAQ) has recently been found by Harrison et al. [15] to have a low correlation and poor absolute agreement with accelerometry during pregnancy. Similarly, Oostdam et al. [16] found very little association between accelerometry and the Activity Questionnaire for Adults and Adolescents (AQuAA), which appears to overestimate PA levels during pregnancy. The Global Physical Activity Questionnaire (GPAQ) has been used extensively in low-tomiddle-income countries (LMICs) [20], mostly due to its usefulness in capturing PA in various domains such as occupation, domestic tasks, walking for transport and recreation. Furthermore, a moderate agreement has been found with accelerometry for moderate-to-vigorous physical activity (MVPA, r = 0.04–0.48), but this was in non-pregnant populations [21, 22]. It has yet to be validated during pregnancy, despite being used to assess PA during the gestational period in some studies [23, 24]. The physiological and biomechanical changes that occur during pregnancy make accurate PA measurement a challenge [6], and a recent review by Poudevigne & O’Connor [7] found that much of the literature did not use validated measures of PA during pregnancy when assessing its relationship with health outcomes. Therefore, the aim of this study was to assess the use of the GPAQ to measure PA and SB at two time points during pregnancy (14–18 and 29–33 weeks gestation).
Materials and methods Participants This longitudinal, observational study included a subset of women recruited from a larger study, the Soweto First 1000 Days Cohort (S1000), based at the Medical Research Council (MRC)/Wits Developmental Pathways for Health Research Unit (DPHRU) which is located at the Chris Hani Baragwanath Hospital (CHBH) in Soweto, Johannesburg. Soweto is a large urban area in South Africa with mainly low income households. Women attending CHBH for antenatal care were included into this sub-study if they had healthy singleton pregnancies, and
PLOS ONE | https://doi.org/10.1371/journal.pone.0177996 May 26, 2017
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Validation and responsiveness of the GPAQ during pregnancy
no contraindications to physical activity or exercise [2]. Data were collected at baseline (
Validity and responsiveness of the Global Physical Activity Questionnaire (GPAQ) in assessing physical activity during pregnancy Estelle D. Watson1,2*, Lisa K. Micklesfield2, Mireille N. M. van Poppel3,4, Shane A. Norris2, Matteo C. Sattler3, Pavel Dietz3
a1111111111 a1111111111 a1111111111 a1111111111 a1111111111
1 Centre for Exercise Science and Sports Medicine, School of Therapeutic Sciences, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa, 2 MRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa, 3 Institute of Sports Science, University of Graz, Graz, Austria, 4 Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, the Netherlands * [email protected]
Abstract OPEN ACCESS Citation: Watson ED, Micklesfield LK, van Poppel MNM, Norris SA, Sattler MC, Dietz P (2017) Validity and responsiveness of the Global Physical Activity Questionnaire (GPAQ) in assessing physical activity during pregnancy. PLoS ONE 12 (5): e0177996. https://doi.org/10.1371/journal. pone.0177996 Editor: Pedro Tauler, Universitat de les Illes Balears, SPAIN Received: January 9, 2017 Accepted: May 5, 2017 Published: May 26, 2017 Copyright: © 2017 Watson et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
The physiological and biomechanical changes that occur during pregnancy make accurate measurement of physical activity (PA) a challenge during this unique period. The Global Physical Activity Questionnaire (GPAQ) has been used extensively in low-to-middle income countries, but has never been validated in a pregnant population. In this longitudinal study, 95 pregnant women (mean age: 29.5±5.7 years; BMI: 26.9±5.0 kg/m2) completed the GPAQ and were asked to wear an accelerometer for 7 days at two time points during pregnancy (14–18 and 29–33 weeks gestation). There was a significant difference between accelerometry and GPAQ when measuring moderate-to-vigorous physical activity (MVPA) at 29–33 weeks gestation (16.6 vs 21.4 min/day; p = 0.02) as well as sedentary behaviour (SB) at both 14–18 weeks (457.0 vs 300 min/day; p < 0.01) and 29–33 weeks gestation (431.5 vs 300 min/day; p < 0.01). There was poor agreement between the GPAQ and accelerometry for both PA and SB at both time points (ICC: -0.05–0.08). Bland Altman plots indicated that the GPAQ overestimates PA by 14.8 min/day at 14–18 weeks and by 15.8 min/ day at 29–33 weeks gestation. It underestimates SB by 127.5 min/day at 14–18 weeks and by 89.2 min/day at 29–33 weeks gestation. When compared to accelerometry, the GPAQ shows poor agreement and appears to overestimate PA and underestimate SB during pregnancy.
Data Availability Statement: The authors confirm that all data underlying the findings are fully available without restriction. All relevant data are within the Supporting Information files.
Introduction
Funding: This work is based on the research supported in part by the National Research Foundation of South Africa (grant no. 87944 to EDW). Any opinion, finding and conclusion or recommendation expressed in this material is that of the authors and the NRF does not accept any
It is now generally accepted that regular physical activity (PA) has a fundamental role to play in positive health outcomes during pregnancy. Participating in 20–30 minutes of moderate intensity PA on most days of the week (approximately 150 minutes per week) [1], as recommended by the American College of Obstetricians and Gynecologists (ACOG) [2], provides various benefits such as reduced risk of excessive gestational weight gain, gestational diabetes
PLOS ONE | https://doi.org/10.1371/journal.pone.0177996 May 26, 2017
1 / 14
Validation and responsiveness of the GPAQ during pregnancy
liability in this regard. The study was funded by the Wellcome Trust (UK), Medical Research Council of South Africa. SAN is supported by the MRC/DFID African Research Leader Scheme (UK). This submission also received support from the DSTNRF Centre of Excellence in Human Development at the University of the Witwatersrand, Johannesburg in the Republic of South Africa LKM would like to acknowledge funding from the Academy of Medical Sciences-Newton Advanced Fellowship. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist.
mellitus [3,4] and preeclampsia [5]. In addition, women who are physically active during pregnancy benefit from increased cardiovascular fitness and muscular strength [6], as well as psychological benefits and improved mental health [7]. Although the evidence for the role of PA in birth outcomes is contradictory [8], some studies suggest that PA may have a protective effect on outcomes such as low birth weight, preterm birth and intrauterine growth restriction [9]. There is a general consensus that moderate intensity PA is safe to perform and does not place the fetus at any unnecessary risk [2,10]. The accurate measurement of PA is essential to monitor PA patterns, as well as to determine dose-response relationships and its associations with health outcomes in pregnancy [11]. Clarity on each of these aspects is critical for effective public health interventions, especially during pregnancy, but relies heavily on accurate measurement instruments. Self-reported questionnaires are simple, cost effective methods of assessing levels and patterns of PA in large samples [12, 13]. They are potentially useful to categorize participants as “active” or “inactive” within a population, and can provide useful information on activity domains such as occupational, transport or recreational PA [12]. However, the reliability and validity of questionnaires to measure PA have been called into question [13], and few appear to correlate well with the more objective measures of PA, such as accelerometry [14]. There are various questionnaires which have been used to assess PA during pregnancy, and the validity and reliability of many of these have been assessed [15, 16, 17]. Chasen-Taber et al. [17] developed the Pregnancy Physical Activity Questionnaire (PPAQ), which has been shown to be a moderately reliable measure of PA during this pregnancy. Correlations between the PPAQ and accelerometry cut points have varied between 0.08–0.58 for total PA, 0.20–0.49 for moderate intensity PA and 0.25–0.39 for vigorous intensity PA [18, 19]. In contrast, the International Physical Activity Questionnaire (IPAQ) has recently been found by Harrison et al. [15] to have a low correlation and poor absolute agreement with accelerometry during pregnancy. Similarly, Oostdam et al. [16] found very little association between accelerometry and the Activity Questionnaire for Adults and Adolescents (AQuAA), which appears to overestimate PA levels during pregnancy. The Global Physical Activity Questionnaire (GPAQ) has been used extensively in low-tomiddle-income countries (LMICs) [20], mostly due to its usefulness in capturing PA in various domains such as occupation, domestic tasks, walking for transport and recreation. Furthermore, a moderate agreement has been found with accelerometry for moderate-to-vigorous physical activity (MVPA, r = 0.04–0.48), but this was in non-pregnant populations [21, 22]. It has yet to be validated during pregnancy, despite being used to assess PA during the gestational period in some studies [23, 24]. The physiological and biomechanical changes that occur during pregnancy make accurate PA measurement a challenge [6], and a recent review by Poudevigne & O’Connor [7] found that much of the literature did not use validated measures of PA during pregnancy when assessing its relationship with health outcomes. Therefore, the aim of this study was to assess the use of the GPAQ to measure PA and SB at two time points during pregnancy (14–18 and 29–33 weeks gestation).
Materials and methods Participants This longitudinal, observational study included a subset of women recruited from a larger study, the Soweto First 1000 Days Cohort (S1000), based at the Medical Research Council (MRC)/Wits Developmental Pathways for Health Research Unit (DPHRU) which is located at the Chris Hani Baragwanath Hospital (CHBH) in Soweto, Johannesburg. Soweto is a large urban area in South Africa with mainly low income households. Women attending CHBH for antenatal care were included into this sub-study if they had healthy singleton pregnancies, and
PLOS ONE | https://doi.org/10.1371/journal.pone.0177996 May 26, 2017
2 / 14
Validation and responsiveness of the GPAQ during pregnancy
no contraindications to physical activity or exercise [2]. Data were collected at baseline (
