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

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. 1. Description of the problems: responses of MS
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
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
· refusal
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
TO QUESTION PE.5. OTHERWISE ASK PE.4.
PE.4 During the past 7 days, how much time did you spend doing moderate
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?
INTERVIEWER CLARIFICATION: THINK ONLY ABOUT THE WALKING THAT YOU DO FOR AT
LEAST 10 MINUTES AT A TIME.
TO INTRODUCTION 23. OTHERWISE ASK PE.6.
PE.6 During the past 7 days, how much time did you spend walking?
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 data and 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
Some problems were pointed out only by some countries, but some of the comments were made by about half of the MS.
The same activity could be understood differently by respondents of different age, health status and living conditions.
(e.g. in rural areas where physical labour is common, the performance of hard tasks could be reported as moderate activity or not mentioned at all

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.
The terms used in module:
Physical activity
Occupational physical activity
Leisure time
Sleeping time
According to definition, PA is any body movement that works your muscles and uses more energy than you use when you're resting (Caspersen et al, 1985). Public health surveys focuses more on health enhancing physical activity (HEPA). HEPA is not only sports or exercise, but all daily physical activity on at least moderate level (Meusel, 2008).
Our recommendation is to use the whole package of the original short version IPAQ, which deals with the whole dimension of PA. IPAQ measures total physical activity whereas the recommendations are based on activity (usually leisure-time or recreational) over and above usual daily activities.
Significant reductions in risk of cardiovascular disease occur at activity levels equivalent to 150 minutes a week of moderate-intensity physical activity. Both aerobic (endurance) and muscle-strengthening (resistance) physical activity are beneficial. Several studies have focused on the role that physical activity plays in many health outcomes, including physical fitness, such as aerobic capacity, and muscle strength and endurance.  
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. Occupational PA explains physical effort of the respondent's everyday work.
In the questionnaire structure the occupational PA questions may be part of the occupational background variable and situated separate from health determinats module. Also question about sleeping time might be of interest to other modules, such as mental health, and therefore in the structure of the questionnaire it may also be located separately of the PA issues.

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. .
 PA is any body movement that works your muscles and uses more energy than you use when you're resting.(Caspersen et al, 1985).
HEPA is not only sports or exercise, but all daily physical activity on at least moderate level (Meusel, 2008

10. 2. Definition of the concepts/ standardized instruments
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: .
GPAQ (Global PA Questionnaire) was developed in 2001 as part of the WHO Stepwise approach to HCD risk factor surveillance (STEPS) program.
IPAQ - was developed in 1997 as result of various research projects. The short IPAQ form about last 7 days.

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 years old compared to 7 questions of short IPAQ which is validated for use among years old. .
 . The short IPAQ form last 7 day recall is recommended for national monitoring

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! It was 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 activities like 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 activities like carrying light loads, bicycling at a regular pace, or doubles tennis? Do not include walking.
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
5. During the last 7 days, on how many days did you walk for at least 10 minutes at a time?
No walking Skip to question 7
6. How much time did you usually spend walking on one of those days?
7. During the last 7 days, how much time did you spend sitting on a week day?

16. 4. Presentation of the instrument: optional questions
In the last 7 days, how much of the following sports-related activities did you do in your leisure time?
Endurance training, which elevates your heart beat and makes you breath more rapidly (e.g. jogging, ball games, cycling)
_____ days per week
_____ hours _____ minutes per day
Muscle training, which improves or maintains strength of your muscles (e.g. weight training, sequence training, muscle exercises at home)
_____ hours _____ minutes per day
2. In the last 7 days, how would you describe the physical activity level of your work?
I do not currently work
 Go to question X
Mainly sitting without interruptions. 
Mainly sitting with short periods of physical exertion such as standing, walking, light carrying etc.
Mainly standing or walking with no extra physical exertion.
Mainly standing or walking with some extra physical exertion such as climbing stairs, light carrying or lifting etc.
A lot of physical activity with heavy physical exertion such as digging, shoveling, hacking, heavy lifting and carrying etc.
3. In the last 7 days, how much did you sleep per 24 hours?
_____ hours _____ minutes per 24 hours

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:
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:
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accessed 13 Sept 2010
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accessed 13 Sept 2010
Global Physical Activity Surveillance. 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.
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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,
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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:
Sleep and Sleep Disorders. Centers for Disease Control and Prevention. accessed 13 Sept 2010
WHO, (2009) Workshop on integration of data on physical activity patterns, Zurich, Switzerland, 25–26 February Meeting report.

19. Thank you!
Be Active!