Abstract
Objectives
Updating Baecke physical activity questionnaire in French, validating this version named AQAP and developing software for a personalized interpretation of the results.
Method
Validation conducted on 702 consultants in health prevention centers aged 18–79 years: reliability of the questionnaire when self-administered, validity according to the energy expenditure per interview and reproducibility after two weeks ( n = 31). After two months, assessment of the questionnaire’s impact on knowledge and behaviors in 320 young adults aged 18–29 years.
Results
The results from self- and interviewer-administered questionnaire were correlated (Kappa > 0.60). Furthermore, the total physical activity index was correlated to the energy expenditure (rho = 0.39, P < 0.0001). The four physical activity indexes calculated from self-administrated questionnaires barely varied at the two-week interval ( P ≥ 0.23, power ≥ 77%, accepted difference ±10%). Two months later, 80% of the participants had read the interpretation software report, 55% became conscious of their physical activity level, 43% increased their physical activity level and 42% reported being aware of the relationship between physical activity and health.
Conclusion
AQAP characteristics are satisfactory and thus this questionnaire can be used on the general population in complement of an individual or collective action to promote physical activity and in epidemiological studies for analyzing the links between individual behaviors and health.
Résumé
Objectifs
Actualisation du questionnaire d’activité physique (AP) de Baecke en français, validation de cette version nommée AQAP et développement d’un logiciel d’interprétation.
Méthode
Validation chez 702 consultants de centres d’examens de santé âgés de 18–79 ans : fiabilité de l’auto-administration, validité en référence à la dépense énergétique par interview, répétabilité à deux semaines ( n = 31). Évaluation à deux mois de l’impact sur les connaissances et le mode de vie chez 320 jeunes adultes âgés de 18–29 ans.
Résultats
Les résultats obtenus par auto-administration et interview du questionnaire étaient concordants (Kappa > 0,60). L’index d’AP global était corrélé avec la dépense énergétique (rho = 0,39, p < 0,0001). Les quatre index d’AP différaient peu à deux semaines d’intervalle ( p ≥ 0,23, puissance ≥ 77 % pour un écart toléré de ±10 %). Deux mois après l’action, 80 % des participants avaient lu la synthèse éditée par le logiciel, 55 % avaient pris conscience du niveau de leur AP, 43 % l’avaient augmentée et 42 % avaient acquis des connaissances sur les liens entre AP et santé.
Conclusion
Les caractéristiques d’AQAP semblent satisfaisantes pour une utilisation en population générale en appui d’une action individuelle ou collective de promotion de l’AP ainsi que dans les études épidémiologiques analysant les liens entre santé et comportements.
1
English version
1.1
Introduction
Promoting physical activity (PA) is one of the nine main objectives of the French National Nutrition and Health Program (PNNS) . It has been validated that regular PA has a positive impact on health and well-being at any age. Conversely, a poor level of PA has been associated to increased rates in mortality , cardiovascular diseases , diabetes , android obesity , high blood pressure , colon cancer , breast cancer in menopausal women , osteoporosis , depression and anxiety as well as greater loss of autonomy and cognitive decline in elderly individuals .
Before inciting subjects to increase their level of PA, it is essential to quantify their habitual level of PA and establish with them a realistic and attainable objective, adapted to their physical abilities and way of life using notebooks and questionnaires, pedometers (step counters), accelerometers and physiological markers. Questionnaire evaluation is the simplest and cheapest method, and it can easily be computerized, thus making it easy and practical for studies and interventions on large cohorts. Several questionnaires have been developed but very rarely in French: Baecke , Modifiable Activity Questionnaire (MAQ) , International Physical Activity Questionnaire (IPAQ) . However some preliminary testing has unveiled the limits of each one of them: Baecke questionnaire was validated about 20 years ago (1992) and since then, the behaviors of the French population have greatly evolved. The MAQ was deemed too complex for people with a low level of education when self-administered. Finally, IPAQ only gives information relating to the past week, which can induce a statistical bias (e.g. getting back from a vacation, transitory incapacity).
Thus, we decided to update Baecke questionnaire and validate its new version, AQAP, in French. Furthermore, since this questionnaire was aimed at being used on large population samples, it seemed relevant to the authors to include specific data-management software able to give an immediate personalized synthesized report for individual benefits as well as for statistical purposes by assessing the physical state of a group of subjects who answered the questionnaire. These characteristics could add to this tool the necessary requirements for use in health education and epidemiology.
1.2
Material and method
1.2.1
AQAP questionnaire (Physical Activity self-Administered Questionnaire): description and tests
Baecke questionnaire evaluates the average PA level of an individual. It is made-up of 22 closed questions and divided into four parts according to the activity’s context: usual daily activities (eight questions), daily outings (one question), regular sport activities (seven questions) and leisure activities (six questions). Three indexes (usual daily activity, sport and leisure-related activity) are calculated (on a scale from 1 to 5). The fourth index assesses the global PA level and is in fact the sum of the three previous indexes (on a scale from 3 to 15). AQAP questionnaire is an updated version of the Baecke questionnaire and was written by a multidisciplinary team that included physicians, nutritionists as well as a nurse, biometrician, statistician, epidemiologist and a student in the sciences and techniques of PA and sports. This new version proposes level examples for activities of daily living and sport activities as well as more common activities (e.g. time spent in front of the TV) or new activities (e.g. sitting in front of a computer, using inline skating to go around). This version of the AQAP questionnaire ( Appendix 1 ) was taken through several test phases.
The questionnaire was tested on 702 men and women (age range: 18–79); these persons were all consultants at one of the 15 Health Examination Centers (CES) in four French regions. They came in for a preventive medical examination proposed by their local social security center (CPAM). AQAP data were added to the behavioral data collected for interpreting the health examination. The personalized synthesized report was then commented by the examining physician or nutritionist.
Self-administration reliability and validity of the obtained results were tested on 524 subjects: at first, the questionnaire was self-administered and then afterwards, each answer was validated or corrected by a nutritionist specially trained for this type of interview. Then the nutritionist continued the interview to evaluate the subject’s energy expenditure (EE) by asking about his or her one by one various activities: on a weekday, on a Saturday, on a Sunday and on a typical vacation day. The interview lasted 30 minutes on average. The EE was then calculated over a year time and then for a regular day by using a compendium of PA , which gives the EE of 850 activities defined by the type of activity and its intensity. To evaluate the questionnaire’s reproducibility, we administered it to a group of 31 subjects twice at a two-week interval without telling them why they were solicited again or what the final objective was.
1.2.2
AQAP software: description and tests
For each AQAP questionnaire filled out, the software proposed a data entry function and storing the answers as well as editing the corresponding personalized synthesis (see an example on Appendix 2 ). Furthermore, for one group of subjects whose answers to the questionnaires were saved and stored, a statistical module integrated to the software permitted the edition of a descriptive report of the group’s PA, per gender, detailing: frequency of answers to the modalities of each item as well as means and distributions of the different PA indexes.
Each personalized PA synthesized report was elaborated by combining different modules taking into account the following person’s characteristics: age, gender, the four calculated activity indexes, fatigue level, regular sport practice, work activity, lifting heavy loads, sweating, body mass index, smoking status, sedentary leisure activities (leisure index < 2.5/5). The synthesis report was written up with the objective to deliver messages following health education recommendations. Furthermore, a summary of the nine main objectives of the PNNS was listed as a reminder on each report.
During 3.5 months, the AQAP questionnaire was proposed to all young adults (age range: 18–29) who came in for a periodical health check-up in the following French health centers: Alençon, Angers, Caen, Cholet, Laval, Le Havre, Le Mans and Saint-Lô ( n = 320); a personalized report was handed out to each of them and commented by the examining physician. Two months later, the same individuals were interrogated by mail to evaluate their perception of the messages delivered and if they were able to assimilate them. Forty-six percent of them ( n = 147) answered the questionnaire that included 33 items related to: developing competencies, ethical acceptability of the synthesis and its impact in terms of adaptation and change of their behaviors.
1.2.3
Statistical methods
Number Crunching Statistical Software (NCSS 2007) was used for data analysis. Data were expressed in means (standard deviation) or percentage (confidence interval at 95%). The concordance between self-reported answers and the ones obtained during the interview was established with the Kappa test. Quantitative data (four indexes) were transformed into semi-quantitative data by replacing each value with another one (from 1 to 5) according to the quintiles of the index values distribution. For all variables (questions, index expressed in quintiles) when the answer from the self-administered questionnaire differed from the one given during the interview we calculated this discrepancy. According to the Kappa test, the concordance was deemed good in the interval [0.61–0.80] and excellent for one test greater or equal to 0.81. The intrasubject concordance between the two series of test administered at a two-week interval was evaluated with the intraclass correlation coefficient (ICC). A Spearman rank correlation test was used to assess the validity of the results between EE and global PA index according to sex, age and employment. The reproducibility of the four indexes was assessed with the Wilcoxon signed-rank test since the distribution of the sport activity index was non-Gaussian. The non-Gaussian distribution of the sport index would not allow for determining the ICC or the power measurement of the reproducibility test’s results. Tests were significant if P < 0.05.
1.3
Results
During the testing phase (reliability, validity and reproducibility), 16 subjects (3%) were excluded for poor comprehension of the French language, unmanageable agenda or inability to evaluate the time spent on each activity. The mean non-response rate for all questions was 2.4% with a maximum of 7.3% reached on the question about estimating the PA over a week according to three levels: weak, moderate or important ( Appendix 1 , question 1).
For each of the 22 questions and four PA indexes, Table 1 lists the percentage of underestimation, concordance and overestimation between self-administration and interview modes. All Kappa tests used to measure the concordance between the two administration modes were superior to 0.60. The concordance levels of the indexes were the same for both sexes except for the usual daily PA index which was lower in women (Kappa 0.66) than in men (Kappa 0.82); the concordance level was higher for working women (Kappa 0.78) than for non-working women (Kappa 0.49). Table 2 lists, per sex, the link between the PA level estimated by the global AQAP activity index and the EE quantified by interview; correlations were presented for the two administration modes of the AQAP questionnaire (self-administration and interview), per sex, age range and working or non-working status. The global activity index was significantly correlated to the EE in all groups except the one of women above the age of 59 ( P = 0.44). For men, correlation levels were noticeably higher when the answers had been pre-validated by a nutritionist and when participants were younger and working.
| 367 men | 157 women | 524 men and women | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Under-estimation (%) | Concordance (%) | Over-estimation (%) | Kappa | Under-estimation (%) | Concordance (%) | Over-estimation (%) | Kappa | Under-estimation (%) | Concordance (%) | Over-estimation (%) | Kappa | |
| Question 1 | 2.0 | 91.0 | 7.0 | 0.85 | 2.8 | 81.6 | 15.6 | 0.66 | 2.3 | 88.3 | 9.4 | 0.80 |
| Question 2 | 5.2 | 93.2 | 1.6 | 0.91 | 11.5 | 88.5 | 0.0 | 0.84 | 6.2 | 92.6 | 1.2 | 0.89 |
| Question 3 | 3.2 | 94.3 | 2.5 | 0.92 | 5.0 | 92.5 | 2.5 | 0.89 | 4.0 | 93.4 | 2.6 | 0.91 |
| Question 4 | 2.0 | 90.5 | 7.5 | 0.85 | 0.6 | 87.8 | 11.6 | 0.82 | 1.6 | 89.6 | 8.8 | 0.84 |
| Question 5 | 0.0 | 95.3 | 4.7 | 0.94 | 1.2 | 87.4 | 11.4 | 0.82 | 0.4 | 92.8 | 6.8 | 0.90 |
| Question 6 | 0.9 | 98.8 | 0.3 | 0.99 | 0.0 | 100.0 | 0.0 | 1.00 | 0.6 | 99.2 | 0.2 | 0.99 |
| Question 7 | 1.2 | 97.9 | 0.9 | 0.97 | 0.0 | 99.4 | 0.6 | 0.99 | 0.8 | 98.4 | 0.8 | 0.98 |
| Question 8 | 4.0 | 90.6 | 5.4 | 0.87 | 9.1 | 88.1 | 2.8 | 0.82 | 5.4 | 90.2 | 4.4 | 0.85 |
| Question 9 | 2.8 | 80.9 | 16.3 | 0.76 | 3.4 | 83.7 | 12.9 | 0.75 | 3.0 | 81.0 | 16.0 | 0.76 |
| Question 10 | 1.7 | 92.2 | 6.1 | 0.83 | 1.3 | 92.7 | 6.0 | 0.83 | 1.6 | 92.3 | 6.1 | 0.83 |
| Question 11 | 0.9 | 95.2 | 3.9 | 0.91 | 2.5 | 95.0 | 2.5 | 0.89 | 1.6 | 94.8 | 3.6 | 0.90 |
| Question 12 | 4.0 | 90.6 | 5.4 | 0.84 | 5.1 | 90.7 | 4.2 | 0.80 | 4.4 | 90.4 | 5.2 | 0.83 |
| Question 13 | 0.3 | 96.4 | 3.3 | 0.93 | 2.0 | 94.6 | 3.4 | 0.89 | 0.8 | 96.8 | 2.4 | 0.92 |
| Question 14 | 0.6 | 94.9 | 4.5 | 0.85 | 0.7 | 96.5 | 2.8 | 0.86 | 0.6 | 95.5 | 3.9 | 0.85 |
| Question 15 | 2.2 | 95.4 | 2.4 | 0.87 | 1.2 | 97.5 | 1.3 | 0.89 | 2.0 | 96.0 | 2.0 | 0.87 |
| Question 16 | 0.0 | 98.5 | 1.5 | 0.95 | 0.7 | 98.6 | 0.7 | 0.94 | 0.2 | 98.6 | 1.2 | 0.95 |
| Question 17 | 6.4 | 91.1 | 2.5 | 0.87 | 10.5 | 88.8 | 0.7 | 0.82 | 7.7 | 90.3 | 2.0 | 0.86 |
| Question 18 | 4.7 | 89.9 | 5.4 | 0.86 | 3.7 | 89.9 | 6.4 | 0.84 | 4.5 | 89.8 | 5.7 | 0.86 |
| Question 19 | 0.3 | 94.2 | 5.5 | 0.93 | 0.0 | 96.6 | 3.4 | 0.95 | 0.0 | 95.2 | 4.8 | 0.93 |
| Question 20 | 0.6 | 95.8 | 3.6 | 0.94 | 0.6 | 95.7 | 3.7 | 0.92 | 0.6 | 95.6 | 3.8 | 0.94 |
| Question 21 | 0.3 | 99.7 | 0.0 | 1.00 | 0.0 | 100.0 | 0.0 | 1.00 | 0.2 | 99.8 | 0.0 | 1.00 |
| Question 22 | 5.2 | 89.3 | 5.5 | 0.84 | 3.4 | 93.9 | 2.7 | 0.91 | 4.8 | 91.0 | 4.2 | 0.86 |
| Usual daily PA a index b | 7.1 | 85.6 | 7.3 | 0.82 | 8.5 | 73.6 | 17.9 | 0.66 | 7.4 | 82.4 | 10.2 | 0.78 |
| Sport PA a index b | 4.6 | 90.0 | 5.4 | 0.87 | 2.4 | 91.2 | 6.4 | 0.89 | 4.5 | 89.8 | 5.7 | 0.88 |
| Leisure PA a index b | 4.6 | 69.4 | 26.0 | 0.61 | 2.8 | 72.7 | 24.5 | 0.66 | 4.0 | 70.6 | 25.4 | 0.63 |
| Global PA a index b | 5.4 | 80.0 | 14.6 | 0.75 | 6.1 | 74.7 | 19.2 | 0.68 | 5.5 | 78.6 | 15.9 | 0.73 |
| AQAP | |||||
|---|---|---|---|---|---|
| Self-administration | After interview validation | ||||
| n | rho a | P a | rho a | P a | |
| Men | |||||
| All men | 286 | 0.37 | 0.0001 | 0.42 | 0.0001 |
| Age | |||||
| < 50 yrs | 85 | 0.50 | 0.0001 | 0.52 | 0.0001 |
| 50–59 yrs | 150 | 0.38 | 0.0001 | 0.43 | 0.0001 |
| > 59 yrs | 51 | 0.31 | 0.03 | 0.44 | 0.001 |
| Working | |||||
| No | 96 | 0.39 | 0.0001 | 0.47 | 0.0001 |
| Yes | 190 | 0.43 | 0.0001 | 0.46 | 0.0001 |
| Women | |||||
| All women | 113 | 0.30 | 0.001 | 0.34 | 0.0003 |
| Age | |||||
| < 50 yrs | 39 | 0.44 | 0.005 | 0.48 | 0.002 |
| 50–59 yrs | 44 | 0.31 | 0.04 | 0.32 | 0.04 |
| > 59 yrs | 30 | 0.15 | 0.44 | 0.22 | 0.24 |
| Working | |||||
| No | 48 | 0.32 | 0.03 | 0.38 | 0.007 |
| Yes | 65 | 0.36 | 0.003 | 0.39 | 0.001 |
| Men and Women | |||||
| All men and women | 399 | 0.39 | 0.0001 | 0.43 | 0.0001 |
| Age | |||||
| < 50 yrs | 124 | 0.51 | 0.0001 | 0.53 | 0.0001 |
| 50–59 yrs | 194 | 0.39 | 0.0001 | 0.42 | 0.0001 |
| > 59 yrs | 81 | 0.33 | 0.003 | 0.40 | 0.0002 |
| Working | |||||
| No | 144 | 0.40 | 0.0001 | 0.47 | 0.0001 |
| Yes | 255 | 0.44 | 0.0001 | 0.47 | 0.0001 |
Indexes calculated from the questionnaires that were filled out at a two-week interval did not vary significantly ( Table 3 , P ≥ 0.05 and power greater or equal to 77% for an accepted difference of ±10%).
| T0 | T0 + 2 weeks | P a | ICC (95% CI) b | |
|---|---|---|---|---|
| n = 31 | n = 31 | |||
| Usual daily PA index | 2.58 (0.51) | 2.50 (0.53) | 0.50 | 0.88 (0.77–0.94) |
| Sport PA index | 2.90 (0.57) | 2.86 (0.53) | 0.95 | c |
| Leisure PA index | 2.96 (0.59) | 2.91 (0.55) | 0.43 | 0.78 (0.60–0.89) |
| Global PA index | 8.45 (1.25) | 8.31 (1.21) | 0.23 | 0.87 (0.75–0.94) |
b All intraclass correlation coefficients (ICC) were significant at P < 0.0001.
Table 4 described the content of the synthesized report handed out to the subject according to three evaluation criteria of one health education tool: developing knowledge, know-how and appropriate behaviors. The context and meaning of each comment’s message are also explained. The answers to the evaluation test regarding the impact of the AQAP questionnaire two months after its use are presented in Table 5 .
| Conditions taken into account for editing the message | Messages delivered in the AQAP synthesis |
|---|---|
| Developing know-how | |
| Not working | Information about the health benefits of PA |
| Working | Importance of maintaining or strengthening the activity |
| Often tired and very few daily activities | PA increases fatigue’s resistance and prevents anxiety |
| All (adapted to age and gender) | PNNS recommendations on nutrition and diet |
| Smokers | Tobacco’s negative impact on the heart and lungs |
| Overweight a or obese b | Weight loss associated to a better body image |
| Men | Association sport and pleasure |
| Women | Association sport and body tone |
| Developing how-to | |
|---|---|
| No sport | Recommendations on practicing at least one sport |
| Listing of adapted sports (age, sex) and tests before choosing | |
| Idea for finding sport associations: see city hall | |
| If the person does not like sport, brisk walking at least 30 min/d | |
| Only one sport | Listing of sports that are good at improving health conditions |
| At least one regularly practiced sport | Medical examination for all with stress test if > 50 yrs |
| Sport practiced only part of the year | Precisions on the importance of practicing sports regularly |
| Insufficient intensity and/or duration of the sportive activity | Advice on increasing the intensity or duration |
| Few daily activities and not working | Development of daily activities |
| Few daily activities and working | Development of daily activities during free time |
| Excessive sweating with high activity level | Hydration advice |
| Smoker | Orientation towards a consultation with family physician |
| Overweight a | Advice for talking to family physician about PA and nutrition |
| Lifting heavy loads | Advice for preventing and limiting back pain |
| Tired | Advice on resting before any PA |
| Developing appropriate behaviors | |
|---|---|
| Low or moderate PA | Taking responsibility for one’s health |
| High and intense sport activity all year long | Try and encourage less-motivated persons |
| Low leisure PA | Increase group activities during leisure |
| PA perceived lower than same age persons PA | Objective: reach the same PA level |
a Overweight: BMI [25–30 kg/m 2 ].
| Questions | n responses | Yes or true (%) | [95% CI] a |
|---|---|---|---|
| Did the “AQAP” physical activity questionnaire help you gain more knowledge on the relevance of physical activity and its positive impact on one’s health? Yes/no | 147 | 41.5 | 33.4–49.9 |
| In practice, did you increase your physical activity? Yes/no | 139 | 43.2 | 34.8–51.8 |
| If yes, how so? (please answer each question) Yes/no | |||
| I increased my daily physical activities (e.g. taking the stairs, walking or biking) | 59 | 78.0 | 65.3–87.7 |
| I increased my physical activities for leisure (e.g. DIY, walking) | 55 | 70.9 | 57.1–82.4 |
| I started a new sport (e.g. sport club registration, swimming) | 56 | 28.6 | 17.3–42.2 |
| If no, why? (please answer each question)? Yes/no | |||
| I intended to do so but I did not get around to it yet | 70 | 72.9 | 60.9–82.8 |
| I already have a high level of physical activity | 67 | 32.8 | 21.8–45.4 |
| I do not want to | 64 | 12.5 | 5.6–23.2 |
| I believe it is not necessary to my health status | 64 | 10.9 | 4.5–21.2 |
| Other reason, please be specific: | 75 | 13.3 | 6.6–23.2 |
| Did this physical activity questionnaire and its results handed by the physician help you evaluate your level of physical activity? Yes/no | 141 | 55.3 | 46.7–63.7 |
| If yes, how so? (please answer each question) Yes/no | |||
| I never thought about it | 77 | 62.3 | 50.6–73.1 |
| I had a false notion of my level of PA (over- or under-estimation) | 77 | 33.8 | 23.4–45.4 |
| Other reason, please be specific: | 77 | 3.9 | 0.8–11.0 |
| If no, why? (only one possible answer)? Yes/no | |||
| I already knew how to evaluate it correctly | 59 | 72.9 | 59.7–83.6 |
| The physician did not comment my results | 59 | 22.0 | 12.3–34.7 |
| I think this evaluation is not valid | 59 | 3.4 | 0.4–11.7 |
| Other reason, please be specific: | 59 | 1.7 | 0.0–9.1 |
| Did you entirely read the report on your physical activity in the days following your health examination? Yes/no | 145 | 80.0 | 72.6–86.2 |
| Did you talk to your close ones about the recommendations given to you? Yes/no | 146 | 52.7 | 44.3–61.1 |
| If yes, with whom? (please answer each question) Yes/no | |||
| Family (e.g. spouse, parents, brothers and sisters) | 70 | 92.9 | 84.1–97.6 |
| Friend(s) | 67 | 68.7 | 56.2–79.4 |
| Work colleague(s) | 59 | 44.1 | 31.2–57.6 |
| Other, please be specific: | 76 | 2.6 | 0.3–9.2 |
| Following your health examination did you encourage your close ones to increase their physical activity? Yes/no | 146 | 27.4 | 20.3–35.4 |
| For you, is physical activity an important point of the discussion during a health examination? Yes/no | 146 | 95.2 | 90.4–98.1 |
| How did you perceive this physical activity questionnaire? (please answer each question) Yes/no | |||
| I felt it was an encouragement to pursue or increase my physical activity | 139 | 79.1 | 71.4–85.6 |
| I perceived it as a physical activity check-up | 140 | 78.6 | 70.8–85.1 |
| I felt it was a source of information on physical activity | 139 | 66.2 | 57.7–74.0 |
| I perceived it as a negative comment on my level of physical activity | 136 | 14.0 | 8.6–21.0 |
| I felt it was an intrusion into my personal life | 137 | 11.7 | 6.8–18.3 |
| I felt it depreciated the efforts I am already doing | 137 | 8.0 | 4.1–13.9 |
| Other, please be specific: | 145 | 5.5 | 2.4–10.6 |
1.4
Discussion
The choice to update Baecke questionnaire to evaluate a person’s usual PA was justified by its easy to understand questions, shortness (22 questions) and performances when compared to other approaches for evaluating PA that might be more precise but also more difficult to implement. Two studies validated the good reproducibility of Baecke questionnaire with correlation coefficients at 0.93 and 0.86 . Correlation coefficients with other methods for evaluating PA level were satisfying for the number of steps (0.44 and 0.49 ), doubly labeled water validation (0.69 ) and VO 2max (0.54 ). Baecke and IPAQ questionnaires have very similar results for evaluating the level of PA however Baecke questionnaire is more sensitive at detecting the link between abdominal obesity and PA, especially in men and is also better correlated to the number of steps (0.44 vs. 0.33) . MAQ questionnaire focuses on the activities from the past year; it has been validated but its self-administration remains quite problematic in the general population because its reliability has only been validated in a population of individuals with a higher than average education level .
The updates proposed in the AQAP version included new activities such as leisure time spent in front of a computer or console as well as using roller skates or push scooters to get around. For PA during a normal day or sports day some examples of activities were suggested for each of the increasing levels: 1, 2 and 3 ( Appendix 1 ). The questionnaire explored the main usual activities rather than the ones from the previous days in order to avoid biases induced by seasons, vacation days, sick days, etc. Short questions written up with an easily accessible vocabulary facilitated the participation of subjects and limited the non-response rate to an acceptable mean level of 2.4%.
Several metrological tests were conducted on the AQAP questionnaire: validity of self-administration answers, validity related to EE obtained during the interview, reproducibility at a two-week interval and performance of the synthesis as a health education tool. The comparison of answers obtained at each question, either by self-administration or during the interview, was very satisfactory ( Table 1 ). In fact, the Kappa tests for each question were superior or equal to 0.80, except for the two questions where answers were overestimated in self-administration mode: daily journeys (for men and women) and daily activities’ level (for women). Comparisons were also satisfactory for indexes expressed in quintiles, with Kappa coefficients all above 0.60; the best coefficients were obtained for the regular sport activity corresponding most often to a sports club subscription and thus a sport practice that is well organized according to an agenda. Usual daily activities were less accurately estimated by women who did not work compared to those who worked (0.49 vs. 0.78). We can note a slight over-estimation of the leisure PA when the questionnaire was self-administered (Kappa 0.61 and 0.66 respectively for men and women), contrarily to the underestimations obtained with the MAQ questionnaire in self-administration mode . In conclusion it is possible to use the AQAP in self-administration mode.
The global index calculated from the answers given to the self-administrated AQAP was moderately correlated (rho = 0.37 and 0.30 respectively for men and women) but it was significantly correlated ( P < 0.0001) for the EEs estimated by the interview. Correlations were stronger for young adults and for subjects who were working ( Table 2 ) and also, as expected, after validation by the interview. The correlation deficit for women over the age of 59 suggests limiting the use of this questionnaire to subjects under the age of 60 and studying the possibility of a special version for older persons.
According to the data collected at a two-week interval for 31 persons, the indexes calculated were not significantly different ( Table 3 ). For a test–retest accepted difference of ±10%, the tests’ power was estimated respectively at 78%, 77% and 95% for daily, leisure and global activities. A larger cohort could have improved this power. The ICCs were respectively 0.88, 0.78 and 0.87 for daily, leisure and global activities. Daily activities, less varied, had the highest ICC (0.88) and the ICC corresponding to sport activities could not be calculated, since the index’s distribution did not conform to the Gauss curve. The ICCs were very similar to the ones reported for the original Baecke questionnaire with respectively for daily, leisure and global activities: 0.84, 0.78 and 0.87.
Today and with its two successive programs PNNS 2001–2005 and PNNS 2006–2010 , the French healthcare policy clearly aims at improving the dietary habits of the entire French population and at increasing its level of PA. The durability of the PNNS has been validated by the recent evaluation report, which continued to promote an increased PA for the French population . The aim of the AQAP synthesized report was to meet PNNS objectives by providing in writing a personalized PA assessment with, if necessary, proposals to start a behavior-changing process.
This personalized report gave to responding subjects some detailed information on how to acquire knowledge and know-how but also on how to adapt their behaviors according to the answers listed in the questionnaire ( Table 4 ). The link between health and PA was clearly described, as well as the association between sport and pleasure or improved body tone. The specific and practical information given was adapted to the answers according to the intensity of the activity, sex, smoking status, body mass index (especially for overweight or obese subjects) and reported fatigue.
Several recommendations were listed to develop individual competencies (know-how): finding a good sports club, choosing the right sport as well as find proper activities for decidedly non-athletic individuals. Suggestions were aimed at active persons according to the regularity, intensity and duration of their sport practice; especially about the importance of proper hydration and need for medical check-ups and monitoring. Smokers and overweight individuals were given specific recommendations as well. Finally, collective sports were encouraged for the less athletic (stimulation) as well as for the most athletic (emulation) individuals.
Almost one young adult out of two (46%) returned the two-month evaluation questionnaire. Data collected validated that in this sub-group, probably more motivated than the non-respondent group, the three targeted objectives seemed reached: information, education and PA promotion.
The individual impact was evaluated by: awareness of PA level (55%), acquisition of new knowledge regarding the link between health and PA (42%) as well as the reported increased PA (43%). The collective impact was appreciated by talks initiated with friends and family members motivated by reading the reports (53%) and the fact that these young adults relayed the need for increased PA to their closed ones (27%). Only two persons out of 147 contested the veracity of the evaluation proposed in the synthesized report. The health component of PA was very well perceived by these young respondents since 95% of them reported that PA should be considered in a health examination. More than two young respondents out of three felt that this action was a source of information on PA (66%) as well as a good PA assessment and encouragement to continue the efforts to increase their PA (79%). Personalized information, quantitative evaluation of the different types of activities (daily, leisure and sport) as well as targeted recommendations to the answers given are all reasons likely to explain these satisfying results in a young population usually not particularly preoccupied by its health.
AQAP is easy to use and delivers rich information; however we should be aware of the subjectivity of the data collected with the self-administered questionnaire. In fact, Duncan et al. reported that sedentary persons tend to over-estimate their level of PA and suggested that it was even more difficult for them to appreciate PA duration and intensity since they rarely engage in PA. That is not the case with active individuals. Just like the IPAQ questionnaire , the questionnaire’s performances were less satisfactory for older individuals, but only for women in AQAP’s case. There is a version of Baecke questionnaire that is adapted to older persons but the French version remains to be validated.
Furthermore, this questionnaire is not adapted to high-level athletes, professional or not, due to its limitation to the two most practiced sports with a coefficient saturated beyond 4 hours per week. In fact in the sport index calculated by Baecke, time dedicated to sport in a week is divided into four categories (<1 h; 1–2 hrs; 2–3 hrs; 3–4 hrs and > 4 hrs) and each of these categories is given a coefficient (0.5; 1.5; 2.5; 3.5 and 4.5). This last coefficient is too limited for high-level athletes. More performing PA measurement methods exist and are specific to each sport. Furthermore, it seems that in certain cases, the sweat factor increases greatly the PA index for overweight or obese persons; in consequences, specific messages to counterbalance the results were proposed in the synthesis. Finally, it must be noted that this short questionnaire cannot take into account the intensity of PA participation and thus the resulting EE.
In conclusion, taking into account the restrictions described above, the AQAP questionnaire and its interpretation software is a good tool to collect PA data on large samples during individual or collective action and is also a source of individual PA data for epidemiological studies. The advantages of the AQAP questionnaire and its software are mainly the updated questions, easy to use format, validity of the data collected regardless of the public’s education level with expected individual (synthesis) and collective (statistics’ module) benefits. Furthermore, even though the synthesis is mostly targeted on PA, it also promotes other public health issues such as proper nutrition, stopping smoking and detecting obesity. The impact of the personalized prevention messages given by the AQAP questionnaire on changing attitudes and behaviors still need to be explored in a longitudinal study.
Disclosure of interest
The authors declare that they have no conflicts of interest concerning this article.
Acknowledgements
This study was possible with a partial funding from the General Health Direction and CNAMTS in the framework of the projects 2004 for the National Nutrition and Health Program. Data collection was conducted in the Health Examination Centers of Cholet (Dr D. Goxe), Angers (Dr E. Caillez), Tours (Dr B. Royer), Le Mans (Dr A. D’Hour), Caen (Dr C. Geslain), Orléans (Dr P. Lépinay), Blois (Dr C. Paoletti-Melman), La Roche-sur-Yon (Dr D. Chupin), Alençon (Dr M.-C. Chesnier), Chartres (Dr D. Arondel), Le Havre (Dr M. Verhaeghe), Laval (Dr C. Bouté), Saint-Lô (Dr S. Manceau), Bourges (Dr A.-C. Gagnepain), Châteauroux (Dr C. Villeteau).
2
Version française
2.1
Introduction
L’incitation à la pratique d’une activité physique (AP) est l’un des neuf objectifs prioritaires du Programme national nutrition santé (PNNS) . Il est démontré qu’une AP régulière a un impact positif sur la santé et le bien-être à tout âge. En revanche, un niveau faible d’AP est associé à des taux plus élevés de mortalité , de maladies cardiovasculaires , de diabète , d’obésité androïde , d’hypertension artérielle , de cancer du côlon , de cancer du sein chez la femme ménopausée , d’ostéoporose , de dépression et d’anxiété ainsi qu’à une plus grande perte d’autonomie et une accélération du déclin cognitif chez la personne âgée .
Avant d’inciter une personne à augmenter son AP, il est nécessaire d’en quantifier le niveau et de fixer avec lui un objectif accessible, adapté à ses capacités physiques et compatible avec son mode de vie. De nombreuses méthodes existent pour évaluer le niveau d’AP : carnets et questionnaires, compteurs de pas, accéléromètres, marqueurs physiologiques. L’évaluation par questionnaire est la méthode la plus simple, elle est peu coûteuse, facilement informatisable et pratique pour les études et les interventions sur de larges populations.
Des questionnaires ont été développés mais rares sont ceux validés en langue française : Baecke , Modifiable Activity Questionnaire (MAQ) , International Physico Activity Questionnaire (IPAQ) . Cependant, un test préliminaire a révélé les limites d’utilisation de chacun d’eux : le questionnaire Baecke a été validé il y a près de 20 ans (1992) et depuis cette date, les comportements des français ont beaucoup évolué. Le questionnaire MAQ s’est révélé trop complexe pour des publics peu instruits lorsqu’il est auto-administré. Enfin, le questionnaire IPAQ ne renseigne que sur les activités de la semaine passée, ce qui peut induire un biais (retour de congés, incapacité transitoire…).
En conséquence, nous avons choisi d’actualiser le questionnaire de Baecke et de valider cette adaptation nommée AQAP. De plus, ce questionnaire étant destiné à une utilisation sur de larges échantillons, il a paru pertinent aux auteurs de lui adjoindre un logiciel spécifique de saisie des réponses avec édition immédiate d’une synthèse personnalisée pour un bénéfice individuel et possibilité d’une évaluation statistique de l’AP de tout groupe de sujets ayant répondu au questionnaire. Ces caractéristiques pouvant conférer à cet outil les qualités recherchées en éducation pour la santé et en épidémiologie.
2.2
Matériel et méthodes
2.2.1
L’Auto-questionnaire d’activité physique (AQAP) : descriptif et tests
Le questionnaire de Baecke évalue l’AP habituelle moyenne d’un sujet. Il est constitué de 22 questions fermées et se divise en quatre parties suivant le contexte de l’activité : les activités habituelles quotidiennes (huit questions), les déplacements quotidiens (une question), l’activité sportive (sept questions) et l’AP de loisirs (six questions). Trois index (activité quotidienne habituelle, sportive, de loisirs) sont calculés (échelle de 1 à 5). Le quatrième index évalue l’AP habituelle globale et il est calculé en faisant la somme des trois index précédents (échelle de 3 à 15).
Le questionnaire AQAP est une version actualisée du questionnaire de Baecke établie par les auteurs : une équipe pluridisciplinaire composée de médecins, diététiciennes, infirmière, biométricien, statisticien, épidémiologiste et étudiante en sciences et techniques des AP et sportives ; il propose des exemples de niveaux pour les activités quotidiennes et pour les activités sportives et des activités devenues fréquentes (temps passé devant la télévision…) ou des activités nouvelles (position assise devant un ordinateur, usage de rollers pour se déplacer…). Cette version du questionnaire AQAP ( Annexe 1 ) a été soumise à plusieurs phases de tests.
Les tests du questionnaire ont porté sur 702 hommes et femmes âgés de 18 à 79 ans ; tous étaient venus dans l’un des 15 centres d’examens de santé (CES) de quatre régions françaises pour un examen de prévention proposé par leur caisse primaire d’assurance maladie. Les données AQAP s’ajoutaient aux données comportementales recueillies pour l’interprétation de l’examen de santé. La synthèse personnalisée était ensuite commentée par le médecin examinateur ou la diététicienne.
La fiabilité de l’auto-administration et la validité des résultats obtenus ont été testées chez 524 sujets : dans un premier temps, le questionnaire a été auto-administré, puis dans un second temps, chaque réponse a été validée ou corrigée par une diététicienne entraînée à ce type d’interrogatoire. La diététicienne poursuivait l’interview par une évaluation de la dépense énergétique en interrogeant le sujet sur le détail de toutes ses activités : un jour de semaine, un samedi, un dimanche et un jour de vacances habituels. L’interview durait 30 minutes en moyenne. La dépense énergétique était ensuite calculée sur l’année puis sur une journée moyenne en utilisant un compendium des dépenses énergétiques qui donne la consommation énergétique de 850 activités définies par le type d’activité et son intensité.
Pour évaluer la répétabilité du questionnaire, celui-ci a été proposé successivement à deux semaines d’intervalle à un groupe de 31 sujets, sans les informer au préalable de la seconde sollicitation, ni de l’objectif poursuivi.
2.2.2
Le logiciel AQAP : descriptif et tests
Pour chaque répondant au questionnaire AQAP, le logiciel proposait la saisie et l’archivage des réponses et l’édition de la synthèse personnalisée correspondante (exemple : Annexe 2 ) ; de plus, pour un groupe de sujets dont les réponses au questionnaire avaient été archivées, un module statistique intégré au logiciel permettait l’édition d’un rapport descriptif de l’AP du groupe avec, par sexe, fréquences de réponses aux modalités de chaque item, moyennes et distributions des index d’AP.
Chaque synthèse personnalisée de l’AP était élaborée par la combinaison de modules tenant compte des caractéristiques suivantes du sujet : l’âge, le sexe, les quatre index d’activité calculés, le niveau de fatigue, la pratique d’un sport, l’activité professionnelle, le port de charges lourdes, la transpiration, l’indice de masse corporelle, le tabagisme, la sédentarité pendant les loisirs (index loisirs < 2,5/5)… Le compte rendu de synthèse était rédigé avec pour objectif de délivrer des messages conformes aux recommandations établies pour l’éducation à la santé. En particulier, une synthèse des neuf objectifs principaux du PNNS était rappelée sur chaque compte rendu.
Le questionnaire AQAP a été proposé, pendant une période de 3,5 mois, à tous les jeunes adultes âgés de 18 à 29 ans bénéficiaires d’un examen périodique de santé dans les centres d’examens de santé d’Alençon, Angers, Caen, Cholet, Laval, Le Havre, Le Mans, Saint-Lô ( n = 320) ; une synthèse personnalisée a été remise à chacun et commentée par le médecin examinateur. Deux mois plus tard, les mêmes jeunes ont été interrogés par voie postale pour évaluer leur perception et leur réappropriation des messages délivrés. Quarante-six pour cent d’entre eux ( n = 147) ont répondu au questionnaire composé de 33 items relatifs au développement des compétences, à l’acceptabilité éthique de la synthèse et à son impact en termes de modification des comportements.
2.2.3
Méthodes statistiques
Les analyses ont été réalisées à l’aide du logiciel Number Crunching Statistical Software 2007 (NCSS). Les données sont exprimées en moyenne (écart-type) ou pourcentage (intervalle de confiance à 95 %). La concordance des réponses auto-déclarées et des réponses obtenues par interview a été appréciée par le test Kappa. Les données quantitatives (quatre index) ont été transformées en données semi-quantitatives en remplaçant chaque valeur par une valeur variant de 1 à 5 correspondant au quintile d’appartenance dans la distribution des valeurs de l’index. Pour toutes les variables (questions, index exprimés en quintiles), un écart était comptabilisé si la réponse différait entre auto-questionnaire et interview. L’accord a été qualifié de bon pour un test Kappa dans l’intervalle [0,61–0,80] et d’excellent pour un test supérieur ou égal à 0,81. La concordance intrasujet entre les deux séries de tests à deux semaines d’intervalle a été évaluée à l’aide du coefficient de corrélation intraclasses. La validité des résultats a été évaluée par le test de corrélation des rangs de Spearman entre la dépense énergétique et l’index d’AP global, en fonction du sexe, de l’âge et de l’exercice d’une activité professionnelle. La répétabilité des quatre index a été testée par le test de Wilcoxon, la distribution de l’index d’activité sportive étant non gaussienne. La distribution d’allure non gaussienne de l’index sport n’a pas permis le calcul du coefficient de corrélation intraclasses, ni celui de la puissance du résultat du test de répétabilité. Les tests étaient significatifs si p < 0,05.
2.3
Résultats
Lors de la phase de tests (fiabilité, validité, répétabilité), 16 sujets (3 %) ont été exclus pour mauvaise compréhension de la langue française, emplois du temps non maîtrisés ou incapacité à évaluer les temps passés à chaque activité. Le taux moyen de non-réponse sur l’ensemble des questions était de 2,4 % avec un maximum de 7,3 % atteint pour la question portant sur l’estimation de la dépense physique habituelle en semaine en trois niveaux : faible, modéré ou important ( Annexe 1 , question 1).
Le Tableau 1 présente, pour chacune des 22 questions et pour les quatre index d’AP, le pourcentage de sous-estimation, accord et sur-estimation entre l’utilisation du questionnaire par auto-administration et par interrogatoire. Tous les tests Kappa de mesure de l’accord entre les deux modes d’administration étaient supérieurs à 0,60. Les niveaux de concordance des index étaient les mêmes pour les deux sexes à l’exception de l’index d’activité quotidienne habituelle plus faible chez les femmes (Kappa 0,66) que chez les hommes (Kappa 0,82) ; le niveau de concordance était plus élevé pour les femmes en activité professionnelle (Kappa 0,78) que pour celles sans activité professionnelle (Kappa 0,49).
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