Reviews
Journal of Physical Activity and Health, 2010, 7(Suppl 2), S259-S264
© 2010 Human Kinetics, Inc.
Lessons Learned After 10 Years of IPAQ Use in Brazil
and Colombia
Pedro C. Hallal, Luis Fernando Gomez, Diana C. Parra, Felipe Lobelo, Janeth Mosquera,
Alex A. Florindo, Rodrigo S. Reis, Michael Pratt, and Olga L. Sarmiento
Background: To describe the lessons learned after 10 years of use of the International Physical Activity Questionnaire (IPAQ) in Brazil and Colombia, with special emphasis on recommendations for future research in Latin
America using this instrument. Methods: We present an analytical commentary, based on data from a review
of the Latin American literature, as well as expert consultation and the authors’ experience in administering
IPAQ to over 43,000 individuals in Brazil and Colombia between 1998 and 2008. Results: Validation studies
in Latin America suggest that the IPAQ has high reliability and moderate criteria validity in comparison with
accelerometers. Cognitive interviews suggested that the occupational and housework sections of the long IPAQ
lead to confusion among respondents, and there is evidence that these sections generate overestimated scores
of physical activity. Because the short IPAQ considers the 4 physical activity domains altogether, people tend
to provide inaccurate answers to it as well. Conclusions: Use of the leisure-time and transport sections of
the long IPAQ is recommended for surveillance and studies aimed at documenting physical activity levels in
Latin America. Use of the short IPAQ should be avoided, except for maintaining consistency in surveillance
when it has already been used at baseline.
Keywords: motor activity, questionnaires, developing countries, epidemiologic measurement
Physical inactivity has been recognized as an independent risk factor for the development of cardiovascular
disease,1,2 type 2 diabetes,2–4 metabolic syndrome5 and
some types of cancer.2 In addition, physical inactivity,
along with unhealthy diets, is considered among the most
important preventable causes of mortality due to chronic
disease.1,6,7 The burden of chronic diseases is growing and
80% of the worldwide mortality due to chronic diseases
occurs in low and middle-income countries like those
in Latin America, generating premature deaths as well
as significant social and economic burdens.8 Given the
Hallal is with the Post-graduate Program in Epidemiology,
Federal University of Pelotas, Brazil. Gomez and Mosquera
are with the Health Division, Fundacion FES Social, Bogota,
Colombia. Parra is with the Prevention Research Center in
St. Louis, George Warren Brown School of Social Work,
Washington University in St. Louis. Lobelo is with the CDC/
WHO Collaborating Center for Physical Activity and Health
Promotion, Centers for Disease Control and Prevention, Atlanta,
GA. Florindo is with the Dept of Physical Activity Sciences,
University of Sao Paulo, Brazil. Reis is with the Pontifícia
Universidade Católica do Paraná, Curitiba, Brazil, and the
Universidade Federal do Paraná, Curitiba, Brazil. Pratt is with
the National Center for Chronic Disease Prevention and Health
Promotion, Centers for Disease Control and Prevention, Atlanta,
GA. Sarmiento is with the Dept of Social Medicine, University
of the Andes, Bogotá, Colombia.
importance of physical activity for health, it is essential
to develop valid tools aimed at measuring this behavior.
To achieve this objective, several instruments have been
designed throughout several decades of research.
Until the mid 1990s, comparison of physical activity
data collected in different studies around the world was
hampered by the use of many different instruments. To
overcome this limitation, a group of researchers from
different countries proposed a standardized, culturallyadaptable questionnaire to measure levels of physical
activity at the population level: the International Physical Activity Questionnaire (IPAQ).9 The long version of
the questionnaire provides detailed and comprehensive
information on daily physical activity habits in 4 different
domains, including housework, leisure time, occupational
and transportation activities. The short version comprises
items on walking, moderate- and vigorous-intensity
physical activity, as well as sedentary behavior. The IPAQ
was validated in several countries, including countries
from Latin America and Central America, showing good
reliability properties (Spearman’s rho ~0.8) and moderate
criterion validity.10 However, several studies have documented overestimation of physical activity levels using
the short and long versions of IPAQ.11–13
Soon after IPAQ was created studies using this
instrument were carried out in Latin America.14–17 From
the beginning of its use, Latin American researchers realized the need to make cultural adaptations and changes
S259
S260 Hallal et al
to the instrument to produce more accurate and reliable
information regarding physical activity patterns of the
Spanish and Portuguese speaking populations. In this
paper, we describe the lessons learned after 10 years of
the use of IPAQ in 2 countries from Latin America, placing a special emphasis on recommendations for future
use of the instrument for research purposes in the region.
Methodological Approach
An expert consultation and a literature search were
conducted to synthesize the lessons learned from the
use of IPAQ in Brazil and Colombia. In October 2008,
the Centers for Disease Control and Prevention (CDC)
and the World Health Organization (WHO) Collaborating Center for Physical Activity and Health convened
a workshop for building evaluation capacity for urban
health promotion in Latin America in Bogotá, Colombia.
A multidisciplinary group of researchers from the United
States and Latin America attended this workshop and
discussed some of the lessons learned from administering and validating IPAQ in Latin American countries.
Our literature search included reports of surveys and
field materials used in Brazilian and Colombian studies
that were not published in the peer-reviewed literature,
as well as scientific articles.
Results
IPAQ has been administered to over 15,000 adults in
Pelotas, a Southern Brazilian city, and to more than
27,000 adults in Colombia. In addition, it was used in
several other studies in Brazil and other areas of Latin
America. In the next sections, we discuss the main challenges faced by Colombian and Brazilian researchers
when administering IPAQ.
Challenge 1—Mode of Administration
IPAQ was originally created to be administered by selfapplication or telephone interviews.9 These administration modes are ideal for use in high-income countries in
which telephone coverage and education levels are high.
However, public health surveys in Latin America typically
use face-to-face interviews for data collection. This is due
to several factors. First, a high proportion of the population has low education and literacy levels, making it difficult to use self-administration techniques. Second, the
low coverage of telephone lines in large areas of most of
the countries in the region is problematic. Third, increasing nonresponse rates to telephone surveys compared
with household surveys are seen in Latin America, probably related to widespread telemarketing in the region.
Fourth, personal safety is a concern, because telephone
calls are commonly used as a ploy for initiating financial
scams. And lastly, the quality of the answers may be poor
when self-reported techniques are used, with participants
often skipping some questions, for example, which is
rarely done during face-to-face interviews.
This challenge was discussed in the multicenter
IPAQ validation paper. In 2 of the countries, South Africa
and Guatemala, a telephone script was used to administer
IPAQ by means of personal interview. The option was
considered to be promising by the authors: “Administering the questionnaire this way [face-to-face interviews]
may be the preferred option as some participants completing the questionnaire by self-administration skipped some
questions.”18 From the beginning, IPAQ administration in
Latin America was primarily accomplished by means of
face-to-face interviews. Self-administration is restricted
to studies that include samples with high levels of education, such as college students.
Telephone coverage in Latin American countries
increased markedly from the 1970s to the 1990s, making
it feasible to consider the possibility of administering
IPAQ by telephone in some areas. A recent study which
used the leisure-time and transport-related sections of
the long version of IPAQ19 showed very high agreement
between face-to-face and telephone data, for both continuous and categorical indicators of physical activity.
Based on the experience acquired by researchers
during the last 10 years, administration of IPAQ through
face-to-face interviews is highly recommended in the
Latin American context. Use of telephone interviews may
be encouraged in areas with high phone line coverage, but
further data on the feasibility of this approach are needed.
Challenge 2—Questions, Instructions
and Examples
Questionnaires used in population surveys are designed
based on the assumption that the interviewer will understand the question as the researcher intended them to
be comprehended. However, this is not always the case,
and this is particularly problematic when the instrument
needs to be translated into languages different from the
one for which it was originally created. In Colombia,
experience using qualitative methods such as cognitive
interviews before data collection showed that in many
cases, interviewees do not completely understand the
meaning of questions, particularly people with low levels
of education. This could be due to the length and complexity of the questions. For example, in the IPAQ short
version, each question inquires about physical activities
performed combining all domains, which may generate
difficulties for respondents both in understanding the
domains and summing across them. In addition, the length
of the interview, particularly for the long IPAQ, can cause
respondent fatigue and respondents may lose focus, thus
reducing the ability to effectively interpret the questions.
A Colombian research team developed a manual
for training interviewers in the application of IPAQ,
based on the results from cognitive pretesting. Some
of the steps from cognitive pretesting used to adapt the
IPAQ questionnaire in Colombia were strategies such as
“thinking out loud,” verbal testing and paraphrasing.20
On average 2 pre-testing questions per each item were
designed. However, more questions were allowed accord-
IPAQ in Latin America S261
ing to other aspects and doubts that could arise during the
test. All cognitive interviews were conducted by a social
worker with experience in qualitative research, and with
the support of 2 auxiliary researchers. All the interviews
were tape-recorded. The main results from the cognitive
pretesting process were the following:
Survey Instructions. It was suggested to the respondents
to place emphasis on the practice of daily physical activity
rather than on structured fitness routines. One of the most
common problems understanding IPAQ is the inability
to make distinctions between the 4 different domains
included in the long version. For instance, participants
usually thought that the questions had been previously
asked. Therefore, there was a need to clearly explain
was the purpose of each question was, and that the set
of questions were referring only to specific domains
(occupational, transportation, leisure-time or housework).
One of the recommendations was to incorporate specific
job related activities examples, depending on the person’s
occupation to improve understanding of the questions on
occupational physical activity.
Questions With a Time Dimension. There were
some difficulties determining exact reference times;
for example, when asked about the last 7 days, some
interviewees referred to the last week, from Monday
to Sunday regardless of the day that the interview took
place, or to the last 8 days including the day of the survey.
The original intention of the developers of IPAQ was
to determine the levels of physical activity over the 7
days before the interview. One of the recommendations
from the cognitive pretesting process was to provide the
interviewers with a small calendar that they could show
to the respondents to provide them with a clear time
reference.
Intensity of Physical Activity. IPAQ includes questions
about 3 different types of physical activity: walking,
moderate, and vigorous intensity. Participants had
difficulties distinguishing between moderate and vigorous
intensity activities. It was recommended that specific
examples of different intensity activities be provided
and that they be linked to physiologic signs such as
breathing or heart rate. Interviewers felt this would
help distinguish between these 3 types of activities.
It is also very important to provide culturally relevant
examples; tennis and squash, for example, are not very
commonly practiced in Latin America. Instead, activities
such as playing soccer or dancing can be included. The
original IPAQ proposal already addresses the need for
cultural adaptations in the examples of activities given
to respondents. One of the recommendations from the
cognitive pretesting process was the use of photos that
portray different activities that are culturally relevant.
Duration of Physical Activity. The questions about
duration of particular physical activities require difficult
calculations of time, type of activity, days of the week,
and remembering the 10 minute bout criterion (which
will be introduced later in the paper). It was concluded
that recall processes should be supported by other
resources or materials such as: the use of calendars,
allowing the interviewee to see what is being recorded
in the answer sheet, and, finally, make the questions in
a more conversational way rather than a strict structured
one. Eventually, a table was added with 7 columns and
empty cells that allowed the interviewer to record activity
type and time in minutes for each day of the week. This
process served as a diary that facilitated comprehension
and the averaging process for respondents.
Challenge 3—The 10-minute
Bout Concept
To be consistent with the physical activity recommendations for health, the IPAQ was developed so that it was
possible for participants to report activities that last for
at least 10 continuous minutes. If at least 3 bouts are
achieved during the day, the person meets the minimum
requirement of at least 30 minutes of moderate physical
activity per day.21 However, this concept poses many challenges for the person being interviewed as it is difficult
to keep track of bouts of only 10 minutes, and perception
of bout length may well be inaccurate.
In addition to this problem, issues such as social
desirability and low levels of education of the respondents could lead to overestimation of the 10-minute
bout. This overestimation is more apparent in household
and occupational activities. To decrease overestimation,
interviewers should be trained to clearly explain the
10-minute concept and constantly remind interviewees
about the 10-minutes bouts. To assess over estimation,
a group of Colombian researchers used accelerometers
to validate the self report information from the modified
version of IPAQ (conducted after cognitive pretesting).
They found a modest agreement between the reporting on
the 10-minute bout and accelerometer data.22 Moreover,
the median value of METs minutes week of IPAQ was
10.2 times higher than the median value of METs minutes
week estimated by the accelerometers.22
Challenge 4—Over Reporting
of Occupational and Household
Physical Activity
From the beginning of the IPAQ use in Latin America,
researchers were concerned about the clear tendency for
over reporting of occupational and household physical
activities. The 10-minute bout concept and misperception
of intensity seem to be the main reasons for this problem.
In contrast to leisure-time and transport-related activities, occupational and household ones have considerable
variation from day to day and even within the same day
in terms of types, intensity, bout lengths and periods
of rest. When asked about household or occupational
activities respondents often provide answers such as: “I
take care of a child the entire day, thus I do 8 hours of
S262 Hallal et al
moderate-intensity physical activity per day,” or “I walk
around my office all day, thus I do 8 hours of walking
during the day.”
Even with the changes to the long version of IPAQ
made after the suggestions from the cognitive pretesting,
occupational and household domains remained difficult
to administer. Although the attempt to quantify occupational and household physical activity is interesting
for research purposes, the IPAQ structure of the questions is not adequately designed to provide reliable
and accurate estimates of physical activity in these 2
domains in low- and middle-income countries, in which
these 2 domains represent an important fraction of total
physical activity.
Challenge 5—Duplicate Answers
One of the common problems during use of the long
version of IPAQ was the reporting of the same activity
twice or more in the different parts of the questionnaire.
To solve this problem, 2 solutions are proposed: (a) at
the beginning of the questionnaire, clear instructions
should be included stating that an activity should not be
reported more than once; (b) when an answer was very
similar to a previous one in terms of type, frequency
(days per week) and duration (minutes per bout), the
interviewer should confirm with the respondent whether
this activity was previously mentioned, without adding
judgment or personal opinion to the interview. In case
of a repetition, the interviewer should ask the subject to
clarify in which domain and intensity the activity should
be correctly classified.
Challenge 6—The Average Concept
Another key issue when using IPAQ is the concept of
“average time” which arises by asking “How much time
did you usually spend on one of those days doing physical activities (eg moderate or vigorous)?” Most people
face a recall problem when answering this question.
This problem is inherent to most physical activity questionnaires that use recall questions. Recall, or informal
retrieval, is one of the cognitive aspects that may influence
respondent’s performance on questionnaires.23 Information may be retrieved from memory as episodic events
or in schemas (eg, generalizations). Episodic events are
stored as more detailed information while schemas are
more generic and stored with less or even no details.23
This may explain why it is harder for people to provide
precise information on walking for transportation than
it is for leisure-time walking.
More recently qualitative methods have been
employed to analyze respondent’s understanding of
physical activity questionnaires, and studies have found
that activities which are performed in more than 1
domain (eg, walking) are usually not well classified.24
In accordance with this evidence, studies have found
that IPAQ reliability is higher for vigorous as compared
with moderate or walking activities and also higher for
leisure time than for transportation physical activity.19
Another potential problem resulting from such recall
bias is under-reporting. The European Physical Activity
Surveillance System (EUPASS) compared IPAQ with a
24 hours activity report and found higher scores using
this measure.25 Similar results were found when the short
and long versions of IPAQ were compared,26,27 but higher
scores were observed using the long version.
To deal with these problems it is recommended that
a more detailed approach should be used to ask respondents to describe the daily amount of time they spent
performing each category of activity by intensity for each
domain. This approach has been used both in adult19,28
and older adult29–31 Colombian and Brazilian populations,
with adequate reliability.
Challenges That Were Not Challenging
Some of the initial concerns about the IPAQ were not
particularly challenging in the Latin American context.
For example, the intensity-concept was for the most part
easily understood by Latin American populations after
the inclusion of changes in respiration and heart rate as
prompts to define the intensity of activity (see text of
challenge 2).
IPAQ was originally recommended for adults age 18
to 65 years. However, several studies in Colombia and
Brazil have included older adult, and IPAQ administration
among this age group was not more problematic than it
was for young and middle-age adults. However, small
adaptations pertaining exclusively to this population
group are necessary, for instance providing examples that
are culturally relevant to the older adult population. In
addition, the average concept, discussed in the previous
section, poses some problems that are even more significant among this population group due to recall bias. To
overcome this limitation, interviewers are trained to ask
about usual physical activity for each day of the week as
previously described.
Conclusions
and Recommendations
IPAQ is a widely used instrument for measuring and
tracking physical activity levels in Latin American populations. The use of the instrument in Latin America has
not been without challenges, and has required several
cultural and structural adaptations. It is important to highlight that the creators of the tool were able to foresee these
issues and allowed for the tool to be culturally adapted
and translated into different languages. Colombian and
Brazilian researchers have informed the use and improvement of the questionnaire by using several qualitative and
quantitative techniques such as cognitive interviews, pre
testing activities, and also validation studies, with the
use of test-retest techniques and validation against more
IPAQ in Latin America S263
objective measures of physical activity such as accelerometers and pedometers. While the changes introduced
into the questionnaire and the administration protocol
have technically increased the length of the instrument, in
actuality administration has been faster with fewer errors
and less need for repetition due to increased clarity of
the instrument and process.
One of the main lessons learned from this series of
adaptations of the instrument is how essential it is to pre
test an instrument even when it has been previously used
in a similar population, and also to document any changes
made to the instrument. Researchers should always strive
to conduct some type of reliability and validity testing of
the instrument and to document this process. For IPAQ,
the use of test-retest and validation against pedometers
or accelerometers is recommended.
To conclude, the use of leisure-time and transportation domains of IPAQ for surveillance and research is
encouraged in Colombian and Brazilian populations. It
is very likely that this recommendation applies to most
other populations from Latin America as well. The inclusion of the housework and occupational sections of the
questionnaire is discouraged unless the specific research
questions require this information; even in these cases,
researchers should consider using other instruments. The
use of the IPAQ short version should be limited to time
trend studies which used this instrument at baseline.
The leisure-time and transportation sections are also
the most relevant for categorizing population levels of
physical activity and for guiding public health policies
and programs. Enhanced interviewer administration of
IPAQ is preferred in Latin American populations to self
administration. Preliminary studies suggest that telephone
administration may be feasible and useful in select urban
areas in Latin America, and further development of this
approach is recommended.
Acknowledgments
The findings and conclusions in this report are those of the
authors and do not necessarily represent the official position
of the Centers for Disease Control and Prevention.
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