Transcultural adaptation and psychometric properties of Spanish version of Pregnancy Physical Activity Questionnaire: the PregnActive project

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GacSanit.2019;33(4):369–376

Original

article

Transcultural

adaptation

and

psychometric

properties

of

Spanish

version

of

Pregnancy

Physical

Activity

Questionnaire:

the

PregnActive

project

Miguel

Ángel

Oviedo-Caro

∗

,

Javier

Bueno-Antequera,

Diego

Munguía-Izquierdo

DepartmentofSportsandComputerScience,SectionofPhysicalEducationandSports,UniversityPablodeOlavide,Seville,Spain

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received20June2017

Accepted31December2017

Availableonline19March2018

Keywords: Exercise

Lifestyle

Pregnancy

Surveysandquestionnaires

Health

a

b

s

t

r

a

c

t

Objective: TotransculturallyadapttheSpanishversionofPregnancyPhysicalActivityQuestionnaire (PPAQ)analyzingitspsychometricproperties.

Methods:ThePPAQwastransculturallyadaptedintoSpanish.Test-retestreliabilitywasevaluatedina subsampleof109pregnantwomen.Thevaliditywasevaluatedinasampleof208pregnantwomenwho answeredthequestionnaireandworethemulti-sensormonitorfor7validdays.Thereliability(intraclass correlationcoefficient),concordance(concordancecorrelationcoefficient),correlation(Pearson correla-tioncoefficient),agreement(Bland-Altmanplots)andrelativeactivitylevels(Jonckheere-Terpstratest) betweenbothadministrationsandmethodswereexamined.

Results: Intraclasscorrelationcoefficientsbetweenbothadministrationsweregoodforallcategories excepttransportation.Alowbutsignificantcorrelationwasfoundfortotalactivity(lightandabove) whereasnocorrelationwasfoundforotherintensitiesbetweenbothmethods.Relativeactivitylevels analysisshowedasignificantlineartrendforincreasedtotalactivitybetweenbothmethods.

Conclusions:SpanishversionofPPAQisabriefandeasilyinterpretablequestionnairewithgood reliabil-ityandabilitytorankindividuals,andpoorvaliditycomparedwithmulti-sensormonitor.Theuseof PPAQprovidesinformationofpregnancy-specificactivitiesinordertoestablishphysicalactivitylevels ofpregnantwomenandadapthealthpromotioninterventions.

Adaptación

transcultural

y

propiedades

psicométricas

de

la

versión

espa ˜

nola

del

cuestionario

de

actividad

física

del

embarazo:

el

proyecto

PregnActive

Palabrasclave:

Ejercicio

Estilodevida

Embarazo

Encuestasycuestionarios

Salud

r

e

s

u

m

e

n

Objetivo:Adaptartransculturalmentelaversiónespa˜noladelPregnancyPhysicalActivityQuestionnaire (cuestionariodeactividadfísicaenelembarazo)analizandosuspropiedadespsicométricas.

Método:Elcuestionariodeactividadfísicaenelembarazofuetransculturalmenteadaptadoalespa˜nol. Lafiabilidadtest-retestseevaluóenunasubmuestrade109embarazadas.Lavalidezseevaluóenuna muestrade208embarazadasquerespondieronelcuestionarioyllevaroncolocadoelmonitormultisensor durante7díasválidos.Sevaloraronlafiabilidad(coeficientedecorrelaciónintraclase),laconcordancia (coeficientedecorrelacióndeconcordancia),lacorrelación(coeficientedecorrelacióndePearson),el gradodeacuerdo(gráficoBland-Altman)ylosnivelesdeactividadrelativos(testJonckheere-Terpstra) entrelasdosadministracionesylosdosmétodos.

Resultados:Loscoeficientesdecorrelaciónintraclaseentrelasdosadministracionesfueronbuenospara todaslascategorías,exceptoeltransporte.Unacorrelaciónbaja,perosignificativa,seencontróparala actividadtotal(suaveysuperior),mientrasquenoseencontrócorrelaciónparaotrasintensidadesentre losdosmétodos.Elanálisisdelosnivelesdeactividadrelativosmostróunatendencialinealsignificativa paraelincrementodeactividadtotalentreambosmétodos.

Conclusiones:Laversiónespa˜noladelcuestionariodeactividadfísicaenelembarazoesunbrevey fácil-menteinterpretablecuestionario,conbuenafiabilidadyhabilidadparaordenarpersonas,ybajavalidez encomparaciónconelmonitormultisensor.Elusodelcuestionariodeactividadfísicaenelembarazo aportainformaciónsobreactividadesespecíficasdelembarazoconelobjetivodeestablecerlosniveles deactividadfísicadelasmujeresembarazadasyadaptarintervencionesparalamejoradelasalud.

∗ _{Corresponding}_author.

E-mailaddress:[email protected](M.A.Oviedo-Caro).

https://doi.org/10.1016/j.gaceta.2017.12.004

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M.A.Oviedo-Caroetal./GacSanit.2019;33(4):369–376

Introduction

Physicalactivityduringpregnancyhaspotentialhealthbenefits inpregnantwomen,suchasreducedriskofgestationaldiabetes mellitusandpreeclampsia,andpreventionofexcessiveweightgain and weight retention.1–3 _Similarly, _inactivity _during _pregnancy

hasbeenassociatedwithadverseperinataloutcomes.4–6_Pregnant

womenwithabsenceofmedicalorobstetricscomplications,are advisedtoaccumulateatleast30minutesofmoderateintensity activityperdayonmost,ifnotall,daysoftheweek.7

Validandreliablemethodstomeasuretheduration,frequency andintensityofphysicalactivityduringpregnancyareneededto provideinformationinordertoestablishhealthpromotion strate-giesthat prevent excessive weightgain and improve pregnant women’s health. Questionnaires are the most commonly used methodin epidemiologic and largepopulationstudies because theirinherentcharacteristicsaseasyadministration,non-invasive andrelativelyinexpensivemethod.Severalphysicalactivity ques-tionnaireshavebeendevelopedandvalidatedinadults.Mostof thememphasizeonmoderateandvigorousintensitysports,and failtoincludehouseholdorchildcareactivities,whichcomprisea substantialproportionofthetimespendinphysicalactivityduring pregnancy.8_This_may_result_in_{misclassification}_that_limits_the

abil-ityofquestionnairestoestimateanddifferentiatephysicalactivity levelsamongpregnantwomen.9

The Pregnancy Physical Activity Questionnaire (PPAQ)9 _is

a tool specifically designed and successfully validated for the assessment of physical activitylevels among pregnant women. The PPAQ has been translated into different languages as Japanese,10_Vietnamese,11_French,12_Turkish,13_Portuguese14 _and

Chinese.15 _In _addition, _these _versions _have _been _validated

againstpedometer,11,13_uniaxial_{accelerometer,}9,10,15 _and_biaxial

accelerometer.12 _Studies _validating _this _devices _and

establish-ing specific cut points have not been developed for pregnant women.12,16_Inherent_limitations_were_found_in_these_devices,_such

asthelimiteduseformonitoringintensityofactivity, impossibil-ityofdetecttheupperbodymovementsduetoitsplacement,low compliance17_and_{uncomfortable}_location_for_pregnant_women.18

Althoughanewmulti-sensormonitorthatovercomesthese lim-itations hasbeenvalidated onpregnant women,18 _none_of _the

standardized physicalactivity questionnairehasbeen validated againstthismonitorinthispopulation.

Despitethe largeamount ofSpanish-speakingpeople inthe world,toourknowledgethereiscurrentlynovalidatedSpanish versionofthePPAQ(PPAQ-S),whichtakesintoaccountthecultural differencesofSpanish-speakingpregnantwomen.Consequently, theaimofthisstudywastotransculturallyadaptthePPAQ-S ana-lyzingitspsychometricproperties.

Methods

Participants

Werecruitedhealthypregnantwomen,18-45yearsoldatthe firstprenatalcarevisitfromhealthclinicsoftheSanitaryAreaof Seville(Spain).Theexclusioncriteriaincludedphysicalillnesses ordisabilitiesthataffectnormaldailyroutineandhighrisk preg-nancy(i.e.,diabetesorhypertension).Weobtainwritteninformed consentofparticipantspriortoenrollinginthestudyandafter receivingdetailinginformationaboutthestudyaimsandprotocol. Aprevioussampleof16pregnantwomenwasusedforthe trans-culturaladaptationprocess.Atotalsampleof260andasubsample of120eligiblewomenwereusedtoanalyzevalidityandtest-retest reliability, respectively, but pregnant women with incomplete

protocolwere excluded.Finally, 208and 109pregnant women wereincludedinthevalidityandreliabilityanalysis,respectively.

Studyprotocol

Thestudyprotocolobtainedethicalapprovalfromthe Medi-calResearchEthicsCommitteeoftheUniversityHospitalVirgen delRocío(Seville,Spain)accordingtotheDeclarationofHelsinki. Thestudyprotocolwasperformedintwostages:thetranscultural translationprocessofthePPAQfromEnglishtoSpanish,andthe analysisofreliabilityandvalidityofthePPAQ-S.

Transculturaladaptationprocess

Asprescribedthescientificliterature,19_the_adaptation_process

for thePPAQ used thedirect and reverse translation (forward-backward translation).Figure Iof online Appendix showedthe stepsfollowedinthisprocess.Subsequently,individualinterviews wereconductedforthepregnantwomentoevaluatetheir under-standing, comprehensibility and feasibility of thequestionnaire (cognitivedebriefing),asdescribedbypreviousstudies.20

Reliabilityandvalidity

Twoface-to-facesessions,separatedbyanintervalof8days was performed to complete the reliability and validity pro-cess.Atthefirstsession,sociodemographicandanthropometrical characteristics,weightandheight,wereevaluatedfollowingthe standardprocedureswithcalibrateddigitalscale(Tanita Corpora-tionBC-420,Tokyo,Japan)andastadiometer(Seca-780,Hamburg, Germany).Bodymassindex(BMI)(kg/m2₎_was_calculated._In

addi-tion, pre-pregnancy BMI was calculated using the weight and heightmeasuredbysanitaryprofessionalsatthefirstprenatalcare visit.InthissessionpregnantwomencompletedthefirstPPAQ-S andamulti-sensormonitorwasplacedontheleftarmofeach par-ticipantwhowasaskednottochangetheirhabituallifestyle.Atthe secondsession,thesecondPPAQ-Swascompletedandthemonitor wasremoved.

Instruments

ThePPAQ9_is_a_{semiquantitative}_{questionnaire}_which_reports

the time spending in 32 activities categorized in five types of activity.Respondentsareaskedtoselectthecategorywhichbest approximatestheamountoftimespentineachactivityperday orweekduringthecurrenttrimester.Thenumberofhoursspent ineachactivitywasmultipliedbytheactivityintensitytoarrive ataveragedailyenergyexpenditure(MET-hours/day)attributable to each activity. This tool used specific metabolic equivalents (METs)valuesforpregnantwomenwhenispossibleaspreviously established.9_Activities _were_categorized_by_intensity,_type_or_as

totalactivity.

Amulti-sensormonitor,SensewearMiniArmband(SWA; Body-MediaInc.,Pittsburgh,USA)wasusedtoassessphysicalactivity andenergyexpenditure.Thismonitorprovidesmoreaccurate esti-mationofenergyexpenditurethanaccelerometry-baseddevices21

and have shown a well correlation with indirect calorimetry measuredonpregnant women.18 _The _SWA_includes _sensors_to

measureenergy expenditureby monitoringtheheat flowfrom the body, skin temperature, galvanic skin response and 3-axis accelerometerformotiondetector.Dataweredownloadedusing Sensewearprofessionalsoftwareversion8.1,andwereexported asMETsdataminute-to-minuteintoexcel,wherewecalculated theMETs·h/week.Themonitorwaswornforeightcompleteddays, exceptduringwater-basedactivities,includingfiveweekdaysand twoweekenddayscompleted.Itmusthavebeencarriedovermore

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M.A.Oviedo-Caroetal./GacSanit.2019;33(4):369–376 371

than95%ofthewholeday(1368min)for consideracompleted day.DataofswimmingweresubstitutedforaconstantMETvalue accordingtotheCompendiumofAinsworthasexplainedby pre-viousresearch.22_To_avoid _any_kind_of_immediate_reactivity,_we

removedfromtheanalysisthefirstcompleteddaymonitored.

Statisticalanalysis

Test-retestreliabilitywasstudiedcalculatingtwo-waymixed average intraclass correlation coefficient (ICC) with 95% con-fident interval. Estimated means and differences between the measurements, the standard deviations of the differences, the intraindividual standard deviation,23 _and _the_standard _error _of

measurement24 _was _studied. _The _agreement_between _test _and

retestwasassessedusingBland-Altmanplots,includingthe95% levelsofagreement.23

ToassessthevalidityofthePPAQ-SwefollowedtheEdinburgh Framework25_and_the_COSMIN_checklist.26_Estimated_means_of

sub-jective(PPAQ)andobjective(SWA)measureswerecalculatedfor thetimespentineachintensitycategories.Thesystematic differ-encesbetweenbothmeasureswerecalculatedbymeansofpaired t-test.Theconcordancebetweentheobjectiveandsubjective meas-ureswasstudiedwithconcordancecorrelationcoefficient.27_The

Pearsoncorrelationcoefficientwasusedasadditionalinformation fortheconcordancecorrelationcoefficient,andtocomparewith previousvaliditystudiesforthePPAQ.

Bland-Altmanplots werecalculated aspreviously explained. Theassociationbetweenthedifferenceandthemagnitudeofthe measurement(i.e.,heterocedasticity)wasexaminedbyregression analysis.Receiveroperatingcharacteristiccurvewasconstructedto determinetheareasunderthecurveand95%confidenceintervals, specificityandsensitivityofthePPAQaspredictorofthefulfillment ofminimumphysicalactivityrecommendationsof≥150min/week inboutsof≥10min28or600METsmin/week.29Toassessrelative activitylevels,weusedtheJonckheere-Terpstratesttoevaluate whetherthetertilegroupsofthePPAQ-Stotaltimerankedactivity fromtheobjectivemeasurementinananticipatedgradedorder.

Weusedparametricstatisticsbecauseofthelargesamplesize; however, some of the study variables were non-normally dis-tributed.Werepeatedtheanalysisusinganonparametricstatistics, andtheresultdidnotsubstantiallychange.Datewereanalyzed usingSPSSpackageversion20.0forwindows(IBMCorporation) withstatisticalsignificancesetatp<0.05.

Results

Studypopulation

Thetransculturaladaptationprocesswasdevelopedina sam-pleof16 pregnantwomen, withages from21 to37years old, gestationalagebetween9and35weeks,andeducationallevels fromnoschoolingtouniversity.Sociodemographiccharacteristic ofsampleandsubsampleusedinthevalidityandreliability analy-sis,respectively,areshowninTable1.Themainintensityandtype ofphysicalactivityreportedusingthePPAQ-Swerelight inten-sityandhouseholdandcaregivingactivities,57%and52%oftotal activityrespectively.

Transculturaladaptationprocess

Duringtheprocessoftheforwardandbackwardtranslation, therangeofdifficultyperceivedbytranslatorsvariedbetween1 and6,whereastheconceptualequivalencevariedbetween7and 10.Items thatpresented thegreatestdifficultyand/ortheleast conceptualequivalenceareshowninTableIofonlineAppendix, and were discussed during the first and second consensus

Table1

Socioemographiccharacteristics.

Totalsample(n=208) Subsample(n=109)

Variables Mean(SD) Mean(SD)

Age,years 32.7(4.3) 32.0(4.4)

PrepegnancyBMI,kg/m2 _24.6_(4.1) _23.7_(4.0)

n(%) n(%)

Ethnicity

Caucasian 208(100%) 109(100%)

Age

18-30years 48(23.1%) 36(33.0%)

31-44years 160(76.9%) 73(67.0%)

Trimesterofgestation

Secondtrimester 126(60.6%) 74(67.9%)

Thirdtrimester 82(39.4%) 35(32.1%)

PrepregnancyBMIa

<25kg/m2 ₁₃₀_(62.5%) ₇₆_(69.7%)

>25kg/m2 ₇₈_(37.5%) ₃₃_(30.3%)

Maritalstatus

Singlewithoutcouple 3(1.4%) 1(0.9%)

Singlewithcouple 66(31.7%) 36(33.0%)

Married 136(65.4%) 68(62.4%)

Divorcedorseparated 3(1.4%) 4(3.7%)

Parity

0 114(54.8%) 68(62.4%)

1 84(40.4%) 35(32.1%)

>1 10(4.8%) 6(5.5%)

Highestlevelofeducation

Non-tertiary 109(52.4%) 64(58.7%)

Tertiary 99(47.6%) 45(41.3%)

Occupationalstatusa

Workers 101(48.6%) 51(46.8%)

Non-workers

Unemployed 53(25.5%) 32(29.4%)

Sickleavefromwork 50(24.0%) 26(23.9%)

a_Four_student_excluded_of_occupational_status_on_total_sample.

BMI:bodymassindex;SD:standarddeviation.

meeting. Individualinterviewswereconductedfor 16pregnant women, to analyze the cognitive debriefing of questionnaire.

TableIIofonlineAppendixshowsthecompleteprocessof trans-culturaladaptation for thefour itemsdiscussed. Regarding the acceptance and formality of the PPAQ-S, all pregnant women found the format comfortable and considered their compre-hension sufficient to suggest changes in specific items of the questionnaire.

Operationalqualities

ThemeantimerequiredtocompletethePPAQ-Swas8±4min perpatient(ranged3to20).Noneofpatientsneededexternalhelp tocompletethequestionnaire.

Test-retestreliability

Resultsoftest-retestreliabilityforthePPAQ-Sscoresare pre-sented in Table 2. ICCwere good for both total activity scores (ICC:0.90and0.96),allintensitycategories(ICC:0.87-0.92)and alltypeofactivities(ICC:0.87-0.98);excepttransportationdomain whichwasmoderate(ICC:0.65).Meandifferencesbetweentestand retestdidnotdiffersubstantiallyfromzeroandwerelowerthan thestandarderrorofthemean.Standarderrorofmeasurement forallPPAQ-Ssummaries variedfrom0.0 to19.2METsh/week. Bland-Altmanplotsandthelimitsofagreementfortotalactivity (−75.8,60.2),moderatetovigorousactivityandmoderate

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Table2

Test-retestreliabilityofthePPAQ-Sscoresinpregnantwomen(n=109).

PPAQsummaryscores Mean(SD)test1

(mets·h/week)

Mean(SD)test2

(mets·h/week)

Differencemean(SD)

(mets·h/week)

IntrapatientSD

(mets·h/week)

ICC CI95% SE(mets-h/week) LoA HT

Summaryactivityscores

Totalactivity(>1.5METs) 133.2 (61.9) 125.4 (55.3) -7.8 (34.7) 57.4 0.90 0.86- 0.93 19.2 -75.8, 60.2 0.252

Moderatetovigorous

activity(>3METs)

40.6 (43.2) 37.5 (43.1) -3.1 (17.3) 22.9 0.96 0.94- 0.97 8.8 -37.0, 30.8 0.039

Byintensity

Sedentaryactivity(<1.5

METs)

23.5 (16.1) 21.4 (15.0) -2.0 (10.4) 15.0 0.87 0.82- 0.91 5.7 -22.4, 18.4 0.000

Lightactivity(1.5-2.9

METs)

84.1 (39.8) 79.9 (34.3) -4.2 (24.0) 31.3 0.88 0.83- 0.92 13.5 -51.2, 42.7 0.048

Moderateactivity(3-6

METs)

40.5 (43.2) 37.4 (43.1) -3.1 (17.3) 22.8 0.96 0.94- 0.97 8.8 -37.0, 30.8 0.039

Vigorousactivity(>6

METs)

0.0 (0.2) 0.0 (0.1) 0.0 (0.1) 0.1 0.92 0.88- 0.95 0.0 -0.2, 0.1 0.005

Bytype

Household/caregiving 79.3 (52.6) 72.6 (44.6) -6.8 (28.9) 50.0 0.90 0.86- 0.93 16.3 -63.5, 49.9 0.003

Occupational 28.1 (41.2) 27.7 (42.5) -0.4 (11.1) 2.8 0.98 0.97- 0.99 5.5 -22.2, 21.4 0.000

Sports/exercise 8.9 (8.6) 8.8 (9.1) -0.1 (4.2) 1.0 0.94 0.91- 0.96 2.1 -8.3, 8.0 0.000

Transportation 11.6 (10.1) 11.5 (9.5) -0.1 (9.9) 0.7 0.65 0.49- 0.76 5.9 -19.5, 19.4 0.000

Inactivity 20.2 (15.7) 18.2 (14.6) -2.0 (10.3) 14.6 0.87 0.81- 0.91 5.6 -22.1, 18.1 0.000

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100

(a)

(b)

(c)

50

0

–50

–100

–150

–200

–200 0,00

0 50 100 150 200 250 300

50,00 100,00 150,00 200,00 250,00 300,00

–150 –100 –50 50 100

0

–200 –150 –100 –50 50 100

0

0 50

Diff

erences of total activity > 1,5

METs betw

een tests (METs-h/w)

Diff

e

rences of moder

ate to vigorous activity

betw

Diff

erences of moder

ate activity

betw

Mean of total activity > 1.5 METs test 1 and test 2 (METs-h/wk)

Mean of moderate to vigorous activity by test 1 and test 2 (METs-h/wk)

Mean of moderate activity by test 1 and test 2 (METs-h/wk)

100 150 200 250 300

Figure1.BlandandAltmanplotsofthedifferencesbetweentest1andtest2for

thePregnancyPhysicalActivityQuestionnairescores.a)Totalactivity.b)Moderate

tovigorousactivity.c)Moderateactivity.Themeansofthedifferences(solidlines)

andlimitsofagreement(dashedlines)within±2standarddeviationsareshown.

ity (−37.0, 30.8 for both) were shown in Figure 1. There was asignificantassociationbetweenthedifferenceandthe magni-tudeofthetest-retest PPAQ-Sscoresforallsummaries(␤from 0.190to0.487),exceptfortotalactivitysummarywhichwasnot significant.

Validity

The PPAQ-S overestimated physical activity by 32% of total activity(32.3METsh/week)and14%ofmoderatetovigorous activ-ity (5.1 METsh/week) compared withthe SWA. The difference betweenbothmethodswassignificantforallintensitycategories, exceptfor moderate activityand moderate tovigorous activity

(Table3).However,assessing relative activitylevels, we found a significant linear trend for increased total activity based on the SWA data across tertiles of activity based on the PPAQ-S scores(p =0.005). A low but significantcorrelation wasfound for sedentaryactivity and total activity,whereas no significant correlationwasfoundforotherintensitycategories.The concord-ance correlation coefficientvalue between thePPAQ-S and the SWA rangedfrom −0.011to 0.133for all summary categories. Attending to specific subgroups, the PPAQ-s presented signifi-cantly higher total activity compared with the SWA across all stratifiedsubgroups,andsignificantdifferencesbetween moder-atetovigorous physicalactivityvalueswerefoundonworkers, non-workers,BMI≥25kg/m2,secondtrimesterandmultiparous subgroups. The subgroupof young,BMI ≥25, secondtrimester, nulliparousandworkersshowedslightlystrongercorrelationsin total activitybetween thePPAQ-Sand theSWAmeasurements comparedwiththeirrespectivecounterparts(TableIIIofonline Appendix).

Figure 2shows Bland-Altmanplots and thelimits of agree-mentfortotal(−92.3,32.4),moderatetovigorous(−88.6,5.2)and moderate(−88.2,5.4)activity.Therewasasignificantassociation betweenthedifferenceandthemagnitudeofthePPAQ-Sandthe SWAmeasurementsforallintensitycategories(␤from−0.211to 0.981).

Receiveroperatingcharacteristicanalysisidentifiedthe PPAQ-S as poorpredictor of the proportion of women who meeting minimumphysicalactivityrecommendationof ≥150minutesof moderatetovigorousphysicalactivityinboutsof10minutesand ≥600METsmin/week,showinga highsensitivity(81% and78% truepositive,respectively)butlowspecificity(29%and20%true negative,respectively).

Discussion

This studyprovides adequatetranscultural adaptation,good reliability,goodabilitytorankphysicalactivitylevelsofpregnant and poor validity analysis of the PPAQ-S, which is the first standardized physical activityquestionnaire validatedagainst a multi-sensormonitorinpregnantwomen.

In the transcultural adaptationprocess, no significant prob-lems appeared throughout the translation into Spanish or the evaluationoftheconceptualequivalenceoftheitems.The abil-ity of pregnant women to comprehend the questionnaire was good and the mean administration time of the questionnaire was similar to the original version, approximately 8 versus 10minutes.9

The median total activity reported was similar to Japanese version,10 _lower _than _Turkish,13 _and _higher _than _original,9

Vietnamese11_and_Chinese15_versions._The_predominance_of_light

intensityandhouseholdandcaregivingactivitiesfoundinour sam-pleisinlinewithotherPPAQversions,9–11,13_,_and_can_be_explained

bytheselectionoflessdemandingactivities30_during_pregnancy

for compensatetheincrease of basal energyexpenditure31 _and

becauseapproximatelyhalfofoursamplewereun-employedor sickfromworkandmultiparous,prevailinghouseholdand care-givingactivitiesintheirdailylife.

Ourreliabilityresultsfortotalactivitywerehigherthan origi-nalversion9_,_and_similar_with_other_versions,10,11_explained_by_the

similarperiodoftimebetweenbothapplications.Thedifference withoriginalversionmaybeduetothemailedadministrationused forthesecondadministrationintheoriginalversion.Bland-Altman plotsandheterocedasticityanalysisrevealedthatfortotalactivity summarywhentheamountofactivityreportedbythePPAQ-Swas higher,thedifferencesbetweentest-retestscoresdidnotincrease, suggestingthatthissummarymayberepeatableirrespectiveofthe

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Table3

ComparisonofintensitycategoryvaluesbetweenSenseWearArmbandandPPAQ-Sinpregnantwomen(n=208).

Estimated (SWA) (METs-h/week)

Self-reported (PPAQ-S) (METs-h/week)

pvalue

between methods

DM(SD)

(METs-h/w)

CCC Pearson PPearson LoA HT

Summaryactivityscores

Totalactivity

(>1.5METs)

101.8(31.2) 134.1(62.0) 0.000 32.3(63.6) 0.133 0.201 0.004 -92.3,156.9 0.000

Moderateto

vigorous

activity(>3

METs)

36.5(19.4) 41.6(43.4) 0.121 5.2(47.8) -0.011 -0.015 0.826 -88.6,98.9 0.000

ByIntensity

Sedentary

activity(<1.5

METs)

66.1(12.4) 23.4(15.6) 0.000 -42.7(17.6) 0.039 0.224 0.001 -77.3,-8.2 0.002

Lightactivity

(1.5-2.9 METs)

65.3(18.3) 83.6(37.1) 0.000 18.3(39.3) 0.081 0.122 0.079 -58.7,95.3 0.000

Moderate

activity(3-6

METs)

36.2(19.1) 41.6(43.4) 0.104 5.4(47.7) -0.014 -0.019 0.787 -88.2,99.0 0.000

Vigorous

activity(>6

METs)

0.2(0.8) 0.0(0.1) 0.000 -0.2(0.8) 0.021 0.082 0.242 -1.9,1.4 0.000

CCC:concordancecorrelationcoefficient;DM:differencemeanbetweenmethods;HT:heterocedasticityanalysis;LoA:limitsofagreement;Pearson:Pearsoncorrelation

coefficient;PPearson:pvalueforPearsoncorrelationcoefficient;SD:standarddeviation.

amountofactivityreported.Focusonintensitycategories,the reli-abilityresultswereslightlygreaterformoderateactivitythanother intensitycategories,consistentwithotherPPAQversions.9,11–13_.

Focusontypeofactivitycategories,inlinewithothersPPAQ ver-sions,thereliabilityresultsweregoodforalltypesofactivity,10–13

excepttransportation.10,12_This_may_reflect _a_true_variability_on

thisactivityand couldbeexplainedbecausepregnancy implies structured medical visits that may change this behavior in thedaily life of pregnantwomen. Nevertheless household and caregiving, and occupational activities could be more routine activities.

Inlinewithpreviousstudy,16_the_PPAQ-S_{overestimated}

phys-icalactivitylevelsforallintensitycategoriescomparedwiththe SWA,except for sedentaryand vigorous activities.The validity resultsshowedonlysignificantrelationshipfortotalandsedentary activities,and BlandAltman plots and heterocedasticity analy-sis for total and moderate to vigorous activity indicated that justastheamountofphysicalactivityreportedwashigherthe differences between methods increase. This overestimation of physicalactivityshowsthedifficultyofpregnantwomento dis-criminate the intensity or the duration of their activities, and could be explain by the increase of weight and basal energy expenditure31 _and _the _difficulties _on _movement32 _inherent _to

pregnancythatcouldmakepregnantwomentoperceivethese dif-ficultieswithahigherdurationoreffortlevel.Receiveroperational characteristic analysisrevealed a poorprediction of fulfillment ofphysical activity recommendations,showing a high sensitiv-ity and low specificity, leading to consider this instrument a baddiscriminatorofpeoplewhoreachthephysicalactivity rec-ommendations, but a good instrument to detect moderate to vigorousphysical activity.However,thesignificantlinear trend showedonrelativeactivitylevelsassessmentsuggeststhe abil-ity of the PPAQ-S todiscriminate activity levels, reflecting the truerankingofphysicalactivity,andallowingtoexamine associa-tionsbetweenphysicalactivitylevelsandhealthvariablesduring pregnancy.9,10,15_The_use_of_both_objective_and_subjective

meas-uresofphysicalactivityshouldbeusedsimultaneouslyinfuture studiesinordertoadequatecapturephysicalactivityduring preg-nancy.

Thisstudypresentsseverallimitations,suchastheexclusionof highriskpregnantwomenandtherecruitmentonlyofpregnant womenwhomeeteligibilitycriteriaandvoluntarilyparticipated. Thepercentagesofyoung,overweight/obese,andthirdtrimester womenwereconsiderablylowerthantheircounterpartssoitmay resultinself-selectionbias.Incontrastparity,educationalleveland occupationalstatussubgroupshadasimilarpercentage.The cross-sectionaldesignofourstudyprecludestheidentificationofany casualrelations.Longitudinalstudiesareneededtoexaminethe sensitivitytochangeofthisquestionnaireafterinterventions.The knowlimitationofnonprobabilitysamples,includingtheirless rep-resentativenessandunknownlevelsofsamplingerror,arefurther limitations.

Thestrengthsofthisstudywerethesystematicandrigorous processofthetransculturaladaptation,thestrictstandardization ofmethodology,andtheuse,forfirsttime,of24hoursmulti-sensor monitortovalidatethePPAQ,whichmaysolvethemainlimitations of accelerometers and pedometers, used in previous validation studies.Moreover,theuseofthesameunits(METs·h/week)for both methods,allowthedirect comparison withoutneedingto establishcutpointstoestimatetheintensities.33_In_addition,_the

useof specific METs values for pregnant women by the PPAQ and thequantificationof energyexpenditureby theSensewear mayappropriatelyaccountforthephysiologicaland cardiovascu-larchanges thatoccurduringpregnancy.Otherstrengthof this studyis thestrictquantificationperiodused.Althoughbetween 3 to 5 days of monitoring are sufficient to estimate habitual physicalactivity,22_we_used_a_period_of_at_least_eight_completed

days(upperthan 95%of theday),eliminatingthefirst andthe lastdaytominimizethereactivityofworetheSensewear Arm-bandand to capturean habitual weekof lifestyle of pregnant women.

Sinceself-reportedinstrumentsfacilitate thestudyof physi-calactivitypatternsonclinicalpractices,epidemiologicandlarge populationstudies,future research shouldconsiderer the com-parisonofthepsychometricpropertiesofdifferentquestionnaires against multi-sensordevices onpregnant women toknow the most adequate self-report measure of physical activity during pregnancy.

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Diff

erences of total activity > 1,5

METs betw

een methods (METs-h/w)

Mean of total activity > 1.5 METs by PPAQ-S and SWA (METs-h/wk)

Diff

erences of moder

ate to vigorous activity

betw

Mean of moderate to vigorous activity by PPAQ-S and SWA (METs-h/wk)

Diff

erences of moder

ate activity

betw

Mean of moderate activity by PPAQ-S and SWA (METs-h/wk) –100

–50 0 50 100 150 200 250

(a)

(b)

(c)

–150

–150 –100 –50 0 50 100 150 200 250

0 50 100 150 200 250

Figure2.BlandandAltmanplotsofthedifferencesbetweenPregnancyPhysical

ActivityQuestionnaireandSensewearfor(a)totalactivity,(b)moderatetovigorous

activity,and(c)moderateactivity.Themeansofthedifferences(solidlines)and

limitsofagreement(dashedlines)within±2standarddeviationsareshown.

Conclusions

Theresultsobtainedin thepresent studyindicated thatthe PPAQ-Sisabriefandeasytointerpretquestionnairewithagood reliability and ability torank pregnantwomen respectto their physical activity, and a poor validity compared against multi-sensormonitor.Theavailabilityofvalidatedversionsoftheoriginal questionnaireintodifferentlanguagesallowstheuseofthis ques-tionnaireincross-nationalclinicaltrials.

Werecommendtheusefulnessofthisinstrumentto discrim-inatephysicalactivitylevelsamongpregnantwomen,providing pregnancy-specificactivitiesinformationinordertopredict mater-naland fetalhealthoutcomesandtoproposehealthpromotion strategiesduringpregnancy.

Whatisknownaboutthetopic?

PPAQisaspecificallydesignedquestionnaireforpregnant

women that overcomes the limitation of questionnaires

designedforadults,takingintoaccounthouseholdand child-care activitiesand not onlymoderate and vigorous sports. PPAQhavenotbeentransculturallyadaptintoSpanish.

Whatdoesthisstudyaddtotheliterature?

This study provides the Spanish version of PPAQ and

establishesthefirstvalidationofstandardizedphysical

activ-ity questionnaire in pregnant women using a multi-sensor

monitor,whichovercomesthelimitationsofaccelerometers. TheSpanishversionofPPAQ,whichincludesspecificcultural adaptation, is required to develop research studiesamong

Spanish-speakerpregnantwomen.

Editorincharge

MercedesCarrascoPorti˜no.

Transparencydeclaration

Thecorrespondingauthoronbehalfoftheotherauthors guar-antee the accuracy, transparency and honesty of the data and informationcontainedinthestudy,thatnorelevantinformation hasbeenomittedandthatalldiscrepanciesbetweenauthorshave beenadequatelyresolvedanddescribed.

Authorshipcontributions

D. Munguía-Izquierdo and M.A. Oviedo-Caro designed the studyandplannedthedatacollection.Allauthorswere respon-sible for the acquisition of the data. M.A. Oviedo-Caro and D. Munguía-Izquierdoperformedthestatisticalanalysesandwrote the manuscript. All authors provided critical review of the manuscriptandapprovedthefinalversion.

Acknowledgments

Theauthorsgratefullyacknowledgeallwomenfortheir collab-oration.Wealsoacknowledgethehealthclinicmembersinvolved intherecruitmentfortheireffortandgreatenthusiasm.

Funding

ThestudywasfundedbyResearchGroupCTS-948ofUniversity PabloofOlavide(Seville),thisfundingincludedmaterialand equip-mentfortheresearch.Therewasnoexternalfinancialsupport.J.B. issupportedbytheSpanishMinistryofEducation(grantnumber FPU13/05130).

Conflictsofinterests

None.

AppendixA. Supplementarydata

Supplementarydataassociatedwiththisarticlecanbefound,in theonlineversion,atdoi:10.1016/j.gaceta.2017.12.004.

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