Ruth F. Hunter

Validity of the Global Physical Activity Questionnaire (GPAQ) in assessing levels and change in moderate-vigorous physical activity and sedentary behaviour

BackgroundFeasible, cost-effective instruments are required for the surveillance of moderate-to-vigorous physical activity (MVPA) and sedentary behaviour (SB) and to assess the effects of interventions. However, the evidence base for the validity and reliability of the World Health Organisation-endorsed Global Physical Activity Questionnaire (GPAQ) is limited. We aimed to assess the validity of the GPAQ, compared to accelerometer data in measuring and assessing change in MVPA and SB.MethodsParticipants (n = 101) were selected randomly from an on-going research study, stratified by level of physical activity (low, moderate or highly active, based on the GPAQ) and sex. Participants wore an accelerometer (Actigraph GT3X) for seven days and completed a GPAQ on Day 7. This protocol was repeated for a random sub-sample at a second time point, 3–6 months later. Analysis involved Wilcoxon-signed rank tests for differences in measures, Bland-Altman analysis for the agreement between measures for median MVPA and SB mins/day, and Spearman’s rho coefficient for criterion validity and extent of change.Results95 participants completed baseline measurements (44 females, 51 males; mean age 44 years, (SD 14); measurements of change were calculated for 41 (21 females, 20 males; mean age 46 years, (SD 14). There was moderate agreement between GPAQ and accelerometer for MVPA mins/day (r = 0.48) and poor agreement for SB (r = 0.19). The absolute mean difference (self-report minus accelerometer) for MVPA was −0.8 mins/day and 348.7 mins/day for SB; and negative bias was found to exist, with those people who were more physically active over-reporting their level of MVPA: those who were more sedentary were less likely to under-report their level of SB. Results for agreement in change over time showed moderate correlation (r = 0.52, p = 0.12) for MVPA and poor correlation for SB (r = −0.024, p = 0.916).ConclusionsLevels of agreement with objective measurements indicate the GPAQ is a valid measure of MVPA and change in MVPA but is a less valid measure of current levels and change in SB. Thus, GPAQ appears to be an appropriate measure for assessing the effectiveness of interventions to promote MVPA.

The validation of Fitbit Zip™ physical activity monitor as a measure of free-living physical activity

BackgroundThe new generation of activity monitors allow users to upload their data to the internet and review progress. The aim of this study is to validate the Fitbit Zip as a measure of free-living physical activity.FindingsParticipants wore a Fitbit Zip, ActiGraph GT3X accelerometer and a Yamax CW700 pedometer for seven days. Participants were asked their opinion on the utility of the Fitbit Zip. Validity was assessed by comparing the output using Spearman’s rank correlation coefficients, Wilcoxon signed rank tests and Bland-Altman plots. 59.5% (25/47) of the cohort were female. There was a high correlation in steps/day between the Fitbit Zip and the two reference devices (r = 0.91, p < 0.001). No statistically significant difference between the Fitbit and Yamax steps/day was observed (Median (IQR) 7477 (3597) vs 6774 (3851); p = 0.11). The Fitbit measured significantly more steps/day than the Actigraph (7477 (3597) vs 6774 (3851); p < 0.001). Bland-Altman plots revealed no systematic differences between the devices.ConclusionsGiven the high level of correlation and no apparent systematic biases in the Bland Altman plots, the use of Fitbit Zip as a measure of physical activity. However the Fitbit Zip recorded a significantly higher number of steps per day than the Actigraph.

Exercise and Auricular Acupuncture for Chronic Low-back Pain: A Feasibility Randomized-controlled Trial.

Objectives:To evaluate the feasibility of a randomized-controlled trial (RCT) investigating the effects of adding auricular acupuncture (AA) to exercise for participants with chronic low-back pain (CLBP). Methods:Participants with CLBP were recruited from primary care and a university population and were randomly allocated (n=51) to 1 of 2 groups: (1) “Exercise Alone (E)”—12-week program consisting of 6 weeks of supervised exercise followed by 6 weeks unsupervised exercise (n=27); or (2) “Exercise and AA (EAA)”—12-week exercise program and AA (n=24). Outcome measures were recorded at baseline, week 8, week 13, and 6 months. The primary outcome measure was the Oswestry Disability Questionnaire. Results:Participants in the EAA group demonstrated a greater mean improvement of 10.7% points (95% confidence interval, –15.3,−5.7) (effect size=1.20) in the Oswestry Disability Questionnaire at 6 months compared with 6.7% points (95% confidence interval, −11.4,−1.9) in the E group (effect size=0.58). There was also a trend towards a greater mean improvement in quality of life, LBP intensity and bothersomeness, and fear-avoidance beliefs in the EAA group. The dropout rate for this trial was lower than anticipated (15% at 6 mo), adherence with exercise was similar (72% E; 65% EAA). Adverse effects for AA ranged from 1% to 14% of participants. Discussion:Findings of this study showed that a main RCT is feasible and that 56 participants per group would need to be recruited, using multiple recruitment approaches. AA was safe and demonstrated additional benefits when combined with exercise for people with CLBP, which requires confirmation in a fully powered RCT.

Physical Activity Loyalty Cards for Behavior Change: A Quasi-Experimental Study

BACKGROUND Financial incentives have been advocated by the UK and U.S. governments to encourage adoption of healthy lifestyles. However, evidence to support the use of incentives for changing physical activity (PA) behavior is sparse. PURPOSE To investigate the effectiveness of financial incentives to increase PA in adults in the workplace. DESIGN Two-arm quasi-experimental design. SETTING/PARTICIPANTS Employees (n=406) in a workplace setting in Belfast, Northern Ireland, UK. INTERVENTION Using a loyalty card to collect points and earn rewards, participants (n=199) in the Incentive Group monitored their PA levels and received financial incentives (retail vouchers) for minutes of PA completed over the course of a 12-week intervention period. Participants (n=207) in the comparison group used their loyalty card to self-monitor their PA levels but were not able to earn points or obtain incentives (No Incentive Group). MAIN OUTCOME MEASURES The primary outcome was minutes of PA objectively measured using a novel PA tracking system at baseline (April 2011); Week 6 (June 2011); and Week 12 (July 2011). Other outcomes, including a self-report measure of PA, were collected at baseline, Week 12, and 6 months (October 2011). Data were analyzed in June 2012. RESULTS No significant differences between groups were found for primary or secondary outcomes at the 12-week and 6-month assessments. Participants in the Incentive Group recorded 17.52 minutes of PA/week (95% CI=12.49, 22.56) compared to 16.63 minutes/week (95% CI=11.76, 21.51) in the No Incentive Group at Week 12 (p=0.59). At 6 months, participants in the Incentive Group recorded 26.18 minutes of PA/week (95% CI=20.06, 32.29) compared to 24.00 minutes/week (95% CI=17.45, 30.54) in the No Incentive Group (p=0.45). CONCLUSIONS Financial incentives did not encourage participants to undertake more PA than self-monitoring PA. This study contributes to the evidence base and has important implications for increasing participation in physical activity and fostering links with the business sector.

Connectivity and physical activity: using footpath networks to measure the walkability of built environments

There is now a strong body of research that suggests that the form of the built environment can influence levels of physical activity, leading to an increasing interest in incorporating health objectives into spatial planning and regeneration. There have been a number of strands to this research, one of which has sought to develop objective measurements of the built environment using geographic information systems involving measures of connectivity and proximity to compare the relative ‘walkability’of different neighbourhoods. The development of the ‘walkability index’ has become a popular indicator of the spatial distribution of those built environment features that are considered to have the greatest positive influence on levels of physical activity. The success of this measure is built on its ability to capture succinctly correlates of physical activity using routinely available spatial data, which includes using road centre lines to measure connectivity. In this paper we discuss two key aspects of the walkability index. First, as suggested by others, that the use of a footpath network, rather than road centre lines, may be far more effective in evaluating walkability. This may be particularly important for assessing changes in walkability arising from pedestrian-focused infrastructure projects, such as greenways. Second, we explore the implications of this for how connectivity can be measured. We take six different measures of connectivity and first analyse the relationships between them and then test their correlation with actual levels of physical activity of local residents in Belfast, Northern Ireland. We find that the best measurements appear to be intersection density and metric reach and use this finding to discuss the implications for developing tools that may better support decision-making in spatial planning.

Physical activity and the rejuvenation of Connswater (PARC study): protocol for a natural experiment investigating the impact of urban regeneration on public health

BackgroundThere is a dearth of evidence regarding the impact of urban regeneration projects on public health, particularly the nature and degree to which urban regeneration impacts upon health-related behaviour change. Natural experiment methodology enables comprehensive large-scale evaluations of such interventions. The Connswater Community Greenway in Belfast is a major urban regeneration project involving the development of a 9 km linear park, including the provision of new cycle paths and walkways. In addition to the environmental improvements, this complex intervention involves a number of programmes to promote physical activity in the regenerated area. The project affords a unique opportunity to investigate the public health impact of urban regeneration.Methods/DesignThe evaluation framework was informed by the socio-ecological model and guided by the RE-AIM Framework. Key components include: (1) a quasi-experimental before-and-after survey of the Greenway population (repeated cross-sectional design), in tandem with data from a parallel Northern Ireland-wide survey for comparison; (2) an assessment of changes in the local built environment and of walkability using geographic information systems; (3) semi-structured interviews with a purposive sample of survey respondents, and a range of community stakeholders, before and after the regeneration project; and (4) a cost-effectiveness analysis. The primary outcome is change in proportion of individuals identified as being regularly physically active, according to the current UK recommendations. The RE-AIM Framework will be used to make an overall assessment of the impact of the Greenway on the physical activity behaviour of local residents.DiscussionThe Connswater Community Greenway provides a significant opportunity to achieve long-term, population level behaviour change. We argue that urban regeneration may be conceptualised meaningfully as a complex intervention comprising multiple components with the potential, individually and interactively, to affect the behaviour of a diverse population. The development and implementation of our comprehensive evaluation framework reflects this complexity and illuminates an approach to the empirical, rigorous evaluation of urban regeneration. More specifically, this study will add to the much needed evidence-base about the impact of urban regeneration on public health as well as having important implications for the development of natural experiment methodology.

The effect of changing the built environment on physical activity: a quantitative review of the risk of bias in natural experiments.

BackgroundEvidence regarding the association of the built environment with physical activity is influencing policy recommendations that advocate changing the built environment to increase population-level physical activity. However, to date there has been no rigorous appraisal of the quality of the evidence on the effects of changing the built environment. The aim of this review was to conduct a thorough quantitative appraisal of the risk of bias present in those natural experiments with the strongest experimental designs for assessing the causal effects of the built environment on physical activity.MethodsEligible studies had to evaluate the effects of changing the built environment on physical activity, include at least one measurement before and one measurement of physical activity after changes in the environment, and have at least one intervention site and non-intervention comparison site. Given the large number of systematic reviews in this area, studies were identified from three exemplar systematic reviews; these were published in the past five years and were selected to provide a range of different built environment interventions. The risk of bias in these studies was analysed using the Cochrane Risk of Bias Assessment Tool: for Non-Randomized Studies of Interventions (ACROBAT-NRSI).ResultsTwelve eligible natural experiments were identified. Risk of bias assessments were conducted for each physical activity outcome from all studies, resulting in a total of fifteen outcomes being analysed. Intervention sites included parks, urban greenways/trails, bicycle lanes, paths, vacant lots, and a senior citizen’s centre. All outcomes had an overall critical (n = 12) or serious (n = 3) risk of bias. Domains with the highest risk of bias were confounding (due to inadequate control sites and poor control of confounding variables), measurement of outcomes, and selection of the reported result.ConclusionsThe present review focused on the strongest natural experiments conducted to date. Given this, the failure of existing studies to adequately control for potential sources of bias highlights the need for more rigorous research to underpin policy recommendations for changing the built environment to increase physical activity. Suggestions are proposed for how future natural experiments in this area can be improved.

Different frequencies of acupuncture treatment for chronic low back pain: An assessor-blinded pilot randomised controlled trial

OBJECTIVES To examine the feasibility of a main RCT to compare the effectiveness of two frequencies (2 versus 5 times/week) of acupuncture treatment for chronic low back pain (LBP). METHODS Participants (n=30) with chronic LBP were randomised into two groups to receive 10 acupuncture treatments: Low Frequency Group, 2 times/week for five weeks (n=15); High Frequency Group, 5 times/week for two weeks (n=15). The following outcomes were measured blindly at baseline, 2 weeks, 5 weeks, 3 months and 1 year: pain on a VAS, functional disability using the RMDQ, quality of life using the Measure Yourself Medical Outcome Profile (MYMOP-2), psychological impact with the Coping Strategies Questionnaire (CSQ) and Pain Locus of Control (PLC) questionnaire. Two objective outcomes, the Shuttle Walk Test (SWT) and Lateral Trunk Flexibility (LTF), were also measured. RESULTS The compliance rate was 100% for each group. Some of the measurements were shown to be sensitive (VAS, RMDQ, MYMOP-2 Wellbeing). 66-330 participants would be required for a fully powered non-inferiority trial. The groups were balanced at baseline for LBP and demographic characteristics. There were no significant differences between the groups in terms of any of the outcomes, at each follow-up time point. It was notable however that the clinically important improvement in terms of pain, functional disability, quality of life, and SWT in both groups was achieved within the first two weeks, which was maintained at one year follow-up. CONCLUSIONS It is feasible to conduct a main RCT, to compare different frequencies of acupuncture for LBP, using sensitive measurements. Also the trend for early clinically important improvement within a minimum of four measurements is worthy of further study.

Exercise and manual auricular acupuncture: a pilot assessor-blind randomised controlled trial. (The acupuncture and personalised exercise programme (APEP) Trial)

BackgroundEvidence supports the use of exercise for chronic low back pain (CLBP); however, adherence is often poor due to ongoing pain. Auricular acupuncture is a form of pain relief involving the stimulation of points on the outer ear corresponding with specific body parts. It may be a useful adjunct to exercise in managing CLBP; however, there is only limited evidence to support its use with this patient group.Methods/DesignThis study was designed to test the feasibility of an assessor-blind randomised controlled trial which assess the effects on clinical outcomes and exercise adherence of adding manual auricular acupuncture to a personalised and supervised exercise programme (PEP) for CLBP. No sample size calculation has been carried out as this study aims to identify CLBP referral rates within the catchment area of the study site. The researchers aim to recruit four cohorts of n = 20 participants to facilitate a power analysis for a future randomised controlled trial. A computer generated random allocation sequence will be prepared centrally and used to allocate participants by cohort to one of the following interventions: 1) six weeks of PEP plus manual auricular acupuncture; 2) six weeks of PEP alone. Both groups will also complete a further six weeks of self-paced exercise with telephone follow-up support. In addition to a baseline and exit questionnaire at the beginning and end of the study, the following outcomes will be collected at baseline, and after 7, 13 and 25 weeks: pain frequency and bothersomeness, back-specific function, objective assessment and recall of physical activity, use of analgesia, perceived self-efficacy, fear avoidance beliefs, and beliefs about the consequences of back pain. Since this is a feasibility study, significance tests will not be presented, and treatment effects will be represented by point estimates and confidence intervals. For each outcome variable, analysis of covariance will be performed on the data, conditioning on the baseline value.DiscussionThe results of this study investigating the adjuvant effects of auricular acupuncture to exercise in managing CLBP will be used to inform the design of a future multi-centre randomised controlled trial.Trial RegistrationCurrent Controlled Trials ISRCTN94142364.

International inter-school competition to encourage children to walk to school: a mixed methods feasibility study

BackgroundActive travel to school can be an important contributor to the total physical activity of children but levels have declined and more novel approaches are required to stimulate this as an habitual behaviour. The aim of this mixed methods study was to investigate the feasibility of an international walk to school competition supported by novel swipecard technology to increase children’s walking to/from school.MethodsChildren aged 9–13 years old participated in an international walk to school competition to win points for themselves, their school and their country over a 4-week period. Walks to and from school were recorded using swipecard technology and a bespoke website. For each point earned by participants, 1 pence (£0.01) was donated to the charity of the school’s choice. The primary outcome was number of walks to/from school objectively recorded using the swipecard tracking system over the intervention period. Other measures included attitudes towards walking collected at baseline and week 4 (post-intervention). A qualitative sub-study involving focus groups with children, parents and teachers provided further insight.ResultsA total of 3817 children (mean age 11.5 ± SD 0.7) from 12 schools in three cities (London and Reading, England and Vancouver, Canada) took part in the intervention, representing a 95% intervention participation rate. Results show a gradual decline in the average number of children walking to and from school over the 4-week period (week 1 mean 29% ± SD2.5; week 2 mean 18% ± SD3.6; week 3 mean 14% ± SD4.0; week 4 mean 12% ± SD1.1). Post intervention, 97% of children felt that walking to school helped them stay healthy, feel happy (81%) and stay alert in class (76%). These results are supported by qualitative findings from children, parents and teachers. Key areas for improvement include the need to incorporate strategies for maintenance of behaviour change into the intervention and also to adopt novel methods of data collection to increase follow-up rates.ConclusionsThis mixed methods study suggests that an international walk to school competition using innovative technology can be feasibly implemented and offers a novel way of engaging schools and motivating children to walk to school.