Original Article
The SQUASH was a more valid tool than the OBiN for categorizing adults according to the Dutch physical activity and the combined guideline

https://doi.org/10.1016/j.jclinepi.2011.05.005Get rights and content

Abstract

Objective

To examine whether the “Short QUestionnaire to ASsess Health-enhancing physical activity” (SQUASH) and the “Injuries and Physical Activity in the Netherlands” questionnaire (“Ongevallen en Bewegen in Nederland,” OBiN) were valid in assessing adherence to physical activity (PA) guidelines.

Study Design and Setting

Participants (N = 187) aged 20–69 years were categorized as “inactive,” “semiactive,” or “norm-active” according to the Dutch PA, the American College of Sports Medicine (ACSM), and the combined guideline (adhering to either or both of two other guidelines) by the questionnaires and a combined heart rate monitor and accelerometer (Actiheart). Percentage of exact agreement and maximum disagreement (difference of two categories) for the categorization between questionnaires and Actiheart was calculated.

Results

The SQUASH had a significant higher agreement than the OBiN for the Dutch PA (SQUASH: 78%, OBiN: 46%; P < 0.01) and combined guideline (SQUASH: 84%, OBiN: 55%; P < 0.01). Both questionnaires had a low agreement regarding the ACSM guideline (SQUASH: 37%, OBiN: 34%; P = 0.45). The SQUASH had a significant higher maximum disagreement than the OBiN for this guideline (SQUASH: 19.8%, OBiN 8%; P < 0.01).

Conclusion

The SQUASH was a more valid measure than the OBiN for categorizing adults according to the Dutch PA and the combined guideline. Both questionnaires failed to correctly categorize adults according to the ACSM guideline.

Introduction

What is new?

  • The “Short QUestionnaire to ASsess Health-enhancing physical activity” (SQUASH) was a more valid measure than the “Injuries and Physical Activity in the Netherlands” questionnaire (“Ongevallen en Bewegen in Nederland,” OBiN) in categorizing Dutch adults according to the Dutch physical activity (PA) guideline and the combined guideline (combination of adhering to either or both of the Dutch PA guideline and the American College of Sports Medicine [ACSM] guideline for cardiorespiratory fitness). Both the SQUASH and the OBiN questionnaire failed to correctly categorize adults according to the ACSM guideline.

  • PA questionnaires are often used to measure PA behavior. In the Netherlands, the SQUASH and OBiN questionnaire are often used but have not been validated with the same objective measurement before. This study gains insight in the ability of these questionnaires to measure adherence to PA guidelines.

  • PA may be ultimately measured with objective instruments, but until then, it is of great importance that future research will aim to obtain more insight into the validity of both objective and subjective instruments.

It is well established that physically active people have higher levels of health-related fitness, lower rates of various chronic diseases, and a lower risk profile for developing several disabling medical conditions [1], [2]. Physical activity (PA) guidelines have been developed to help populations to achieve these health benefits [1].

In the Netherlands, generally three PA guidelines are used.

  • 1.

    The Dutch PA guideline, recommending 30 minutes or more of at least moderate intense PA for a minimum of 5 days per week [3]

  • 2.

    The 1998 American College of Sports Medicine (ACSM) guideline—also known as the guideline for cardiorespiratory fitness—recommending 20 minutes or more of vigorous PA for at least 3 days per week [4]

  • 3.

    The combined guideline, which means adhering to either or both of the above two described guidelines [5].

These guidelines are similar to those in, for example, the United States [1], but they differ with respect to cutoff values of moderate and vigorous intense PA. In the Netherlands, cutoff values of respectively 4.0 and 6.5 METs are used, whereas internationally, cutoff values of 3.0 and 5.0 are more common. This results in, for example, walking being excluded from the guidelines in the Netherlands as opposed to other countries.

In the Netherlands, two questionnaires are used to monitor adherence to these guidelines in country-wide representative surveys on a yearly basis: the “Short QUestionnaire to ASsess Health-enhancing physical activity” (SQUASH; Appendix 1 [see Appendix 1 on the journal's Web site at www.elsevier.com]) [6] and the “Injuries and Physical Activity in the Netherlands” questionnaire (“Ongevallen en Bewegen in Nederland,” OBiN; Appendix 2 [see Appendix 2 on the journal's Web site at www.elsevier.com]) [7]. Although both questionnaires provide the opportunity to measure adherence to guidelines, they differ substantially in reference period, type of questions, and operationalization of the guidelines. The SQUASH has been designed to measure the habitual activity level in general [6], whereas the OBiN questionnaire has been specifically designed to measure habitual activity level in terms of adherence to the three guidelines mentioned above [7]. Both the SQUASH and OBiN questionnaire have been validated in the past, but never simultaneously. Furthermore, different reference methods (i.e., Computer Science and Applications Activity Monitor and extensive PA questionnaire) and outcome measures (i.e., PA scores and adherence to guidelines) have been used [6], [7].

There is consensus that for the purpose of validating questionnaires, an objective measure (e.g., doubly labeled water, accelerometer, or heart rate monitor) is preferred over a subjective measure (e.g., direct observation, diary, or questionnaire) [8]. Recently, a combined accelerometer with a heart rate monitor (Actiheart; Cambridge Neurotechnology, Cambridge, UK) has been developed, which provides a more valid measure of PA levels than using an accelerometer or heart rate meter separately [9]. This makes the Actiheart a good objective measure to validate questionnaires.

The aim of the present study was to validate results of the SQUASH and OBiN questionnaire against the Actiheart within an adult population by using adherence to the Dutch PA guideline, ACSM guideline, and combined guideline as outcome measures.

Section snippets

Study population

Participants were included if they were aged between 20 and 69 years and were not suffering from a disorder that would influence heart rate measurements. Also, participants had to be able to walk for 10 minutes without aid. Participants were recruited from two sources: (1) a volunteer database from the Julius Center for Health Sciences and (2) advertisement posters, which were placed at the Utrecht University Medical Center. We used the large volunteer database because it included participants

Characteristics of the population

Table 1 shows the characteristics of the study population. The population consisted of 27 men and 160 women aged 57 ± 11 years (men: 51 ± 10 and women: 58 ± 11 years). Approximately three-quarters of participants were aged 55 years and older. About half of the study population had a high educational level (Table 1).

Adherence to the guidelines

Fig. 1 shows the proportion of the study population categorized as “inactive,” “semiactive,” or “norm-active” according to the three guidelines under study. The SQUASH showed patterns

Discussion

The present study showed in a population of 187 adults aged 20–69 years that the SQUASH had a higher exact agreement with the Actiheart than the OBiN questionnaire to categorize participants according to the Dutch PA guideline and the combined guideline. Both questionnaires had a relatively low but comparable exact agreement with the Actiheart regarding the ACSM guideline.

In the present study, we used the Actiheart to validate the two questionnaires, which is a more accurate method than using

Conclusion

The SQUASH was a more valid measure in categorizing adults according to the Dutch PA guideline and the combined guideline than the OBiN questionnaire. Both the SQUASH and the OBiN questionnaire failed to correctly categorize adults according to the ACSM guideline.

Acknowledgments

The study was performed in cooperation with the Julius Center for Health Sciences, Primary Care University Medical Center, Utrecht, the Netherlands, and Cambridge Neurotechnology, Cambridge, UK. The Julius Center measured anthropometrics and physical activity. Cambridge Neurotechnology cleaned the Actiheart data.

The fieldwork was coordinated by a trained research coordinator of the Julius Center for Health Sciences and supervised by a principal researcher from the National Institute for Public

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