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Volume
3:
No. 4, October 2006
ORIGINAL RESEARCH
The Rapid Assessment of Physical Activity
(RAPA)
Among Older Adults
Tari D. Topolski, PhD, James LoGerfo, MD, Donald L. Patrick, PhD, MPH,
Barbara Williams, PhD, Julie Walwick, MSW, MAJ Marsha B. Patrick, PhD
Suggested citation for this article: Topolski TD, LoGerfo J, Patrick
DL, Williams B, Walwick J, Patrick MB. The Rapid Assessment of Physical Activity
(RAPA) among older adults. Prev Chronic Dis [serial online] 2006 Oct [date
cited]. Available from: http://www.cdc.gov/pcd/issues/2006/
oct/06_0001.htm.
PEER REVIEWED
Abstract
Introduction
The Rapid Assessment of Physical Activity (RAPA) was developed
to provide an easily administered and interpreted means of assessing levels of physical activity among adults older
than 50
years.
Methods
A systematic review of the literature, a survey of geriatricians,
focus groups, and cognitive debriefings with older adults were conducted, and an
expert panel was convened. From
these procedures, a nine-item questionnaire assessing strength, flexibility, and
level and intensity of physical activity was developed. Among a cohort of 115 older
adults (mean age, 73.3 years; age range, 51–92 years), half of whom were regular
exercisers (55%), the screening performance of three short self-report physical
activity questionnaires — the RAPA, the Behavioral Risk Factor
Surveillance System (BRFSS) physical activity questions, and the
Patient-centered Assessment and Counseling for Exercise (PACE) — was compared
with the Community Healthy Activities Model
Program for Seniors (CHAMPS) as the criterion.
Results
Compared with the BRFSS and the PACE, the RAPA was more positively correlated
with the CHAMPS moderate caloric expenditure (r = 0.54 for RAPA, r = 0.40 for BRFSS,
and r = 0.44 for PACE) and showed as good or better sensitivity (81%),
positive predictive value (77%), and negative predictive value (75%) as the
other tools. Specificity, sensitivity, and positive predictive value of the
questions on flexibility and strength training were in the 80% range, except for
specificity of flexibility questions (62%). Mean
caloric expenditure per week calculated from the CHAMPS was compared between those who
did and those who did not meet minimum recommendations for moderate or vigorous
physical activity based on these self-report questionnaires. The RAPA
outperformed the PACE and the BRFSS.
Conclusion
The RAPA is an easy-to-use, valid measure of physical activity for use
in clinical practice with older adults.
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Introduction
Physical activity has been demonstrated to improve management of chronic
conditions and delay decline in function in older adult populations (1). Current
indicators, however, show that less than 20% of U.S. adults older than 64 years
engage in the surgeon general’s recommended amount of physical activity, and
only 11% engage in strength training (2). Additionally, several groups,
including adults aged 75 years and older, women, individuals with disabilities,
African Americans, and Hispanics are among the most sedentary (3).
In recent years, there has been a growing interest in a comprehensive
approach to preventing and managing chronic disease that emphasizes
self-management. A critical element of this self-management approach is tracking
important processes and outcomes through disease registries and linking clinical
practice to community-based support systems, as exemplified in the Chronic Care
Model (4). (A description of this model is available from
www.improvingchroniccare.org.*) In our work with community support programs that
complement clinical practice, including those promoting physical
activity for older adults, we have found that integration of care requires
common measures of key variables in both clinical settings and community support
programs. We undertook this study to develop and test an easily administered
questionnaire that assesses and monitors physical activity levels among older adults.
Currently, there are no published reports comparing the validity of the commonly
used physical activity measures with a more detailed, validated measure of actual levels of activity in
older adults. In our work disseminating the EnhanceWellness Program (5), nurse
coaches requested a measure that indicated more gradation of light physical
activity so that they could give positive feedback as seniors evolved from being
sedentary to being more active (6,7).
The goals of this study were to 1) develop a short, self-administered, and
easily scored tool that could be used in a clinical setting to assess and
monitor physical activity levels of older adults (aged 50 years and older),
and 2) compare the accuracy of the new tool with the Patient-centered
Assessment and Counseling for Exercise (PACE), a measure of level of and stage
of readiness to engage in physical
activity currently used by clinicians (6), and the measure
of activity used in the Behavioral Risk Factor Surveillance System (BRFSS) for
population-level monitoring of physical activity among adults (8) against the criterion measure Community Healthy Activities Model Program for Seniors
(CHAMPS) (9-11). We chose to test the PACE because it is a measure of activity
currently used for clinical counseling, and we chose the BRFSS because it is
currently used for surveillance. Both tend to focus on moderate and vigorous
activity, and the PACE instrument has not been validated against other measures
in older populations.
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Methods
Literature review of existing instruments
In 2000, a systematic literature review was conducted to determine whether an
assessment or monitoring instrument existed that could be easily used in a
primary care setting with adults aged 50 years and older. Age 50 was used
because community-based organizations often use this age as the lower-end cutoff and
because it was the age cutoff used in the National Blueprint program for
increasing physical activity among older adults (12). Searches of Medline, PsycINFO, and the World Wide Web and queries of physical activity assessment
experts and geriatric physicians helped us to identify 53 questionnaires that
have been used in the past 25 years to assess physical activity. Search terms
included physical activity, exercise, questionnaire, instrument,
measurement, and assessment. Questionnaires were included if they
were self-reported, used with adults, published or discovered through physical
activity assessment experts, and available in English. These instruments were
evaluated for 1) feasibility of collecting data in a primary care setting and feasibility of producing a summary for inclusion in a medical record;
2) psychometric properties of an optimal self-report screening instrument,
including reliability and criterion validity; and 3) acceptability and
relevance of the instrument to major ethnic populations in the United
States, including Latinos and African Americans.
Members of the research team reviewed the instruments according to the
following criteria: 1) dimensions of the questionnaires; 2) complexity; 3) recall
time frame; 4) use as an outcome measure; 5) reliability/validity/responsiveness;
6) cultural adaptability; and 7) purpose of development. All but 12 of the 53
instruments identified in the literature search were eliminated because they
were deemed to be too long and did not meet at least four of the review
criteria. (A table showing questionnaires and criteria met is available from the
authors). These 12 instruments were then submitted to an expert panel consisting
of physical activity researchers and gerontologists who reviewed the instruments
using these same criteria. The panel deemed none of these instruments to be
completely acceptable either because they were too complex or because they had
not been adequately validated.
Development of the Rapid Assessment of Physical Activity instrument
Items for the Rapid Assessment of Physical Activity (RAPA) were
developed based on Centers for Disease Control and Prevention (CDC)
guidelines of 30 minutes or more of moderate physical activity on every or most
days of the week and included additional questions added to assess strength and
flexibility because of the association of these activities with preventing
falls. The instrument was designed according to criteria described by Dillman
(13,14) with emphasis on the cognitive burden of the questions, response layout, response format, amount of white space, font size, order of
questions, repetition of the instructions, and type of examples provided. After
the initial draft of the instrument was complete, the expert panel reconvened to
discuss items.
Focus groups
Five focus groups, with three to 12 participants in each, were conducted to
assess the instrument’s understandability, content, ease of completion, and
cultural relevance (15). Recruitment was through a local gerontology practice at
Group Health Cooperative, senior centers, and churches in the Seattle area. The
focus group participants were 24% Latino, 20% Vietnamese, 26% Chinese American,
26% white, and 4% African American. Three focus groups were conducted in
English, one was conducted in Spanish, and two were conducted in Vietnamese.
Several versions of the newly developed instrument were presented to the focus
groups for completion and discussion. All participants preferred a version of
the questionnaire that included a written description and pictorial
representation of the levels of physical activity (light, moderate, and
vigorous), and the majority preferred a dichotomous response format.
Cognitive debriefing
Cognitive debriefing is a method by which individuals assess the relevance,
importance, and ease of comprehension of measures (16,17). In this step,
we conducted one-on-one interviews with 12 English-speaking older adults.
Participants were presented a version of the questionnaire that had been revised
based on input from the focus groups. Participants were asked to think out loud
as they answered the questionnaire. Upon completion of the instrument, they were
asked if they thought the questions were easy to understand, whether the
questions could be worded more clearly, whether the response options were
appropriate and easy to understand, or if they had any other suggestions to make
the instrument easier to understand and complete. The cognitive debriefing
process was stopped after 12 older adults were interviewed because no new information was being
elicited. Refinements to the instrument were made based on the comments of these
participants and experts on physical activity and gerontology.
The final version of the RAPA (available from
http://depts.washington.edu/hprc/publications/rapa.htm *) was a nine-item questionnaire with the
response options of yes or no to questions covering the range of levels of
physical activity from sedentary to regular vigorous physical activity as well
as strength training and flexibility. The instructions for completing the
questionnaire provide a brief description of three levels of physical activity
(light, moderate, and vigorous) with graphic and text depictions of the
types of activities that fall into each category. The total score of the first
seven items is from 1 to 7 points, with the respondent’s score categorized into
one of five levels of physical activity: 1 = sedentary, 2 = underactive, 3 =
regular underactive (light activities), 4 = regular underactive, and 5 = regular
active. Responses to the strength training and flexibility items are scored
separately, with strength training = 1, flexibility = 2, or both = 3. Clinicians
are encouraged to use this information to have a brief conversation with their
patients about their current level of physical activity.
Quantitative data collection and analysis
Participants (N = 115) for the validation segment of the study were recruited
through senior centers in King County, Washington, and senior programs at Seattle
Parks and Recreation. Flyers were posted at the centers, and staff at the
centers announced the study during exercise and social programs. All
participants in the study provided informed consent, and all procedures were
approved by the institutional review board at the University of Washington.
The long-form CHAMPS (9-11) was used as the criterion self-report measure in
the validation of the RAPA questionnaire because it had been validated
previously against an objective measure of physical activity. The CHAMPS
questionnaire was developed as a research measure and designed to give accurate
estimates of caloric expenditures for all types of activity. It has been shown to
be valid, reliable, and sensitive to change (10). The number of items on this
questionnaire, however, makes it impractical to use in a clinical setting. The
CHAMPS activities were scored as a continuous variable for determining caloric
expenditure per week. To assess the discriminant validity of the three short
physical activity measures, a known groups analysis compared the mean caloric
expenditure between participants who did and did not meet the CDC physical
activity standard of 30 minutes of moderate activity 5 days per week or 20
minutes of vigorous activity 3 days per week. This standard was used as the
physical activity threshold in all analyses. Individuals met the physical
activity threshold if the sum of CHAMPS moderate activities were at least 5 days
per week for a total of 3 or more hours per week, or the sum of CHAMPS vigorous
activities was at least 3 days per week for 1 or more hours per week. Criterion
validity was assessed by calculating Spearman rank-order correlation
coefficients. The known groups analysis was conducted in STATA version 8.0 (Stata
Statistical Software, StataCorp, College Station, Tex) using t test with
unequal variances. The BRFSS questions (seven items) on physical activity (8)
and the PACE (6) questions were chosen to be fielded along with the CHAMPS
because both can provide a summary score that equates to the physical activity
threshold.
For a measure to be of value as an assessment tool, it needs to show good
predictive properties. To assess the sensitivity, specificity, positive
predictive value, and negative predictive value of the RAPA, the CHAMPS were
scored as a dichotomous variable for defining the level of physical activity as
either moderate or vigorous. Moderate-intensity activities were defined by
metabolic equivalent values (METs) from 3.0 to 4.9, and vigorous-intensity
activities were defined by METs of 5.0 or greater. The 2002 BRFSS questions (seven
items) on physical activity (8) and the PACE (eight items) (5) were used in the
construct validity analyses. The questions on both the RAPA and the PACE were
scored and coded on a 5-point scale so that as the amount, frequency, and
intensity of physical activity increased, the score increased (e.g., RAPA = “I
almost never do any physical activities” = 1; “I do 30 minutes or more per
day of moderate physical activity 5 or more days per week” = 5). The BRFSS was
scored on a scale of 1 to 3, with 1 = does not engage in moderate or
vigorous activities for at least 10 minutes at a time; 2 = engages in some activities, but
not on a regular basis; and 3 = engages in moderate activities 5 or more days per week for
at least 30 minutes per day or vigorous activities 3 or more days per week for
at least 20 minutes per day.
Criterion validity of the three short physical activity measures was assessed
by calculating Spearman rank-order correlation coefficients between the three
physical activity measures and the CHAMPS medium caloric expenditure and total
caloric expenditure. Differences in correlations were assessed using the t
test procedure described by Blalock (18). It was expected that the RAPA would be
significantly correlated with both medium and total caloric expenditure.
Readability of the instrument was assessed using the Homan–Hewitt Readability
Formula because it was specifically developed for use with questionnaires (19).
Before the analysis, CHAMPS, BRFSS, PACE, and RAPA items were examined through
various SPSS (SPSS, Inc, Chicago, Ill) software programs for accuracy of data entry, missing values, and
fit between their distributions and the assumption of univariate analyses. No
univariate outliers were found. Missing values on the number of times per week
were imputed for the CHAMPS activities if values were provided for the number of
hours per week. Number of times per week was imputed from the mean times per
week by participants who engaged in the activity the same number of hours per
week.
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Results
The sample was 72% female, 73% white, 18% African American, and 9% other race
or ethnicity; the mean age (± SD) was 73.3 (± 9.6) years, and the mean body mass
index (BMI) (± SD) was 27.3 kg/m2 (± 4.7 kg/m2). Compared with the
2003 American Communities Survey estimates, women and people of color are
overrepresented in this sample. Because of our interest in whether the
instrument could accurately identify older adults who met CDC guidelines for
physical activity, we recruited through senior center exercise programs; thus,
55% of the participants met CDC criteria for being physically active, and
approximately 80% engaged in some sort of physical activity program.
Criterion validity assessments between the three physical activity measures
and the CHAMPS medium caloric expenditure and total caloric expenditure are
shown in Table 1. The results
of the t test of differences in correlations showed that the RAPA was
more highly correlated with CHAMPS moderate calories and total calories than
either the BRFSS (t102 = 2.88, P < .005) or the PACE (t102
= 3.34, P < .001).
The results of the sensitivity, specificity, and predictive value analyses
are presented in Table 2. All
three short questionnaires showed good sensitivity and positive predictive
value. The RAPA had the best sensitivity and negative predictive value of the
three questionnaires. In this sample, information from the RAPA would lead to
incorrectly classifying nonexercisers as exercisers 25% of the time. The RAPA
would lead to incorrect classification of an individual as engaging in strength
training 14% of the time and incorrect classification of an individual as
engaging in flexibility exercises 42% of the time. A review of the data on the
misclassification of individuals engaging in flexibility exercises showed that
those who reported doing yoga on the CHAMPS did not indicate engaging in
flexibility exercises on the RAPA, even though yoga is listed as an example. The
discrepancy may be related to the fact that the RAPA specifies that the activity
must be performed weekly.
The results of the discriminant known groups validity analyses are shown in
Table 3. Mean caloric expenditure was calculated from
the CHAMPS. For all three short physical activity measures, the group who met
the physical activity standard had a significantly higher mean caloric
expenditure. This indicated that all three measures were able to discriminate
between those who reported inadequate and adequate moderate or vigorous physical
activity. The RAPA, however, showed superior performance over the other two
short measures.
Ad hoc analysis of the three physical activity questionnaires compared with
the CHAMPS by respondents’ BMI were performed to assess whether the RAPA correlated
significantly higher with the CHAMPS than PACE or the BRFSS short physical
activity questionnaires (data not shown). The RAPA correlated significantly
higher with the CHAMPS for older adults whose BMI was 30 or higher, and although
the correlation was higher for the group with BMI less than 30, the difference
was not statistically significant.
A Homan-Hewitt Readability Formula analysis (19) showed the readability of
the RAPA to be at the sixth grade level. The observed average completion time for
the RAPA was less than 2 minutes, with a range of approximately 1 to 5
minutes.
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Discussion
Development of the RAPA included qualitative methods, cognitive debriefing
with older adults, and preparation of a field trial instrument. Evaluation of
the RAPA’s measurement properties in this cross-sectional study is
encouraging. The RAPA showed better sensitivity and negative predictive value
than the other short physical activity questionnaires and better specificity and
positive predictive value than the PACE. The RAPA showed good discrimination
between older adults who did and did not engage in regular moderate physical
activity. As is desired by nurse practitioners, the RAPA includes questions about
light physical activity, a feature that allows clinicians to provide positive
feedback to seniors as they move from being sedentary to being more active. Of
the three short physical activity questionnaires, the RAPA is the only one that
assesses strength and flexibility. It is important that a clinical physical
activity measure include these areas because they are significantly related
to fall reduction and maintenance of independence among older adults.
The RAPA is readable at the sixth grade reading level and was easily
understood by most participants in the study. Older adults with cognitive
impairment, however, may require that the RAPA be read to them.
There are several limitations of this study: 1) all participants were
volunteers recruited from Seattle-area senior centers or clinics that promote
physical exercise, which may impact the generalizability of the reported
results; 2) the cross-sectional data did not allow for the assessment of change
over time and the value of the instrument as a monitoring tool; and 3) no
observable measure of physical activity (such as an accelerometer) was used. The
CHAMPS measure, however, has been shown to be sensitive to change, and the fact
that the RAPA instrument tracks well with the CHAMPS provides strong criterion
validity. The PACE has not been tested in such a manner.
The RAPA has been well received by geriatricians at Group Health Cooperative;
many of them are using it in their clinical practice. In addition, the RAPA is
being used in many research projects and program evaluations. It is being used
as part of the diabetes registry in two community clinics in Seattle. As part of
a quality improvement effort, the clinics are linking their patients to a community
support program located at a nearby senior center, which also uses the RAPA to
provide feedback to the clinics. Nurse and social work coaches involved in the EnhanceWellness program at 32 sites in seven states are also using the RAPA (5).
It has been translated into Spanish and Vietnamese; however, these versions have
not yet been validated.
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Acknowledgments
This research was funded by the Centers for Disease Control and
Prevention Prevention Research Center Program, grant
nos. U48/CCU009654 and 1-U48-DP-000050. We thank our expert panel, Anita
Stewart, David Buchner, Christine Himes, and Ronald Ackerman, for their guidance
on this project. We also acknowledge our research assistants Sarah Johnson and
Gillian Marshall for their invaluable assistance with focus groups and
participant interviews. The views expressed in this article are those of the
authors and do not necessarily represent the views of the Department of the
Army.
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Author Information
Corresponding Author: Tari D. Topolski, Seattle Quality of Life Group,
University of Washington, 146 N Canal St, Suite 313, Seattle, WA 98103.
Telephone: 206-685-7259. E-mail: topolski@u.washington.edu.
Author Affiliations: James LoGerfo, University of Washington School of
Medicine, Seattle, Wash; Donald L. Patrick, Barbara Williams, Julie Walwick,
University of Washington, School of Public Health and Community Medicine,
Seattle, Wash; MAJ Marsha B. Patrick, U.S. Army–Baylor University Graduate
Program in Health and Business Administration, Waco, Tex.
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