ORIGINAL ARTICLE

A Review of Physical Activity Measures Used Among USLatinos: Guidelines for Developing Culturally AppropriateMeasures

Suzanna M. Martinez, MS &

Barbara E. Ainsworth, Ph.D., MPH &

John P. Elder, Ph.D., MPH

Published online: 15 October 2008# The Society of Behavioral Medicine 2008

AbstractBackground As the US population continues to grow anddiversify, there is a need for progressive physical activitymeasurement and cross-cultural research. Studies suggestthat US Latinos are among the most sedentary of ethnicgroups compared to others; however, study findings may bebiased given that some measures may not be culturallysensitive for assessing behaviors that are not characterizedas leisure time physical activity.Purpose The primary objective of this review was toidentify and evaluate measures used to quantify physicalactivity among US Latinos.Methods A review of the literature was performed andstudies examining levels of physical activity among

Spanish and English speaking Latinos were documented.This process involved identifying existing guidelines forthe purpose of culturally adapting and/or translating (intoSpanish) physical activity measures for the Latino population.These guidelines were used as the minimal criteria for theevaluation of the 13 identified measures of physical activity.Results Of these 13 measures, four were available inEnglish and nine were available in Spanish. One Englishmeasure met the guidelines for being culturally adapted forassessing physical activity among Latinos. There were noSpanish measures that met all the guidelines for physicalactivity assessment among Spanish-speaking Latinos.Lastly, the identified guidelines for developing culturallyappropriate measures were improved to advance physicalactivity measurement among ethnic and cultural groups.Conclusion Future research should merit the use ofculturally appropriate guidelines to increase the understand-ing of physical activity patterns in the USA.

Keywords Physical activity measures .

Cultural translation and adaptation . Latino

Background/Introduction

The USA is experiencing an increasing prevalence of healthconditions related to overweight and obesity. Obesity is amajor cause for mortality and morbidity and it affects 30%of the US population (among whom 60% are overweight)[1]. Being overweight or obese is a major risk factor fordiabetes and cardiovascular disease and both affect Latinosat disproportionate levels [2]. An estimated 2.5 millionLatinos aged 20 years or older are diagnosed with diabetes,twice that reported for non-Latino whites [3]. Cardiovas-cular disease is the leading cause of death for people living

ann. behav. med. (2008) 36:195–207DOI 10.1007/s12160-008-9063-6

Electronic supplementary material The online version of this article(doi:10.1007/s12160-008-9063-6) contains supplementary material,which is available to authorized users.

S. M. Martinez : J. P. ElderSan Diego Prevention Research Center,San Diego State University& University of California at San Diego,San Diego, CA, USA

B. E. AinsworthDepartment of Exercise and Wellness,Arizona State University,Mesa, AZ, USA

J. P. ElderGraduate School of Public Health,San Diego State University,San Diego, CA, USA

S. M. Martinez (*)9245 Sky Park Ct. Ste. 221,San Diego, CA 92123, USAe-mail: smartinez@projects.sdsu.edu

with diabetes, and it accounts for 31% of all Latino deaths[4]. Given that Latinos will comprise 24.5% of the USpopulation by 2050, the existing health disparities arepressing public health issues [5].

Physical inactivity is an independent risk factor forchronic disease and obesity. Given the low rates of physicalactivity among Latinos, public health interventions areheavily focusing on physical activity (PA) promotion in theLatino population [7]. Despite the diverse US populace, PAmeasures have been developed for and validated inmainstream English speakers. For lack of measures devel-oped for ethnic minorities, researchers have adapted andtranslated the available PA measures for English- andSpanish-speaking Latinos. Using health-related measuresthat have been developed for the mainstream population [6]reduces the validity of past research for Latinos and limitsthe extent to which cross-cultural differences can bedetected. Extending PA measurement to the Latino popu-lation is warranted so that researchers can make validjudgments about PA patterns of Latinos. Improving PAmeasures may increase the validity of PA studies and mayprovide better insight for designing effective PA interventions.

Assessing Physical Activity in Latinos

Data from the National Health and Nutrition ExaminationSurvey (NHANES) and Behavioral Risk Factor Surveil-lance Survey (BRFSS) show a high prevalence of physicalinactivity during leisure time among Latinos when com-pared to non-Latino whites [7, 8]. According to the 2004BRFSS, an estimated 40% of Latinos reported insufficientleisure time physical activity (LTPA) as compared withnon-Latino whites [9]. Multiple studies using PA measureshave replicated the low prevalence of PA in Latinopopulations [7, 10, 11]. These studies suggest a consistentlevel of leisure time physical inactivity or that measureshave not been culturally adapted to assess other domains ofPA among US Latinos. Also worth mentioning is that PAmeasures in national surveillance surveys [i.e., NHANES,BRFSS, National Health Interview Study (NHIS)] havebeen validated with objective measures for non-Latinowhites [12, 13].

Past research may not consider cultural validity todetermine how Latinos interpret “leisure time”. Duringimplementation of National Health and Nutrition Examina-tion Survey III (NHANES III), Crespo et al. [7] founddifficulties in measuring PA outside of leisure time amongLatinos. Furthermore, PA is not always operationalized thesame as PA measures do not consistently include incidental,transportation, and occupational activities. This is animportant consideration because modern household con-veniences, transportation, and assembly-line type jobsdecrease opportunity for LTPA in some subgroups [14].

While PA measures have been translated from English toSpanish for use in surveillance settings, there has been littleto no cultural adaptation to account for cultural sensitivityand cultural differences between Latinos and non-Latinowhites [15]. Given that most measures are not open-ended,researchers are less able to discern culturally differentpatterns of PA across ethnic/minority groups. For instance,BRFSS results showed that using open-ended questions toassess types, intensities, and durations of PA results indifferent interpretations of PA among Latinos and AfricanAmericans respondents [8]. As a consequence, Latinos maybe engaging in other forms of PA, such as occupational orhousehold duties, that are not commonly assessed by LTPAmeasures. For this reason, cultural adaptation and tailoringare necessary and should go beyond linguistic appropriate-ness to allow consideration of other cultural-based behav-iors that entail PA.

Cognitive processes and cultural perceptions may alsointroduce cultural bias in measures that aim to assesspsychosocial correlates of PA. Ways in which measurementitems are worded or organized may influence results, as thequestions may not have the same validity or reliability inthe Latino population as in the mainstream Americanpopulation. Less acculturated Spanish-speaking Latinosalso are unable to distinguish beyond four levels of scaleresponse, are confused by negatively worded items, and useextreme points of a scale more often than non-Latino whites[14, 23]. Cultural values and beliefs shared within Spanishspeakers have shown that health is viewed as a token ofgood luck rather than a benefit of healthy behaviors [8]. Inaddition, interviews conducted with US-born Latinos havedemonstrated that Spanish speakers are less likely to reportexcellent or good health compared to more acculturatedEnglish speakers [16, 17]. For example, in an examinationof the Hispanic Health and Nutrition Examination Survey,cross-tabulations were conducted between individuals’ self-reported health and physicians’ assessments for the samepatients. Compared to physician assessment, analysesshowed that Spanish speakers reported relatively poorerhealth compared to English speakers.

Baker et al. [22] found that patients with inadequatehealth literacy tended to rate their health as poor comparedto those with adequate literacy. On the contrary, Latinoshave the tendency to acquiesce when items are notunderstood or relevant [18]. Marín and Marín [18] statethat “yea-saying” (respondents agreeing with statements orquestions regardless of their content) is a problem in datacollection efforts among Latinos. The issue of “yea-saying”may be related to low literacy and, in part, may explainwhy better-than-expected health-related and morbidity out-comes are reported among some Latinos (a phenomenonknown as the Hispanic paradox). In 1992, one in fiveAmericans was affected by low literacy resulting in the

196 ann. behav. med. (2008) 36:195–207

inability to read, understand, and act on health information[20]. While Latino immigrants may have low literacy skillsin English proficiency, they may also be affected by lowliteracy in Spanish [21]. As a consequence of low literacy,Latinos may not respond to self-administered measures,reliably resulting in “yea-saying” as explained by Marínand Marín [18].

Culturally Appropriate Measures

The availability of culturally appropriate and valid meas-ures of PA limit health promotion efforts among ethnicminorities. Physical activity has many facets (e.g., physicaland social environments) in addition to different domains(e.g., leisure time, sports, occupational, housework, activetransport, moderate and vigorous intensity), all of whichmake PA a challenge to measure, especially when makingcross-cultural comparisons. A goal of PA measurementshould be to maintain equivalence in PA assessments acrosscultures while being culturally appropriate and sensitive toassess and reduce health inequalities in subgroup popula-tions. Measures should aim to keep constructs universalrather than too culture-specific for use in cross-culturalpopulations; however, they should be modified according tolinguistic appropriateness of a target population’s readingand comprehension levels. Given the increasing number ofLatinos immigrating to the USA, researchers shouldconsider the heterogeneity of the Latino population (e.g.,Puerto Rican, Mexican, Guatemalan). Prior to translatingmeasures intended for the mainstream population, forma-tive research (e.g., focus groups, interviews) should beconducted with members of the target community to ensurethat the content is culturally appropriate. Bilingual reviewand assessing readability can be performed to review thequality of adaptation for developing culturally appropriatemeasures [24–26]. For the most part, measures wereintended for the general population; therefore, these mixedmethods are recommended for increasing the performanceof measures in culturally diverse groups. To maintaincultural relevance, culturally appropriate measures shouldconsider the following social concepts:

& Shared norms: socially desirable behavior (e.g. “thedo’s and don’ts”);

& Shared beliefs: ideas or assumptions about the world;and

& Shared values and expectations: moral standards per-ceived as desirable and esteemed.

In addition to social concepts, Geisinger [24] and Sperber[25] recommend forward translation and adaptation bysomeone who is fluent in both languages (e.g., English andSpanish). The translator should possess a deep understand-ing of both cultures and expertise in characteristics and

content that the measure aims to assess. Back-translationshould be performed separately by a second individual andfollowed by an editorial review [25]. Both versions shouldbe reviewed for equivalence in English and Spanish forvalidation of similarities in language and interpretability,and content should be adapted according to the reviewers’comments [24, 25]. Geisinger suggests pilot testing in thetarget population prior to field testing for internal consis-tency and test–retest reliability analyses. Item-responsetheory can also be performed on the measure, and allanalyses should be compared to the corresponding resultsof the instrument in its original language. Lastly, a manualshould be disseminated as well as other documents for ameasure’s professional use, translation, and adaptation.

High-quality PA measures should be consistent withcultural norms and language to minimize cultural bias. Forthis reason, the goal of this review was to identify andevaluate the quality of PA measures that have beenadministered to Latino groups. The measures were evalu-ated by how well they conformed to adaptation andtranslation guidelines for extending the use of Englishmeasures to Latinos. Due to lack of a gold standard, pastresearch has included different approaches for developingculturally appropriate measures. As a result, the last aim ofthis review was to improve existing guidelines to guide andfurther advance the field of PA measurement.

Methods

Data Sources

To identify PA questionnaires that have been used in English-and Spanish-speaking US-Latino populations, a Pubmed®search was performed using a combination of the followingkeywords: culturally appropriate and sensitive, culturalsensitivity, adaptation, acculturation, guidelines, Latino, His-panic, Mexican-American, physical activity, exercise, leisure,validity, measure, scale, instrument, survey, Spanish, andtranslation. Emails were also sent to 16 Prevention ResearchCenters (PRC) focusing on Latino health and physicalactivity. The PRCs are funded by the Center for DiseaseControl and Prevention to conduct community-based partic-ipatory research in the USA.We requested any information orinsight about measures of PA being used in the PRCs’ Latinocommunities. For the resources obtained, authors werecontacted to obtain a more descriptive approach in theirtranslation and adaptation processes.

Selection Process

Primary selection was based on instruments (i.e., paper-based surveys and interviews, referred to here as measures)

ann. behav. med. (2008) 36:195–207 197197

used in Hispanic/Latino populations to assess PA. Measureswere included if they had been developed in English andculturally adapted to the Latino culture or if they had beentranslated into Spanish. The purpose of this sorting processwas to assess the measure’s level of cultural adaptation(English and Spanish measures) and translation (Spanishmeasures) to detect PA differences in the Latino population.Inclusion criteria for PA measures included their use in aLatino sample or in a study where Latinos were the largestsubgroup. Measures were excluded if they had not beenused to assess PA in Latino samples or if Latinos were notthe majority of the sample (e.g., BRFSS with less than 10%of Latinos sampled) [33].

Identifying Guidelines for Cultural Adaptationand Translation

A review of the literature identified cultural adaptation andtranslation guidelines based on the work of Sperber, Devellis,Boehlecke, and Geisinger [24, 25]. Given the followingrationale, we used these guidelines as the minimum toevaluate successful approaches for culturally adapting andtranslating measures of PA for use among Latinos. Theguidelines were disseminated to guide and improve thecurrent methods [29–32] for PA measurement in diversepopulations. In addition, these guidelines were established tomaintain cultural sensitivity while adapting the InternationalPhysical Activity Questionnaire (IPAQ, www.ipaq.ki.se) intomultiple languages for research purposes [27, 28]. Therigorous translation process of the IPAQ involved “forwardtranslation” (guideline 1) into Spanish by two native Spanishspeakers. The translators were similar to the intendedsubgroup of the Latino community so as to maintain thesame meanings (guideline 2). “Backward translation” backinto parallel English was used to maintain conceptual andcultural equivalence (guideline 3), also performed by twodifferent translators (guideline 4). Next, a review of the finalversion by all translators (guideline 5) took place to achieveconsensus and comparability in both versions (for culturalappropriateness). Finally, the measure was pilot-tested in aLatino community (guideline 6).

The IPAQ translation guidelines were first used in aninternational study designed to establish the validity andreliability of the IPAQ. A mixed-methods approach wasused to translate and test the IPAQ in 14 centers in 12countries [28]. Long and short forms were developed andassessed as self-administered or telephone interviews. Thelong IPAQ measures domains of PA (household, occupa-tional, family care, transportation, moderate and vigorous)and inactivity. The short IPAQ measures moderate- andvigorous-intensity PA and inactivity only. Test–retestreliability using Spearman correlations were conducted inboth forms to produce reliable items. Validity was estab-

lished using content, concurrent, and criterion-relatedvalidity checks. A strength in the development of the IPAQincludes comparison of self-report with the CSA model7164 (Computer Science and Applications, Inc., Shalimar,FL, USA) accelerometer measure of PA. Furthermore,qualitative feedback was collected and used to identifyissues about interpretation of PA terms. For example,participants gave their definition of “a usual week” anddistinguished between moderate- and vigorous-intensityPA. In addition, “pace” was not relevant in some cultures,and some participants inaccurately estimated 10-min boutsof PA. The IPAQ differs from other PA questionnaires (i.e.,BRFSS), as it measures multiple domains of activity (e.g.,occupational, active transport) instead of only leisure timePA [24]. Although not a gold standard for assessing PA, theIPAQ emphasizes the importance of cultural equivalence(e.g., “responsibility” vs. “burden”) and appropriateness toallow investigators to compare measures and results acrosscultures.

Scoring Method for Spanish Measures (Translatedand Adapted)

To perform a systematic evaluation, the recommended sixsteps in the IPAQ guidelines were used to score the level towhich variousmeasures of PA that have been culturally adaptedfor use in the Latino population. The guidelines were obtainedfrom the IPAQ page for cultural adaptation and translation(www.ipaq.ki.se). One point was given for meeting each ofthe six recommended guidelines of the IPAQ culturaltranslation process (summarized above). The points weresummed for each measure and sorted from the highest tolowest in terms for meeting the IPAQ translation and culturaladaptation guidelines.

Scoring Method for English Measures (Adapted, NotTranslated)

English PA measures used among English-speaking Latinosdid not require translation; therefore, the measures wereevaluated by the last two IPAQ guidelines (nos. 5 and 6) foraccomplishing cultural adaptation. The points weresummed for each measure and sorted from highest tolowest.

Results

Thirteen PA measures were identified as previouslyadministered in English to Latino populations or previouslytranslated from English to Spanish and administered toLatino populations (see Table 1). Nine questionnaires wereobtained from peer-reviewed journals and/or the Internet

198 ann. behav. med. (2008) 36:195–207

Tab

le1

Descriptio

nof

physical

activ

itymeasuresadministeredto

Eng

lish-

andSpanish-speakingLatinopo

pulatio

nsandpo

pulatio

ndemog

raph

ics

Nam

eof

measure

PAitems

Sam

plecharacteristics

(n=,M/F,ethnicity

)No.

ofitems

Metho

dof

adop

tion

Validity

(typ

e)Reliability(typ

e)or

other

EnglishPA

Measuresused

amongEnglish-SpeakingLatinos

Rapid

Assessm

ent

ofPhy

sical

Activity

-

Eng

lish[34]

Walking,stretching

,yard

work

orvacuum

ing,

aerobics,

strength

training

swim

ming,

stairs

jog/run,

tennis,

racquetball

Focus

groups

15Self-report,

self-

administered

English:

criterion

(Spearman)with

Com

munity

Health

yActivities

Mod

el

Program

forSeniors

(r=0.54

,ρ<0.001);

Con

struct

with

BehavioralRiskFactor

Surveillance

System

(BRFSS)andPatient-

CenteredAssessm

entandCounselingfor

Exercise(PACE)(.52

,ρ<0.001);

Sensitiv

ity:RAPA

(84),BRFSS(73),PA

CE(81)

24%

Latino,

20%

Vietnam

ese,

26%

Chinese

American,2

6%

white,and4%

black,

maleandfemale,

51–

92yearsold

PPV,N

PV:R

APA

(73,

77),BRFSS(76,67

),PA

CE(69,

70)

NationalHealth

Interview

Survey

Walking

Sup

plem

ent

Walking,PA

psycho

social

correlates

(i.e.,barriers,

enjoym

ent,self-efficacy,

social

support,35

)

N=12

8,10

0%females,

58Hispanic,

24–

55yearsold

2Self-report;

trained

interviewers

English:

constructandconcurrent

criterion-

related[51]

Test–retest(r=0.55–0.86);Internal

consistency(α

=

0.61–0.91);Eigenvalues

<2[51]

Mod

erateandvigo

rous

PA,

flightsof

stairs,walking,

sportsandleisuretim

ePA

[36]

N=45

,bicultu

ralLatinos

18–55yearsold,

53%

male,

47%

female,

meanage33

yearsold

2Structured

interview

English:

criterion

with

Caltrac

monito

rand

‘significant

other’

interview;Construct

with

self-efficacyandbarriers

concepts

Test–retestby

[36]

Pearson

:NHIS

(r=0.31)

Physicalactiv

ity

social

support

[37]

Leisure

time,lifestyle/household

chores,exercise,sportsand

social

supp

ortforPA

N=2,91

2,10

0%females,

660Hispanic,

40–70+

yearsold

5Teleph

one

Survey

7-Day

Phy

sical

Activity

Recall

[38]

N=37

9,10

0%Hispanic

female,

42%

Eng

lish

interviewsmean,

age

40yearsold

Interview

Spanish

PAmeasuresused

amongSpanish-speakingLatinos

International

Physical

Activity

Questionnaire

[28]

Occupational,transport,Yard,

household,

leisure,

sitting

N=15

5,77

Fem

ale,

78

Male27

yearsold(SD=

5.3)

81%

employ

ed

7 (Sho

rt)

27 (Lon

g)

Teleph

one

Survey

Spanish/English:

Concurrent(com

pared

samedayadministeredshortandlong

form

s);Criterion

(CSA)

Spanish

(sho

rtform

):Test–retest:Spearman,0.88

(urban);0.25

(rural)

Spanish

(lon

gform

):Spearman,0.85

(urban);0.52

(rural)

Modified

Physical

Activity

Questionnaire

[41]

Cleaning,

cook

ing,

shop

ping,

leisure/sports

N=71

,60–87yearsold

10Mexican-

American

interviewer

Eng

lish:

Con

current(Blair7d

Recall);

Con

struct

(Stagesof

Chang

e)

Eng

lish:

Test–retest,r=

0.89;Spearman,0.78;Pearson

,

0.72

Spanish:Con

tent

viaU.S.-Mexican

wom

en

ann. behav. med. (2008) 36:195–207 199199

Tab

le1

(con

tinued)

Nam

eof

measure

PAitems

Samplecharacteristics

(n=,M/F,ethnicity

)

No.

of

items

Metho

dof

adoptio

n

Validity

(type)

Reliability(type)

orother

EPIC

Phy

sical

Activity

Questionnaire

2

[42]

Hom

eactiv

ities,activ

ityat

work,

recreatio

n

N=17

3,86

female,

69

male,

meanage

29yearsold(SD=7.9)

$15,00

0/less

(61%

)

23–46

Self-

administered/

Interview

assisted

Spanish:Criterion

(CSA);MLT

PAQ

items

valid

ated

by[39,

40]

Not

stated

Minnesota

Leisure

Tim

e

Phy

sical

Activity

Questionnaire

[39,

40]

Dancing

,walking,surfing,

bowlin

g,martialarts,

householdactiv

ities

N=25

0,18

–40years,

middleclass

63Interview

Spanish:criterion

(maxim

altreadm

ill

exercise

test,electrocardiogram

and

systolic

bloo

dpressure)

Pearson:(exercise

duratio

n)To

talEEPA

(0.47)

Heavy

EEPA

(0.43)

Mod

EEPA

(0.14)

Light

EEPA

(0.27)

Hou

se

EEPA

(0.14)

Spearman:(Fitn

ess)

Total

EEPA

(0.39)

Heavy

PA

(0.51)

Mod

EEPA

(0.13)

Light

EEPA

(−0.02)Hou

seEEPA

(−0.30)

Lifestyle

Behaviors

Questionnaire;

ModifiedHPLP

II,[46]

Walking,parkingfarfrom

destination,

exercising,

gardening,

aerobics,jogging,

swim

ming

N=25

6,6males,25

0

females

Latino

commun

ity

7Lay

health

advisors

Spanish:Content

(Expert)

Spanish:Internal

consistency,

α=0.77

Rapid

Assessm

entof

Phy

sical

Activity

(RAPA

Spanish)

Light,mod

erate,

vigo

rous

PA

(walking,stretching,yard

workor

vacuum

ing,

aerobics,

strength

training

swim

ming,

stairs

jog/run,

tenn

is,

racquetball)

13Latinoseniors

9Assisted

survey

by

Mexican

interviewer

Spanish:valid

ationstud

yin

underw

ayNot

available

NationalHealth

andNutritio

n

Examination

SurveyIII[7]

Walking,runn

ing,

smallmotor

movem

ents(exercising,

gardening),h

eavy

housew

ork,

heavyplaying/exercise,

organizedsports/PE

N=4,893,

2,467male,

2,426femaleMexican-

American

8(4

open-

ended)

Trained

bilin

gual

interviewers

Not

stated

Not

stated

Health

-

Promoting

Lifestyle

Profile

II[14]

Walking,parkingfarfrom

destination,

exercising,

gardening,

aerobics,jogging,

swim

ming

N=54

0,22

8male,

312

emale18–81yearsold

7Translator

assisted

English:

Content

(literature

review

,expert

evaluatio

n);Construct

(factoranalysis);

Convergent(PersonalLifestyle

Questionnaire);Criterion-related

(perceived

health

status

andquality

oflife)

English:

Test–retest,r=

0.89;internal

consistency,α=

0.94,0.79–0.87

Spanish:Internal

consistency,

α=.94

7-Day

Physical

Activity

Recall

[38]

N=37

9,10

0%Hispanic

female,

58%

Spanish/

bilin

gual,meanage

40yearsold

Interview

PPVpo

sitiv

epredictiv

evalue,

NPVnegativ

epredictiv

evalue

200 ann. behav. med. (2008) 36:195–207

[28, 35–40], two were referred by PA researchers [34], andtwo questionnaires were obtained from individual research-ers [41, 42].

The 13 PA measures were evaluated for the accuracy ofcultural adaptation and translation (if applicable) using therecommended IPAQ guidelines. Among the 13 measuresreviewed, all had been tested for one or more types ofvalidity (construct, criterion, convergent, content, andexpert validity) and had been published in peer-reviewedjournals, with the exception of one measure (RapidAssessment of Physical Activity, RAPA-Spanish). Meas-ures that were translated into Spanish included sampletesting and translation performed by English–Spanishbilingual speakers. All measures conceptualized PA differ-ently, ranging from activities such as walking, exercise/aerobics, sports, jogging/ running, household chores, andother LTPA. Some measures used intensity levels, such asmoderate- and vigorous-intensity PA, to classify levels of PAperformed, while others expressed intensity using differentterms. Four (Physical Activity Social Support and Self-Report Survey and the 7-Day Physical Activity Recall inEnglish and Spanish) measures included questions aboutpsychosocial correlates of PA in addition to PA assessments.Results for English measures are presented first and followedby the results for Spanish-translated measures.

Evaluation of Measures Administered in English to LatinoPopulations

Four English language PA measures have been adminis-tered and evaluated in English-speaking Latino populations(Rapid Assessment of Physical Activity [34], NationalHealth Interview Survey Walking Supplement [35, 36],Physical Activity Social Support [37], and the 7-DayPhysical Activity Recall [38]) in four different studies (seeTable 1). Given that the questionnaires were administeredin English, details of the translation process were notrelevant; therefore, the measure was evaluated for culturaladaptation by two guidelines (nos. 5 and 6). One of theEnglish measures met both of these guidelines.

Rapid Assessment of Physical Activity

The RAPA is a nine-item measure designed to allowclinicians to monitor physical activity levels in their olderadult patients [34]. Of the four measures [34–38] adminis-tered to an English-speaking Latino population, RAPA-English was the only measure that used both guidelines(nos. 5 and 6) for cultural adaptation. Methods used toidentify cultural appropriateness were focus groups andcognitive interviews with 22 older adults. The RAPA-English was also pilot-tested in the older Latino adultpopulation and correlated with body mass index [34].

Physical Activity Social Support

The Physical Activity Support (PASS) was administered inEnglish to a Latino population in the US Women’sDeterminants Study [37]. The measure met one of the twoIPAQ criteria [27] in that it was pilot-tested prior toimplementation with Latinos (guideline no. 6); however, itlacked review for cultural appropriateness (guideline no. 5).The PASS was pilot-tested [37] in two ethnic minorities(Hispanic and non-Hispanic black) in addition to a whitesample population. The pilot test occurred with middle- andolder-aged minority women and also included structuredpersonal interviews to assess social support. As noted byEyler et al. [37], a limitation in their pilot study was thatPASS was not developed to achieve a level of culturalcompetence. The PASS was developed for the English-speaking population, which is why it was difficult togeneralize its use in minority subgroups and subcultures.Furthermore, the authors noted that the tool was notculturally sensitive to social views and language barrierspertaining to those less acculturated, including immigrants[37].

NHIS Walking Supplement

The NHIS walking supplement did not meet any of theIPAQ translation guidelines, as it was not reviewed forcultural relevance or pilot-tested in a Spanish-speakingpopulation [35]. The supplement, however, was validatedby Rauh et al. [37] who evaluated the test–retest reliabilityand validity with Caltrac (Hemokinetics, Inc., Madison,WI, USA) accelerometers in a Latino population. Theauthors noted that the reliability of the NHIS walkingsupplement scores were minimal (r=0.31) and rated low inconstruct validity (r=−0.19–0.18), thus limiting the abilityto assess moderate-intensity physical activities in Latinos[37]. Castro et al. [35] built on the validity study of Rauh etal. [37] by including the NHIS walking supplementquestions in the Self-Report Survey to investigate thepsychosocial correlates of PA among ethnic minorities.The measure was not reviewed for cultural relevance norwas it pilot-tested in the target population prior todetermining PA prevalence [35]. Castro et al. [35] conclud-ed that collected data did not detect significant differencesin psychosocial correlates or demographics within theirtotal sample of ethnic minorities or when stratified by theirstudies intervention conditions.

7-Day Physical Activity Recall [34]

The 7-Day Physical Activity Recall (PAR) was adminis-tered to English- and Spanish-speaking Latinos in aculturally appropriate PA intervention. The English version

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of the 7-Day PAR administered to English-speaking Latinosdid not meet any of the criteria for being culturally sensitiveto Latino culture. The published source did not mention ifthe measure was pilot-tested or reviewed for culturalrelevance in the Latino population [38]; however, authorswrote that the measure was reliable and valid based on thestudy conducted by Rauh et al. [36]. Interestingly, theintervention was designed to be culturally appropriate suchthat materials and facilitators were bilingual; however,formative research on cultural understanding of the measurewas not conducted. Results for the Spanish 7-Day PAR willbe discussed below.

Evaluation of Measures Administered in Spanish to LatinoPopulations

Nine Spanish PA [7, 14, 27, 38, 40–42] measures wereidentified using the aforementioned selection guidelines:translation from English to Spanish with PA assessment inLatino samples or Latino majority samples (see Table 1).Using the IPAQ guidelines (nos. 1–6) for cultural adapta-tion and translation, one of nine measures met all sixrecommended guidelines. Four of the measures met four ormore of the six recommended guidelines, two measures metthree of the recommended guidelines, and two measuresmet fewer than three of the recommended guidelines.

Measures that Met Four or More Translation Guidelines

The IPAQ [28], Minnesota Leisure Time Physical ActivityQuestionnaire (MLTPAQ) [39, 40], Voorrips et al. PhysicalActivity Questionnaire [41], and EPIC Physical ActivityQuestionnaire (EPAQ2) [42] met four or more of therecommended six cultural adaptation and translation stepsprior to administration in Spanish-speaking populations.

International Physical Activity Questionnaire [28]

Following the IPAQ guidelines, the adapted IPAQ wastranslated into Spanish by three native Spanish-speakingtranslators from Mexico, Puerto Rico, and Colombia (SouthAmerica) for use in the National Physical Activity andWeight Loss Study [43]. A fourth translator then back-translated all versions and noted differences in terminologyused between the Spanish language translations. The threetranslators agreed on the appropriate term to use for the USSpanish-speaking population to create the final SpanishIPAQ version, which was then back-translated andevaluated for fidelity with the English language IPAQversion. This process met five of the six translationguidelines. The IPAQ was not pilot-tested or validatedin the US Spanish-speaking population before use in anational research study.

Modified PAQ [41]

The modified PAQ administered by Laffrey et al. was amodified version of Baecke’s PAQ that conceptualized PAas cleaning, cooking, shopping, and leisure/sports [41, 44].The modified PAQ was forward-translated from English toSpanish and back-translated to English by native Spanish-speaking translators. After forward and backward translation,the Spanish items were reviewed for cultural sensitivity bytwo bilingual Latinas from the target population. Itemcontents were reviewed for linguistic and content appropri-ateness. The process met five of the 6 IPAQ guidelines (nos.1–5) but was not pilot-tested prior to being administered in aLatina sample [41]. Women reported that they were moreactive than expected compared to previous literature thatused more traditional measures of PA, such as sport andexercise [7, 45].

Minnesota Leisure Time Physical Activity Questionnaire[39, 40]

The MLTPAQ was used to assess PA in the Spanishcommunity of Minnesota. The measure was forward-translated by fluent Spanish speakers but did not gothrough back translation. The MLTPAQ was reviewed inSpanish and pilot-tested for validity in male and femaleSpanish-speaking residents. Cultural adaptation included amixed method by including/excluding forms of physicalactivity to maintain cultural relevance in the Spanishpopulation. The process met four of the six guidelines(nos. 1, 3, 4, and 5). In its use in a Spanish-speakingpopulation, Elosua et al. [39] found that 25% of theirfemale population reported being a housewife where part oftheir day consisted of housekeeping activities. Because ofthe process of cultural adaptation consisting of inclusionand exclusions of physical activities for this study’spopulation, the MLTPAQ was effective in identifyinghousekeeping activities. These findings were consistentwith findings reported for the EPAQ2 [42] discussed below;however, findings were inconsistent with the NHANES IIIdata evaluated by Crespo et al. [7].

EPIC Physical Activity Questionnaire 2 [42]

The EPAQ2 is a measure that includes items from theMLTPAQ and the Tecumseh Occupational PhysicalActivity Questionnaire and translated for use in aSpanish-speaking population in Chicago, Illinois. Themeasure went through the processes of forward andbackward translation performed by two individuals (abilingual/bicultural doctoral student and a community mem-ber). The Spanish measure was reviewed by a group ofbilingual/bicultural students; however, it was not pilot-tested

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in a Spanish-speaking sample prior to implementation. Theprocess met five of the six guidelines (nos. 1–5). The EPAQ2operationalizes PA as home activities (e.g., modes of travel,TV, and video viewing, stair climbing, and activities aroundthe home), activity at work (e.g., kneeling and squatting,standing and sitting activities, stair climbing, and travel toand from), and recreation (a wide range of activities).Marquez and McAuley [42] were able to conclude genderdifferences in PA among Latinos and that acculturation mayhave accounted for differences in PA as reported in themeasure. The EPAQ2 was validated using accelerometry in aLatino community.

Measures that Met Three Translation Guidelines

The following measures (Lifestyles Behavior Questionnaire[46], RAPA-Spanish, and the 7-Day PAR-Spanish [38]) methalf of the six recommended steps for cultural adaptationand translation prior to administration in Spanish-speakingpopulations.

Lifestyles Behaviors Questionnaire

The Lifestyles Behaviors Questionnaire (LBS) [46], amodified version of the Health-Promoting Lifestyle ProfileII, was forward-translated from English to Spanish by abilingual/bicultural translator and was reviewed in itsSpanish form. The measure was not backward-translated,but it was derived from the Health-Promoting LifestyleProfile II (HPLP II) that did undergo forward and backtranslations. The LBS met three of the IPAQ guidelines(nos. 1, 3, and 5). By using open-ended items to describePA performed, Kim et al. [46] found that participants werebetter able to define how they conceptualized PA (i.e.,walking ranged from walking the dog, walking to pickup the children from school, going to the park, andparking the car a good distance from an establishment)compared to predetermined descriptions of PA listed onthe measure. In addition to the types of PA performed,the LBS identified cultural barriers to PA, such ashusband disapproval and limited time due to holdingmore than one job.

RAPA-Spanish

The RAPA-Spanish was forward-translated into Spanish bynative Spanish speakers but was not back-translated intoEnglish. After forward translation, the measure wasreviewed in Spanish and pilot-tested with 13 Latinos (J.LoGerfo, University of Washington, Prevention ResearchCenter, personal communication). Pilot test findings havenot been reported. The measure met four of the sixguidelines (1, 3, 5, and 6).

7-Day PAR-Spanish [38]

The 7-day PAR-Spanish was used in a culturally appropriateintervention evaluated by Poston et al. [38] and wasadministered to Spanish speakers in the target Latinocommunity. The 7-Day PAR and psychosocial measureswere forward- and backward-translated; however, the meas-ures were not reviewed or pilot-tested for cultural appropri-ateness. The 7-Day PAR data did not show significantchanges in PA, and the intervention was unable to addressbarriers in the Latino community. Lastly, there were a limitednumber of trained bilingual interviewers, and inter-raterreliability was not reported.

Measures that Met Two Translation Guidelines

The NHANES III and the HPLP II met two of the IPAQguidelines prior to use in Latino populations [6, 14].

NHANES III [6]

The NHANES III was translated into Spanish by the PublicHealth Service for use in US health surveillance activities.Details used in the translation process are unknown exceptthat items were translated from English to Spanish andadministration has required bilingual interviewers. Themeasure met two of the six IPAQ guidelines (nos. 1 and 3).

HPLPII [14]

There is limited information about the translation processfor the HPLP II except that it was forward-translated intoSpanish and backward-translated into English. The measuremet two of the six guidelines (nos. 1–2) and was used in astudy of 71 community-residing Latinas aged 60 to 87 yearsof age. Findings from this study showed that 79% of theLatinas reported at least one activity in addition to theirdaily activities, suggesting that Latinas are more active thanhad been expected from the literature.

Discussion

This review identified and evaluated the adaption and/ortranslation methods of measures that have been used toassess PA patterns of Latinos. A total of 13 measures wereidentified, of which four had been used to assess PA inEnglish-dominant Latinos and nine had been translated foruse among Spanish speakers. Using the minimal guidelinesto evaluate the English measures, only one measure(RAPA) met the guidelines for being culturally appropriatefor English-speaking Latinos, one measure (PASS) met halfof the guidelines, and two measures (NHIS walking

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supplement and 7-Day PAR) did not meet any recommen-ded guidelines. Of the Spanish measures, four measures(IPAQ, PAQ, EPAQ2, MLTPAQ) met more than half of theguidelines for minimal translation and cultural adaptation,and three measures (HPLP-II, RAPA-Spanish, 7-Day PAR)met less than half of the guidelines. Most of the Spanishtranslations (IPAQ, PAQ, EPAQ2, MLTPAQ, LBS, RAPA-Spanish, 7-Day PAR, and NHANES III) had been forwardtranslated by bilingual/bicultural translators, with theexception of the HPLP II (procedures were not specified).Also, some acronyms for PA measures were easy toremember (e.g., PASS), while others were not (e.g., HPLPII).The current review implicates a need to extend PAmeasurement to ethnically diverse populations using cul-turally appropriate methods. Advancing the field shouldinvolve the use of qualitative methods and pilot testingduring the extension of measures in Latino or other ethnicminorities. Using a mixed-methods approach prior toimplementing PA measures in target communities willincrease the validity within and across ethnic minorities.Lastly, researchers should use easy to remember acronymswhen developing measures so as to increase the disseminationof PA measures.

Maintaining the same meaning during the process oftranslation can be challenging. Furthermore, consideringcultural relevance during adaptation and translation pro-cesses is important for establishing and increasing validityand reliability of PA measures in diverse populations. FourPA measures (modified PAQ, EPAQ2, MLTPAQ, andHPLP II) established reliability/consistency of items and/or validity of the tools in the Latino Spanish-speakingpopulation. The modified PAQ, the EPAQ2, and theMLTPAQ used criterion-related validity. The strength ofthe EPAQ2 is that accelerometry was used to establishvalidity of the measure in the Spanish-speaking community.A weakness of the HPLP II is that less valid forms ofmeasurement (i.e., expert, perceived health status) were usedto establish validity. The IPAQwas evaluated for validity andreliability in a Spanish-speaking population; however, it wasvalidated in rural Guatemala, which does not make thesefindings relevant to Latinos living in the USA [28].

The instruments with the most rigorous of culturaladaptation and translation processes are likely to be themost sensitive in diverse populations; however, this needsto be confirmed in subsequent studies. For example, theprocesses of cultural translation and adaptation may haveincreased the sensitivity of the MLTPAQ to detect aninverse association between energy expenditure in PArelated to household and fitness that other PA measuresfailed to detect. Very active women may underreport lowintensity PA, especially if they do not consider householdchores as PA. For ethnic minority women, household PAmay be an important form of daily activity and may

represent activity at sufficiently vigorous levels to increasefitness. The modified PAQ was another measure thatachieved a good level of cultural appropriateness; therefore,it was better able to assess the number of Latino personswho reported regular exercise in comparison to the resultsfrom the BRFSS, a measure that did not undergo culturaladaptation (PAQ, 49% and BRFSS, 37%).

The lack of culturally appropriate measures limitsresearch conducted in subgroup populations by restrictingunderstanding of language and the intent of the measure.Published sources also failed to mention issues related toliteracy in terms of how well the respondent understood themeasures as presented. This is important to note given thatlow literacy is a concern for some Latino subgroups andother ethnic groups. Studies conducted in ethnic subgroupsmay not be appropriate to assess PA and psychosocialdifferences related to PA. Furthermore, interventions thatare based on measures that are not culturally appropriatecannot be effective when they are informed by measuresthat are unable to detect differences in subgroup popula-tions. To overcome measurement issues, a measure of PAalso should consider low literacy and maintain a good levelof linguistic and cultural competence to avoid bias in self-report and interview techniques as demonstrated by Laffreyet al. [41]. Having bilingual interviewers made it possible toconduct informal conversational interviews with Latinaswho interchanged between Spanish and English (a.k.a.“Spanglish”). In addition, by broadening the definition ofPA, findings showed that 79% of women in this populationparticipated in at least one form of PA and half were regularexercisers on a daily basis. These results were compared to1997 BRFSS data which showed that only 37% of Latinopersons in this age group exercised regularly.

It should be noted that the IPAQ guidelines may not besufficient to reflect all of the processes needed to ensurecultural adaptation, translation, and acceptability of PAmeasures in different cultures and languages; however, theyare the minimum to achieve an adequate level of culturalappropriateness and achievable by persons not formallytrained in the cultural adaptation of the survey instruments.Based on the results of this review, a deeper understandingof measurement adaptation and translation was gained bydetecting the strengths and limitations of each measure. Aswe had no ultimate criterion to place culturally appropriatemeasures in context, we used the results of this review toimprove the existing IPAQ guidelines. We developed acomprehensive set of guidelines for the purpose of reachingan optimal level of cultural appropriateness during PAassessment. An additional seven steps pertaining to cogni-tive interviewing are recommended for pilot testing. Basedon pilot testing, other changes to the measure can beconsidered if necessary as long as the changes have thesame interpretation.

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To advance cultural competency in PA assessment, amodification of the IPAQ guidelines are presented belowin Table 2. The modified guidelines include 13 steps toprovide added detail for adaptation and translationmethods. The use of these guidelines may help inachieving optimal cultural appropriateness of measuresthat will advance the quality of PA assessment in culturaland ethnic populations. Following these guidelines mayprovide enhanced validity for cross-cultural comparisonsof PA across ethnic minorities in the US population.

These steps should be used with qualitative research toassure that the measures are competent and appropriate tospecific subgroups of ethnic populations. Qualitativeresearch, such as focus groups and cognitive interviews,can improve cultural relevance of measures to gain a betterunderstanding of correlates of PA among Latino immigrants[47]. Focus groups can help to address perceptions, values,benefits, and barriers to PA and other health behaviors.They also provide a way to involve target communitymembers in the research process and enhance understand-ing of the measure given the heterogeneity of the Latino

population. Cognitive interviews can be used to showwhether a population is interpreting survey items in thesame way as the researcher [48]. Applying a mixed-methods approach is suggested for improving the perfor-mance of culturally appropriate assessment of healthbehaviors, such as PA, in ethnic minorities.

In summary, this review only evaluated self-reportmeasures of PA using the IPAQ guidelines previously usedin international research studies. Most measures lacked oneor more of the IPAQ-recommended minimal guidelines forcultural appropriateness. Few were validated to assure thatactivity patterns performed in leisure and/or non-leisuresettings were relevant among Spanish speakers. Ideally,culturally relevant self-report measures should be evaluatedfor accuracy in the target population. Using focus groups,cognitive testing and objective assessment of PA patterns(e.g., direct observations of physical activity using trainedobservers [49, 50] or accelerometers worn by the partic-ipants) can provide culture-free measurement of PA asperformed by Marquez and McAuley [42]. Additional guide-lines are provided for culturally adapting and translating

Table 2 Guidelines for making measures culturally appropriate

Guidelines

Recommended steps for translation [19]1. Translate all materials from the original English version.2. Use at least two independent forward translators to improve the quality of the instrument.Have translators, including those who speak different dialects if necessary, translate the survey and agree on the best translation.3. Review the translated measure in a group of bilingual people who are similar to the target population.4. Have two different translators translate the new version back into English” (back-translation) [39].There should be a back translator for each forward translation.The back translators should reach a consensus on one translation and then consider revising after pilot testing.5. Have a group of bilingual people meet again to review the back-translation and decide on the final version.Cognitive interviews recommended steps for pilot testinga

For each item perform the following:1. Assess comprehensionDid you understand all of the words?2. Ask them to explain how they would answer the questionTalk out loud as you answer the question.Describe what you were thinking as you answer the question.3. Assess clarity of questionWhat do you think is being asked?What does this question mean to you?Tell in your own words what you thought the question was asking4. Determine whether they need additional help in answering the questions such as definitions, examples, etc.What types of examples might help other people understand this question?5. Ask them to describe how they would have asked this question to a sister or a friendIf you were asking this question to a friend or family member, how would you ask it?

At the end of the survey, ask more general questions such as these:1. Did any of the questions make you feel uncomfortable?Indicate whether the question is upsetting2. Were there activities that we missed?3. Would you prefer to have answers to pick from or do you prefer open answers?

a Based on the information collected in the pilot testing, consider if other changes to the instrument are necessary. Make only changes that do notchange the meaning of the instrument.

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measures with more depth than provided by the IPAQguidelines. Using culturally relevant measures to assess PAwill contribute to future interventions and interpretation ofresearch involving Latinos and ethnically diverse populations.For more information about developing or adapting culturallyappropriate measures of PA, visit http://www.sdprc.org.

Acknowledgment Funding for this study was provided by Centersfor Disease Control and Prevention (5U48DP000036-03), inaddition to the SDSU Minority Biomedical Research ScientistNational Institute of General Medical Sciences (1 R25 GM58906-08). Special thanks are extended to all those who were availablethrough personal communication (University of Washington PRCand Dr. David Marquez).

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