Assessment of health-related physical activity: The Development of the International

Physical Activity Questionnaire

Cora L Craig1, Barbara E Ainsworth**, Michael L Booth, Michael Pratt, Michael Sjstrm, and
the International Consensus Group for the Development of an International Physical Activity
Questionnaire

Canadian Fitness and Lifestyle Research Institute, Ottawa, Canada

**

Department of Epidemiology and Biostatistics, Department of Exercise Science, School of

Public Health, University of South Carolina, Columbia, USA

The Children's Hospital at Westmead, Sydney, Australia

WHO Collaborating Center, Centers for Disease Control and Prevention, Atlanta, U.S.A

PrevNut at Novum, Karolinska Institutet, Stockholm, Sweden

Address for correspondence:

Cora Lynn Craig
Canadian Fitness and Lifestyle Research Institute
201-185 Somerset St. W.,
Ottawa, Ontario,
Canada
K2P 0J2

Members of the International Consensus Group for the Development of an International Physical
Activity Questionnaire were: Barbara Ainsworth; Adrian E Bauman; Hamadi Benaziza; Stephen
Blair; Michael L Booth; Cora L Craig; Alana Diamond; W Drygas; Ulf Ekelund; Peter Fentem;
Shigeru Inoue; Deborah Jones; Toshihito Katsumura; Ilona Kickbusch; Vicki Lambert; Brian Martin;
Victor Matsudo: Willem van Mechelen; Pekka Oja; Rimma Potemkina; Michael Pratt; Michael
Sjstrm; James F Sallis; Ilkka Vuori; Alexander Woll and Agneta Yngve.

Background. Physical inactivity is a global public health issue, which warrants a

collaborative global response. However, differences in definitions and methods make
international comparisons of prevalence rates impossible. In 1996, Dr. Booth (Australia) initiated
an international effort to develop a questionnaire to standardize the assessment of physical
activity.
Methods. An international group of experts developed short (9 items) and long (31 items)
questionnaires that were designed to be comparable. The purpose of the International Physical
Activity Questionnaire (IPAQ) was to assess health-related physical activity and sedentary
behavior in adults across domains of activity relevant in a broad range of cultures: work, chores,
transportation and leisure. Respondents were asked to quantify frequency and duration of
activities within moderate- and vigorous-intensity categories. Standard methods of translation
and cultural adaptation were followed in each country. During 1999, qualitative pilot testing was
conducted on 6 continents with test-retest reliability and validity examined in Canada and
Sweden, respectively. In 2000, the revised instruments were subjected to extensive reliability
and validity testing among 2700 adults in 14 centres around the world following a common
protocol. The CSA accelerometer was the primary validation criterion.
Results. The initial pilot test demonstrated reasonable reliability and validity. Details of the
subsequent multi-site, international reliability and validity studies appear in Marshall et al14
Conclusion. The pilot testing underscored the need for systematic cultural adaptation, but
supported feasibility and acceptability of the instruments. IPAQ has been extensively tested
worldwide for use in health-related physical activity research, including epidemiologic studies
and population surveillance.
Key words. international, health, physical activity, measurement, epidemiology

Over the last decade, it has become increasingly clear that physical inactivity is a global
public health issue. This problem is not restricted solely to industrialized countries, but is an
emerging problem in developing countries as well.1 However, the scope of the problem around
the world has often been difficult to gauge. Relatively few countries have included assessment
of physical activity as part of national surveys, and those that do have used a variety of physical
activity questions, which differ in the length, amount of detail, and underlying definitions. This
has meant that while trends in physical activity can be assessed within countries using the same
methods, differences in definitions and methods make international comparisons impossible2.
In the past 15 years, little progress has been made in the global surveillance of physical
activity. In order to better address physical inactivity on a global level, a greater degree of
standardization in definitions and assessment is required. In their 1997 review of physical
activity questionnaires, Kriska and Caspersen3 showed the variety of methods used to identify
participation in physical activity. Evident in this review is the lack of a single questionnaire that
captures the physical activity of daily life that accounts for most activity-related energy
expenditure, including frequency, intensity, and duration in occupation, household and family
care chores, transportation, and leisure-time. The importance of accounting for various types of
physical activity performed by different population groups may be important for the correct
classification of physical activity status in surveillance studies and to identify causal
relationships between daily physical activity and health outcomes4,5. The narrow scope of
activities asked on existing questionnaires limits their use for physical activity surveillance and
epidemiology studies among adults in developed and developing nations, particularly in light of
the new understanding of health-related physical activity, which includes not only vigorous
leisure time activity but also diverse moderate-intensity activities at work and home and in
transportation6,7

DEVELOPMENT OF THE INTERNATIONAL PHYSICAL ACTIVITY QUESTIONNAIRE (IPAQ)

Background
In 1996, one of us (MB) initiated a collaborative effort to develop a valid and reliable
questionnaire measuring health-related physical activity suitable for research and surveillance.
An international group of physical activity assessment experts interested in public health
surveillance were invited to form a working group, referred to as the International Consensus
Group for the Development of an International Physical Activity Questionnaire. A year later, the
Consensus Group came together at the World Health Organization (WHO) in Geneva,
Switzerland for a meeting sponsored by the WHO Collaborating Centers at the U.S. Centers for
Disease Control (Atlanta, GA) and at the Karolinska Institute (Stockholm, Sweden). The goal
was to develop a standard, internationally agreed upon instrument of health-related physical
activity and sedentary behaviors to inform policy formulation and action planning, while being
brief enough for use in population surveillance. The group subsequently met at the 1998, 1999
and 2000 American College of Sports Medicine Annual Conferences to refine the measures,
plan comprehensive reliability and validity assessment, inform professionals working in the area
about IPAQ and invite comment, and encourage those responsible for physical activity
monitoring to consider adoption of the IPAQ instrument.
The Consensus Group ultimately developed two questionnaires, a short (9 items) and a
long (31 items) version to assess health-related aspects of physical activity and sedentary
behaviour. The shorter version of IPAQ was designed for use in surveillance studies, in which
space is typically very limited, whereas the longer version was designed to provide a
comprehensive evaluation of daily physical activity habits. Furthermore, telephoneadministered and self-administered formats were designed to provide flexibility in administration
styles. Because of the special requirements of self-reported physical activity for young people

and older adults, IPAQ was designed for and tested among young and middle-aged adults (18
to 55 years old).
Design Considerations
Booth8 has outlined the challenges posed in reaching international consensus on the
assessment of physical activity: 1) use of terms; 2) domains of measurement; 3) seasonal
participation; 4) classes of activity versus disaggregation of activity to assist response; 5) use of
symptoms versus examples to illustrate intensity and 6) mode of administration. Each of these
challenges was considered in the context of current public health issues and monitoring needs.
Given the potential use of IPAQ in health monitoring and surveillance systems for policy
purposes, the questionnaires were designed with the intent that they would be sensitive enough
to provide a wide range of values for detecting relatively small changes in population levels of
physical activity, while allowing estimation of the prevalence meeting national guidelines for
physical activity (e.g., 1995 U.S. CDC-ACSM moderate activity recommendation6). Further, with
the emerging worldwide obesity epidemic, an instrument, which could assess total energy
expenditure and provide details related to aerobic intensity across all domains, was highly
desirable. Energy expenditure patterns differ markedly between populations living traditional
lifestyles and those in industrial countries where the physical activity in work and chores is
declining9. Therefore, the instrument had to address energy expended in the various aspects of
life, so that it would be equally relevant to countries in which occupational and chore-related
activity yield the majority of energy expended as well as those in which leisure-time or
transportation related activity are the most prevalent. The longer version of IPAQ was designed
to collect detailed information within various domains and provide the flexibility needed to track
behavior changes between and within various domains of activity that may be important in
economies in transition. The shorter version was developed to capture a more global pattern of

activities as well as the most frequently reported leisure-time activity, walking behavior. Due to
concern about sedentary behaviour and health outcomes such as obesity7, questions on
duration of sitting were included in each version.
Measurement of moderate versus vigorousintensity physical activities was also deemed
important, particularly given the recognition of the benefits of moderateintensity physical
activity and its inclusion in national guidelines. Participation in moderate- and vigorous-intensity
activities can be defined based on absolute or relative intensities. Moderate intensity can be
defined relative to exertion, such as a range of 4560% of a persons maximal aerobic
capacity10. This corresponds to the absolute intensity of 4.87.1 METs among healthy adults 20
39 years and 4.55.9 METs among those 4064 years7. (METs are multiples of resting
metabolic rate.) Relative and absolute definitions result in different prevalence rates11. For
example, varying only the absolute versus relative intensity component results in a difference in
prevalence of 24% versus 15%, respectively, of Canadians aged 1855 who participate in at
least moderateintensity activity for 30 minutes 5 days per week (unpublished observations).
As this illustrates, using an absolute value for intensity relaxes the criteria for moderate intensity
among younger age groups. The IPAQ design is rooted in subjective estimates of moderate and
vigorous physical activities. To increase understanding of intensity of participation, physiological
symptoms for heart rate and breathing volume are provided to respondents and are
supplemented by concrete examples of activities tailored for each country by MET levels as
obtained from the 2000 Compendium of Physical Activities12. From a public health perspective,
individuals having the lowest levels of activity are the most likely to face negative health
outcomes and reducing the proportion of the population in this group is a key public health goal.
Activities like walking may increase the fitness level of this group and lower their risk.13
Therefore, when selecting MET intensities to compute energy expenditure, expressed as METminutes and computed as frequency in times/week x duration in minutes/day x MET value, for

each activity reported, we used absolute standards of 3.0-6.0 METs for moderate intensity and
6.1+ METs for vigorous intensity activities. These definitions are reflected in the moderate- and
vigorous-intensity examples and the scoring of the questionnaire14.
IPAQ investigators adopted the approach of collecting continuous measures of both
duration and frequency, independently for moderate and vigorous activity. This flexible approach
should be sensitive to small changes, allow use of parametric statistics, and allow for the
construction of categorical variables, such as percent meeting national guidelines that may
change over time.
Cultural diversity poses another challenge in the development of any instrument designed
for assessing global public health burden of physical inactivity. While terms, such as exercise
may be readily understood by researchers in different countries, the concept of what constitutes
exercise may not be equivalent for the population more generally. For example, many western
cultures may understand exercise to mean intentional physical activity undertaken for the
purpose of maintaining or improving fitness and health15. However, our pilot testing indicated
that perceptions of physical activity differ greatly between countries. For example, in Brazil,
activities such as soccer, which are considered to be fun or enjoyable, are not perceived to be
physical activity. In Japan, the concept of brisk walking could not be adequately conveyed.
Allowing country- and population-specific examples to define the activity categories was a
flexible method of adapting IPAQ to each culture.
Pilot testing
Despite determined effort, a single questionnaire could not be created for all purposes, so
related questionnaires of two lengths were developed and assessed. The short version seeks
information on the time spent walking, in vigorous- and moderate-intensity activity and in
sedentary activity, with generic questions which included reference to household and yardwork

activities, occupational activity, self-powered transport and leisure-time physical activity, and is
more suited to population monitoring. The long version was designed to collect detailed
information within the domains of household and yardwork activities, occupational activity, selfpowered transport and leisure-time physical activity, and provides the flexibility needed to track
behaviour changes between and within the domains of activity. This more fine-grained
understanding of physical activity participation is useful for understanding: differences between
population groups within a country; differences between countries; economies in transition; and,
in understanding the impact of different styles of intervention, but is too long for regular
administration in large population samples, particularly within health monitoring systems.
Because no data were available, no agreement among the consensus group was reached on
whether the reference period for the items should be a usual week or the last 7 days. As a
result, eight versions of the instruments were created for pilot testing for feasibility and
comprehension of the questionnaires.
Initial qualitative and quantitative pilot testing was conducted in 1999. A two-week testretest study was conducted on a representative sample of residents in Ontario, Canada by the
Institute for Social Research at York University, using random digit telephone interviewing 16.
While the long IPAQ version had good reliability (r = 0.82, n = 133), 20 responses to the short
version included dont know for the duration of activities, which once eliminated, also yielded
good reliability (r = 0.77, n = 113). Initial validity testing was conducted on a convenience
sample of staff at the Universtiy of Orebro, Sweden17. Results indicated a significant
relationship (r = .27, n = 54) between self-reported time spent in activity and total counts from
Computer Sciences and Applications monitors (Model 7164, CSA Inc, Shalimar, FL, USA).
Qualitative data using in-depth, cognitive interviews were gathered on several versions of IPAQ
in Asia, Australia, North and South America, Africa, and Europe. Based on the pilot testing
results, the following modifications were made to the instruments: 1) probes were added to the

short versions to assist respondents in answering the duration items; 2) the items were
restructured to enhance the distinction between vigorous and moderate intensity activities; 3) a
pace question was added to operationalize the concept of brisk walking; and 4) in the long
version, sub-components were reordered so that questions about active transportation followed
work activity. As there was no qualitative or quantitative evidence from pilot testing results that
indicated a preference for the usual week versus the last 7 days recall period, all IPAQ
versions were included in the subsequent reliability and validity studies.

RELIABILITY AND VALIDITY STUDIES

In 2000, the eight versions of IPAQ were evaluated in 14 international study centers. The
purpose of these studies was to investigate the reliability and validity, criterion validity, and
concurrent validity of the short and long instruments, specifically their comparability across type
of form (short and long), reference period (usual week and last 7 days) and data collection
mode (telephone and self-administered). All study centers followed standardized protocols.
Standardized IPAQ Instructions. Standardized instructions were used to administer IPAQ
in all study centers. Interviewer prompts and clarifications for frequently asked questions were
provided using the same script during all administrations of the forms. Instructions to
respondents defining the last 7 days reference period were also standardized, using the same
7-day period for the first and second administrations. For self-administered forms, the last 7
days reference period was highlighted on a calendar. For interview versions, the specific last 7
days period was cited during the first contact and then the same reference period was explicitly
cited during the second contact.
Time Period Between IPAQ Administrations. The time elapsed between administration in
the reliability studies was 3 to 8 days (last 7 days version) and 3 to 10 days (usual week

version), which was deemed short enough so that respondents would be able to adequately
recall their physical activity pattern for the identified week, but long enough to minimize recall of
previous responses. The time period for the validation study was the 7 days prior to the
administration of IPAQ. Given the standardized instructions for the last 7 days version, the
recall period for the self-reported instrument and the data collection period for the criterion
validation study coincided.
Cultural Adaptation. Standard methods were used to translate and adapt the
questionnaires to the study centers in different countries18,19. Study staff translated the
instruments into the native language for their respective country, if needed. Translators were
instructed that literal translations of the words were not being sought, rather that they were to
ensure that the concepts were understandable. The translations were then back translated into
English, with the English versions reviewed by bilingual individuals. Confusion in the wording or
intent of the questions was reconciled to account for conceptual discrepancies. In addition to
the translation protocol, cultural adaptation occurred by replacing the specific examples used to
illustrate moderate and vigorous activity with other examples that were more culturally relevant.
All examples chosen by IPAQ Centre investigators had to conform to the definitions of moderate
and vigorous intensity and were based on standard MET equivalents presented in the
Compendium of Physical Activities.11
Data collection. The reliability and validity studies were conducted in 2000, with the
majority completed by April 30, 2000. The study protocol is presented in Table 1. Two
participant contacts were required for the reliability study protocol, conducted over a 3 to 7 day
period. During the first visit, the short version of IPAQ was completed and demographic data
were obtained. Participants also read and signed institutional human subject consent forms as
required by the study center. A week later, participants completed the second study visit to
complete same short version of IPAQ instrument. Centers that administered the 7day recall

10

instruments also had participants complete a third study visit, three days after the second visit to
explore the reliability of instrument responses across two different 7day recall periods. In
addition to the minimum protocol requirements for all centers to evaluate the short IPAQ, some
centers also evaluated the long version of IPAQ. This was done to determine concurrent validity
of the short and long forms of the same instrument and to determine the reliability and validity of
the long IPAQ. In the validity studies, participants completed the same activities as described
for the reliability study, wore a motion detector for the period between visits one and two, and
had height and weight measured.
-- Table 1 here-Reliability Criteria. Test-retest reliability was determined by comparing similarity of
responses between visits one and two.
Validity Criteria. IPAQ was validated using Computer Sciences and Applications monitors
(Model 7164, CSA Inc, Shalimar, FL, USA) to provide direct measures of intensity and duration
of physical activity and of sedentary periods during the 7 days of the validity study. Chosen
because of the data of its reliability and validity20, the CSA is a small, light, unobtrusive uniaxial
accelerometer that detects changes in vertical acceleration. Acceleration data are filtered by an
analog bandpass filter and digitized by an 8-bit A/D converter at a sampling rate of 10 samples
per second. CSA movement data are stored in one-minute intervals for a period of 21 days.
During the first study visit, the CSAs were initialized and the participant was familiarized with the
equipment. The CSAs were worn for 7 days in a carrying pouch that was snugly attached to the
waist near the hipbone. Participants were instructed to wear the monitor during all waking
hours, excluding bathing or when in water. To standardize the data collection period, all CSAs
were set to begin recording at 7:00 am of the day following the first study visit. During the
second visit, seven days later, the CSAs were returned to the study center and downloaded into

11

a personal computer. An automatic data reduction program written for this study was applied to
the CSA data for all study participants with minute-by-minute data summarized into daily
averages for activity counts (cts/min/d) and for activity durations (min/d) in specific intensity
levels as described by Marshall et al14.
Inter-instrument comparisons were assessed during a third study visit scheduled three
days after the second visit. Some study centers chose to compare the concurrent validity of
IPAQ instruments by administering short and/or long instruments that differed by administration
style (telephone versus self-administered) or by recall frame (usual week versus last 7 days).
Study Participants: As IPAQ was designed for gathering information on young to middleaged adults, participants were selected primarily from within the age group of 18 to 55 years.
Since the validity study methods did not easily lend themselves to application on randomly
selected representative samples, convenient samples were acceptable. However, in order to
cover the diversity in their populations, participating centers were encouraged to design studies
involving both men and women and adults covering a range of ages and education levels. The
IPAQ study investigators reviewed all study center protocols to ensure that the study samples
included men and women, and covered a range of age groups, education groups, and activity
levels ranging from sedentary to very active.

CONCLUSION
Despite the challenges, development of IPAQ shows it is possible to convene a group of
international experts to develop an internationally accepted instrument for measuring healthrelated physical activity for use in epidemiologic studies and surveillance. This cooperation,
supported by the WHO Collaborating Centers, the U.S. Centers for Disease Control and
Prevention and the Karolinska Institute, as well as project sponsors and investigators in each of

12

the participating countries, led to the development and evaluation of IPAQ. A product of this
involvement has resulted in a short and long version of a standardised instrument, which were
evaluated by studying their reliability and validity in 14 study centers in 12 countries on 6
continents, totaling roughly 2,700 participants. The results of the validity and reliability studies
are presented in the following paper by Marshall et al14.
Acknowledgements
Support for the Geneva meeting of the International Consensus Group for the Development of
an International Physical Activity Questionnaire was provided by the WHO Collaborating
Centers, the U.S Center for Disease Control and Prevention, Atlanta; and the Unit for Preventive
Nutrition, Karolinska Institute, Stockholm. Support for individual studies was provided by
sponsors within each country. Thanks are due to Drs Adrian Bauman, Alison Marshall, Pekka
Oja and James Sallis for their comments on an earlier draft of the manuscript.

13

TABLE 1 Data Collection Scheme for the International Physical Activity Questionnaire
Reliability and Validity Studies

Visit

Reliability Study Only

Subject tracking

Validity Study Only

Subject tracking

Reliability and Validity Study

Subject tracking

Informed consent, if

Informed consent, if needed

Informed consent, if needed

needed

IPAQ short version

IPAQ short version

IPAQ short version

Demographics

Demographics

Demographics

Measured height and weight

Measured height and weight

Optional IPAQ long version

Initialization of CSA monitor

Initialization of CSA

Optional validity measures

Optional validity measures

Optional IPAQ long version
IPAQ short version

Visit

IPAQ short version

Optional IPAQ long version

IPAQ short version

Corresponding IPAQ long

Download CSA data

Download CSA data

version

Optional validity measures

Optional validity measures

Visit

For study centers

Optional IPAQ long version

For study centers evaluating

Optional IPAQ long version

For study centers evaluating

evaluating the last 7 days

the last 7 days recall

the last 7 days recall

recall versions only

versions only

versions only

last 7 days IPAQ short

last 7 day IPAQ short version

last 7 days IPAQ short

version

Optional last 7 days IPAQ

version

Optional last 7 days IPAQ

long version

Optional last 7 days IPAQ

long version

long version

14

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