Applying a rigorous method of forward-backward translation, a German-language version of the RAPA questionnaire has been produced for the Austrian context. Cognitive debriefing interviews with 13 older adults have provided insights into respondents’ understandings and interpretations of questionnaire content, enabling further iterative refinement and thorough qualitative linguistic validation of the newly translated questionnaire.
Questionnaire-based assessment of physical activity constitutes a methodological cornerstone for physical activity research and promotion, and a considerable number of physical activity questionnaires have been developed in the past. The aforementioned scientific statement of the AHA identified 131 unique physical activity questionnaires originally developed for or feasible to deploy in healthcare settings [4]. A recent consensus statement by a panel of international experts across the fields of sports science, psychology and public health has affirmed the continued relevance of questionnaires for the assessment of physical activity [12]. This expert panel recommends to identify and translate already existing and published physical activity questionnaires (rather than to develop new instruments) and highlights the importance of examining cultural and linguistic aspects of translated questionnaires through qualitative methods [12]. Qualitative data on cultural adaptation and linguistic validation unfortunately often remain unpublished or are afforded only brief descriptions in reports of psychometric validation studies. Similarly, qualitative investigations of respondents’ cognitive processes when completing a questionnaire feature less prominently in the literature, although these analyses can provide crucial insights for developers and users of questionnaires alike [13]. This article therefore intends to augment the literature by reporting on the process and outcome of the translation to Austrian German and qualitative validation of the RAPA.
Prominent examples for physical activity questionnaires which are available in German language are the International Physical Activity Questionnaire (IPAQ) [14, 15], the European Health Interview Survey – Physical Activity Questionnaire (EHIS-PAQ) [16, 17] and the Global Physical Activity Questionnaire (GPAQ) [18, 19]. These questionnaires capture details of weekly amount of time (days, hours, and minutes) spent sedentary and/or doing certain activities (walking, cycling, physical work), allowing a judgement whether the person meets the recommendations for healthy levels of regular physical activity. In comparison to the RAPA questionnaire, these instruments offer more fine-grained and versatile data, including the option to derive weekly metabolic equivalents of task (METs), but at the expense of requiring respondents to recall relatively precise estimates of their physical activity behaviour. A qualitative study by Finger et al. [13] has demonstrated that such precise responses are more easily provided by employed and younger individuals who have a regular exercise or working schedule; but it can be problematic for other respondent groups to provide this information, in particular individuals aged 60 + years and those who do not work regularly (retirees, self-employed or unemployed) or those who performed physical activity irregularly [13]. This supports the design of the RAPA questionnaire with categorical response options that offer participants wide category brackets in terms of weekly frequency and duration of physical activity to compare themselves against. The present study demonstrates that even these comparatively simplified response categories require careful wording in order to achieve adequate comprehension and avoid confusion.
Respondents’ adequate understanding and estimation of levels of intensity of physical activity presents another potentially problematic aspect of physical activity questionnaires. This has been highlighted in several studies that qualitatively explored respondent’s thought processes when completing a questionnaire [13, 20, 21]. Problems that have been reported include: difficulty distinguishing between intensity levels; difficulty classifying activities when different intensity levels occurred within one activity; difficulty deciding which intensity category fits best (even for activities with homogeneous intensity level); not considering activities which do not cause sweating; and only thinking of activities which are mentioned as examples in the questionnaire text [13, 20, 21]. Of note, similar difficulties have been described for the self-reporting of sedentary behaviour (sitting activities) in physical activity questionnaires, for example distinguishing between reading a book in sitting versus reading while lying down [22]. These issues can lead to respondents making arbitrary choices, forgetting about relevant activities, and inappropriately excluding activities or including certain activities repeatedly. In this respect, the RAPA questionnaire differs from many physical activity questionnaires in that it offers respondents an introductory explanation of physical activity and intensity levels (light, moderate, vigorous) that is written in lay language, based on physiological markers of heart rate and respiratory rate and includes images of example activities for each intensity level. Participant feedback from the present study supports this presentation of intensity levels. In particular the point that one and the same activity may be conducted at different levels of intensity, or may constitute different intensity for different individuals, was brought up my most participants; but participants consistently demonstrated their appropriate understanding that they should be guided by heart rate and respiratory rate in classifying their own activities.
The RAPA questionnaire was developed with the intention to offer a brief standardised assessment tool for the clinical setting, to identify and monitor a patient’s physical activity level and initiate a conversation about physical activity promotion if indicated [3]. In Austria, as in many high-income countries, the promotion of regular healthy physical activity remains a high priority item on the public health agenda [11], with fewer than half of the Austrian population meeting WHO recommendation for regular aerobic physical activity, and only about a quarter meeting WHO recommendations for both aerobic physical activity and muscle strengthening exercise [23]. The ‘pandemic of physical inactivity’ [24] presents a major public health concern globally and particularly in high-income countries, where the prevalence of insufficient physical activity was reported at 36.8% (95% confidence interval 35.0–38.0) in 2016 and was observed to have increased over time [25]. In 2018, the WHO has defined the Global Action Plan on Physical Activity 2018–2030 which sets a target of a 15% relative reduction in the global prevalence of physical inactivity in adults and in adolescents by 2030 [26]. Proposed actions towards this target include strengthening the capabilities of healthcare professionals to assess and counsel patients on physical activity, and incorporating the promotion of physical activity across primary and secondary healthcare and social services [4, 26]. The successful implementation and scale-up of population physical activity interventions is undoubtedly determined by numerous implementation factors (barriers and facilitators) and often complicated by complex interplay between multiple factors [27, 28]. Nevertheless, studies of barriers and facilitators of physical activity promotion by healthcare professionals have consistently highlighted the importance of a suitable physical activity assessment tool that offers valid and reliable information and is practicable within health professionals’ limited time resources [29–31]. The new German translation of the RAPA presented in this article may offer such a suitable assessment tool for the Austrian context.
Limitations
Limitations to this study are acknowledged. The sample size was moderate, although the purposive sampling for gender, age and medical background achieved representation of relevant participant profiles, and this sample size is within the range of recommendations for pilot testing of newly translated instruments [6, 32]. Cognitive debriefing was able to uncover problems with clarity of the questionnaire’s wording and content through respondents’ verbalised reflections and through interviewers’ observations. It was not possible, however, to ascertain the accuracy of respondents’ self-ratings which would require a valid parallel assessment of physical activity such as a diary or a sensor measurement.
Future research
In the next step, statistical psychometric validation of the new Austrian German version of the RAPA questionnaire is required to further support its content and construct validity by examining aspects such as convergent/concurrent and divergent/discriminant validity, including comparison of RAPA results with alternative valid measurements of physical activity.