(page number not for citation purposes)International Journal of Behavioral [623627]

BioMed Central
Page 1 of 11
(page number not for citation purposes)International Journal of Behavioral
Nutrition and Physical Activity
Open Access Research
The International Prevalence Stud y on Physical Activity: results
from 20 countries
Adrian Bauman*1, Fiona Bull2,3, Tien Chey1, Cora L Craig4,
Barbara E Ainsworth6, James F Sallis5, Heather R Bowles1,
Maria Hagstromer7, Michael Sjostrom7, Michael Pratt8 and The IPS Group9
Address: 1Centre for Physical Activity and Heal th, School of Public Health, University of Sydney, Sydney, Australia, 2School of Sport and Exercise
Sciences, Loughborough University, Loughborough, UK, 3School of Population Health, The University of Western Australia, Australia, 4Canadian
Fitness and Lifestyle Research Institute, Ottawa, Canada, 5Active Living Research, San Diego St ate University, San Diego, CA, USA, 6Department of
Exercise and Wellness, Arizona St ate University, Mesa, AZ, USA, 7Department of Biosciences and Nutritio n at Novum, Karoli nska Institute,
Stockholm, Sweden, 8US Centers for Disease Control, (Physical Activi ty and Nutrition Branch), Atlanta, GA, USA and 9IPS Collaborating research
groups in each country (see Appendix 1)
Email: Adrian Bauman* – adrianb@ health.usyd.edu.au; Fiona Bull – [anonimizat]; Tien Chey – [anonimizat];
Cora L Craig – [anonimizat]; Barbara E Ainsworth – Barbara.Ai [anonimizat]; James F Sallis – [anonimizat];
Heather R Bowles – [anonimizat]; Mari a Hagstromer – [anonimizat]; Michael S jostrom – michael.sjos [anonimizat];
Michael Pratt – [anonimizat]; The IP S Group – adrianb@he alth.usyd.edu.au
* Corresponding author
Abstract
Background: Physical activity (PA) is one of the most import ant factors for improving population health, but no
standardised systems exist for international surveillance . The International Physical Activity Questionnaire (IPAQ)
was developed for international survei llance. The purpose of this study wa s a comparative international study of
population physical activity prev alence across 20 countries.
Methods: Between 2002–2004, a standardised protocol using IP AQ was used to assess PA participation in 20
countries [total N = 52,746, ag ed 18–65 years]. The median survey response rate was 61%. Physical activity levels
were categorised as "low", "moderate" and "high". Ag e-adjusted prevalence estimates are presented by sex.
Results: The prevalence of "high PA" varied from 21–63%; in ei ght countries high PA was reported for over half
of the adult population. The prevalence of "low PA" varied from 9% to 43%. Males mo re frequently reported high
PA than females in 17 of 20 countries. The prevalence of low PA ranged from 7–41% among males, and 6–49%
among females. Gender differences were noted, especi ally for younger adults, wi th males more active than
females in most countries. Markedly lo wer physical activity preval ence (10% difference) with increasing age was
noted in 11 of 19 countries for males, but only in thr ee countries for women. The ways populations accumulated
PA differed, with some reporting mostly vigorous intensity activities and others mostly walking.
Conclusion: This study demonstrated the feasib ility of international PA surveillance, and showed that IPAQ is
an acceptable surveillance instrument , at least within countries. If assessme nt methods are used consistently over
time, trend data will inform countries about the succe ss of their efforts to promote physical activity.Published: 31 March 2009
International Journal of Behavioral Nutrition and Physical Activity 2009, 6:21 doi:10.1186/1479-5868-6-21Received: 3 September 2008
Accepted: 31 March 2009
This article is available from: http://www.ijbnpa.org/content/6/1/21
© 2009 Bauman et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons. org/licenses/by/2.0 ),
which permits unrestricted use, distribution, and reproduction in any medium, provided the orig inal work is properly cited.

International Journal of Behavioral Nutrition and Physical Activity 2009, 6:21 http://www.ijbnpa.org/content/6/1/21
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(page number not for citation purposes)Introduction
Physical inactivity is an established risk factor for cardio-
vascular disease, cancer and diabetes, which along with
chronic respiratory disease account for more than 60% of
all deaths [1]. More than 80% of chronic disease deaths
occur within low and middle income countries [LMC] [2].
The most recent estimates suggest that almost 2 million
deaths per year worldwide are attributable to inactivit[1],
leading to physical activity being described as 'the best
buy in public health.' [3]. Despite global concerns about
non-communicable disease in LMC [4], increasing obes-
ity, and rapid changes in patterns of work, transport and
recreation, physical activity surveillance and monitoring
is only carried out in a few countries [5].
There is a significant gap in international physical activity
surveillance, compared to surveillance of other chronic
disease risk factors [6]. This gap makes it difficult to esti-
mate the impact of physical inactivity on health out-
comes. The World Health Organization pooled
prevalence estimates to estimate the attributable risk of
physical inactivity in the global burden of non-communi-
cable diseases [1,7]. The lack of comparable data, along
with the recent Global Strategy for Diet, Physical Activity
and Health [DPAS] [8], have created a compelling need
for internationally-comparable measures of physical
activity that can be used to quantify population levels of
exposure and monitor trends over time within and among
countries.
Although some countries conduct national physical activ-
ity surveillance, use of different questionnaires makes it
difficult to assess inter-country differences in physical
activity. In 1997, the International Physical Activity Ques-
tionnaire (IPAQ) was developed as a surveillance instru-
ment to measure multiple domains of physical activity.
This was the first effort to develop an instrument suitable
for global physical activity surveillance. The goal was to
identify a common questionnaire that all countries could
use that would permit comparability among countries on
various domains of physical activity. The IPAQ items cap-
ture moderate and vigorous intensity leisure-time, domes-
tic, occupational and transport-related domains, which
summate to total physical activity [9-11]. Assessing multi-
ple domains of activity is particularly important in devel-
oping and transitional countries, where measures
confined to leisure-time activity may miss substantial
daily physical activity undertaken for the purpose of work
or travel [5]. Sitting time is assessed separately by hours of
sitting time per weekday and weekend day. Inactivity
measures are useful for monitoring the effect of health
promotion strategies that encourage people to sit less and
engage more in ambulatory activity.
The aims of the International Prevalence Study on Physi-
cal Activity (IPS) were to collect and compare for the firsttime nationally representative prevalence estimates on
physical activity from a diverse set of countries and to
qualitatively assess the use of IPAQ in large-scale repre-
sentative population physical activity data collection.
Methods
Development and international validation of the IPAQ
has been previously reported [11]. In brief, surveillance-
oriented questionnaires were developed for adults aged
18 to 65 years. Reliability and validity studies were con-
ducted in 12 countries across 6 continents using standard-
ised methods, and demonstrated reasonable test-retest
reliability (intra-class correlations range 0.7–0.8) and
inter-method validity (median rho = 0.67), with criterion
validity around rho = 0.3 based on comparisons with
accelerometer data. Measurement properties were similar
to those of other physical activity surveys used in devel-
oped countries [12] with the IPAQ offering broader appli-
cability to a wide range of countries and cultures. The
IPAQ short form instrument was considered brief enough
for physical activity surveillance, flexible enough to be
used in telephone interview or self-administered applica-
tions, and adaptable enough to apply across cultures [11].
IPAQ has been used for physical activity surveillance
activities in individual countries and in the European
Union [13,14].
The International Prevalence Study (IPS) was coordinated
by an international group of scientists. The study involved
3 primary phases: [i] country recruitment and develop-
ment of comparable study methods; [ii] within-country
data collection with IPAQ nested within existing surveys
or as a stand-alone survey and [iii] analysis of the pooled
data using standardised protocols. A Data Management
Centre (DMC) provided technical support to participating
countries, collated country-specific data sets, and under-
took pooled analyses. A statement of ethics approval was
obtained from all centres. Informed and voluntary con-
sent was provided verbally or in writing from all partici-
pants.
Countries were invited through existing international and
regional global health and physical activity networks, key
organizations (World Health Organisation; U.S. Centers
for Disease Control and Prevention) and various non-
communicable disease networks. Expressions of interest
were received from 24 countries or large within-country
regions during 2002–2004. The inclusion criteria required
a representative population sample of at least 1500 adults,
using comparable data collection methods in spring or
autumn, and using approved cultural translations of the
IPAQ instrument [see Appendix 2]. A manual of opera-
tions specified the required study protocols and indicated
where modifications could be made to accommodate the
local context.

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(page number not for citation purposes)Table 1: Survey sampling procedures and response details fr om 20 countries; Internationa l Prevalence Study, 2002–2004.
Country Sampling Procedures IPAQ Short
Form
AdministrationMonth Year Response
RateSample Size
18–65 yrs% male %
education>
13 years
Argentina A representative sample of Buenos Aires
– Multistage stratified random selection of
houses/apartments and blocksSelf Jun 2003 72% 1203 44.9 46.6
Australia A nationally repr esentative sample – RDD
with simple random sample of householdsTelephone Apr 2003 55% 2691 44.0 48.8
Belgium A representative sample of Flanders –
Random selection of mu nicipalities/cities
and inhabitants with in municipality/citySelf Mar–May,
Sept–Oct
200328% 1969 51.9 45.1
Brazil State of Sao Paulo representative sample
– Simple random sample proportional to
sizeInterviewer Mar–May
200385% 991 48.5 N/A
Canada A nationally repres entative sample – RDD
sample proportional to number of
households in each provinceTelephone Sept–Nov 02
– Mar–May 0351% 2669 45.3 62.3
China
(Shanghai)A representative sample of Shanghai –
Multistage sampling of 3 communities, 5
neighborhoods within communities, and
adults within householdsInterviewer Nov–Dec
200284% 1593 51.5 32.5
Colombia A representative sample of Bogota DC –
Multistage unequal probability selection
proportional to sizeInterviewer Mar–May
200384% 3000 40.4 19.1
Czech
Republic9 academic worksites in 10 regions; a
nationally representat ive sample – Simple
random sample proportional to size.
Students distributed questionnaires to
permanent/temporary residences, partly
randomly selectedSelf Nov 2002
May 200358% 7513 48.2 42.2
Hong Kong
SAR, ChinaA nationally represen tative sample –
Stratified by districtInterviewer Oct–Dec 02 –
Jan–Feb 0348% 4886 48.9 14.1
India Convenience sample of employees and
their families from 2 worksite populations
in Ghaziabad and NagpurInterviewer Jan–Dec 2003 88% 1005 48.7 38.2
Japan 22 universities and 6 worksites from
different regions of Japan, representing
nearly all areasSelf July 2003 90% 4959 38.4 29.2
Lithuania A systematic random sample from 10
rural districts and the 5 largest Lithuanian
cities – Respondents sampled at fixed
intervals after random selection of a
starting pointInterviewer Apr–May
200377% 2227 41.4 58.0
New
ZealandA nationally represen tative sample –
Simple random sample proportional to
sizeTelephone Mar–Apr
200342% 1495 40.8 36.9
Norway A nationally repr esentative sample –
Simple random samplingSelf Oct 2003 41.3% 1645 47.3 45.8

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(page number not for citation purposes)Twenty countries or large within-country regions were
approved for IPS, completed data collection and provided
population-level data to the DMC. Details of the partici-
pating countries, mode of questionnaire administration,
response rate, data collection period and sample size are
provided in Table 1. Face-to-face IPAQ interviews were
conducted in 6 countries, self-administered question-
naires in 8 countries and telephone interviews in 6 coun-
tries. The median country-level response rate was 61%,
ranging from 28% in Belgium, (due to nesting IPAQ in a
population survey with detailed anthropometric meas-
ures) to above 80%. The total sample sizes across the 20
countries ranged from 1,010 (India) to 11,449 (Czech
Republic). Only data from adults aged 18–65 years were
included, the age range for which IPAQ was designed and
evaluated.
IPAQ was designed to measure physical activity across all
domains of leisure-time, work, transportation, and house-
hold tasks. The IPAQ short form asks respondents to
report frequency and duration of walking, moderate-
intensity and vigorous-intensity activity performed for at
least 10 minutes duration per session. IPAQ also collects
information on total sitting time, but these data are not
reported here. Weekly minutes of walking, moderate-
intensity and vigorous-intensity activity were calculated
separately by multiplying the number of days/week by the
duration on an average day. Reported minutes per week in
each category were weighted by a metabolic equivalent
(MET; multiples of resting energy expenditure) resulting
in a physical activity estimate independent of body
weight, expressed in MET-minutes/week and computed
by multiplying METs by minutes/week [11]. The summaryindicator was used to categorise a population into three
levels of physical activity: "low" [physically inactive],
"moderate" and "high" levels of physical activity. The
"moderate" level nominally indicated meeting physical
activity guidelines of 30 minutes of moderate intensity
activity 5 days a week, 20 minutes of vigorous activity 3
days a week, or a combination [15]. Because guidelines
were based mainly on leisure time activity but IPAQ
assessed four domains, the "high" activity level was devel-
oped and reflects approximately twice the MET-minutes
of the "moderate" level. These categories were based on
standard scoring criteria http://www.ipaq.ki.se .
 Low: Meets neither 'moderate' nor 'high' criteria.
 Moderate : Meets any of the following three criteria:
(a) 3 days of vigorous activity of at least 20 minutes/
day; (b) 5 days of moderate-intensity activity or walk-
ing of > 30 minutes/day for > 10 minutes at a time; or
(c) 5 days of any combination of walking, moderate-
intensity or vigorous-intensity activities achieving at
least 600 MET-minutes/week.
 High : Meets either of two criteria: (a) vigorous-inten-
sity activity on > 3 days/week and accumulating at
least 1500 MET-minutes/week; or (b) >5 days of any
combination of walking, moderate-intensity, or vigor-
ous-intensity activities achieving at least 3000 MET-
minutes/week.
For country specific prevalence estimates, data were
weighted to the national population based on study
design. For international comparisons, all prevalencePortugal A nationally repr esentative sample –
Simple random sample proportional to
sizeSelf Apr–May
2002>80% 1525 47.3 3.1
Saudi
ArabiaA representative sample of Riyadh City –
Simple random sample of telephone-
equipped householdsTelephone Mar–May
200366% 988 65.4 38.3
Spain A representative sample of Catalonia –
Simple random sample proportional to
sizeSelf Oct–Nov
200262.4% 1580 44.9 43.5
Sweden A nationally repr esentative sample –
Simple random samplingSelf Oct–Dec
200259% 1290 45.9 30.8
Taiwan A nationally repres entative sample – RDD
sample proportional to number of
households, in 7 stratified areasTelephone Sept–Nov
200448.3% 4846 47.6 40.8
USA A nationally repres entative sample –
Simple random sample proportional to
sizeTelephone Sept–Nov
200230.9% 4671 42.8 61.4
Note: RDD = Random Digit Dial; CATI = computer-assisted telephone interviewTable 1: Survey sampling procedures and response details fr om 20 countries; Internationa l Prevalence Study, 2002–2004. (Continued)

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(page number not for citation purposes)rates were age standardised to the world population distri-
bution to enable comparability for totals across countries
with varying population distributions by age [16,17].
Data analyses were conducted using SAS software V8.02
[18].
Results
Data were from 20 countries with a total of 52,746 indi-
viduals aged 18–65 years. For most countries there was a
fairly even balance of males and females with the excep-
tion of Colombia, Japan and Lithuania (where around
60% of the samples were female), and Saudi Arabia
(males 65%). Data on education level were available for
19 countries and showed a wide variation among coun-
tries (Table 1).
Table 2 shows the prevalence of physical activity levels in
total, and Table 3 shows these data by gender for each
country. High physical activity was most prevalent in New
Zealand, the Czech Republic, the USA, Canada and Aus-
tralia. Four countries, Belgium, Brazil, Japan and Taiwan
reported less than a third of their populations in the high
PA category. For most countries, males were more active,with only Argentina, Portugal and Saudi Arabia showing
women more active than men. It was noted that more
than half of the males in 12 countries and females in 14
countries did not achieve the high physical activity thresh-
old. The prevalence of low physical activity ranged from
7% to 43% among males and from 6% to 49% among
women.
Further analyses compared these data by age group,
assessing younger (18–39 years) and older adults (40–65
years). Physical activity declined with age (at least a differ-
e n c e o f 1 0 % i n " h i g h " P A p r e v a l e n c e i n t h e o l d e r a g e
group compared to the younger age group) in 11 out of 19
estimates for males, but only three countries showed this
difference among females (Table 4). Although there was a
general decline across age groups, for some countries,
rates of physical activity remained high in the older age
group (for example, New Zealand males and females), or
even increased, compared to the younger age group (Chi-
nese and Hong Kong, SAR females).
Figure 1 shows the relative contributions of walking,
moderate-intensity, and vigorous-intensity physical activ-Table 2: Prevalence* of International Physical Activity Questionnaire categories amon g 18–65 year-olds by country†; International
Prevalence Study, 2002–2004
Country Weighted Valid
n ##Total sample (%)
Low active Moderate Activity High active
Argentina 1189 26.7 (24–29) 35.2 (32–38) 38.0 (35–41)
Australia 2642 17.2 (16–19) 24.3 (23–26) 58.6 (57–60)
Belgium 1922 43.0 (41–45) 27.4 (25–29) 29.6 (28–32)
Brazil 981 30.4 (28–33) 45.0 (42–48) 24.6 (22–27)
Canada 2626 13.7 (12–15) 26.7 (25–28) 59.6 (58–62)
China 1593 6.9 (6–8) 35.4 (33–38) 57.7 (55–60)
Colombia 2974 19.8 (18–21) 27.5 (26–29) 52.7 (51–55)
Czech Rep 7468 9.9 (9–11) 27.2 (26–28) 62.9 (62–64)
Hong Kong 4657 15.3 (14–16) 50.6 (49–52) 34.1 (33–35)
India 1004 23.4 (21–26) 38.7 (36–42) 37.9 (35–41)
Japan 4618 43.3 (42–45) 35.4 (34–37) 21.2 (20–22)
Lithuania 2210 15.0 (14–16) 32.9 (31–35) 52.1 (50–54)
New Zealand 1449 12.2 (10–14) 24.7 (22–27) 63.1 (61–66)
Norway 1625 26.1 (24–28) 33.6 (31–36) 40.3 (38–43)
Portugal 1435 26.2 (24–28) 28.5 (26–31) 45.3 (43–48)
Saudi Arabia 974 40.0 (37–43) 33.8 (31–37) 26.2 (23–29)
Spain 1541 24.2 (22–26) 36.2 (34–39) 39.6 (37–42)
Sweden 1254 23.9 (22–26) 37.3 (35–40) 38.8 (36–41)
Taiwan 4773 42.3 (41–44) 32.9 (32–34) 24.8 (24–26)
USA 4587 15.9 (15–17) 22.1 (21–23) 62.0 (61–63)
* Age and gender standardised to the world population 2002 [US Census Bureau 2002; Doll R et al 1966]
† Australia: Age 18–64 only; Hong Kong: Age 20–64 only; Japan: Age 18–39 only; Portugal: Age 40–65 only
## note that sample sizes differ from Table 1 due to mini mal missing data on some physical activity questions

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(page number not for citation purposes)ity to total MET-minutes/week for each country. In all
countries at least 20% of total MET-minutes/week was
accrued through walking, and walking comprised at least
50% of total MET-minutes/week in Hong Kong SAR, and
China. By contrast, the contribution of vigorous-intensity
activity to total MET-minutes/week varied widely among
countries. For example, vigorous-intensity activity con-
tributed less than 5% of total MET-minutes/week in India,
but more than 45% of total MET-minutes/week in Aus-
tralia, Brazil, Canada, New Zealand and the USA.
Discussion
International comparisons of key non-communicable dis-
ease (NCD) risk factors, such as obesity and tobacco use,
are commonplace [19,20], but comparisons of physical
activity prevalence among countries have not been possi-
ble due to the lack of standardised and validated instru-
ments. Previous reviews have demonstrated very different
prevalence estimates across countries, and these differ-
ences were as likely to be due to variations in questions
and survey methods as they were to true differences in
prevalence [21,22]. The present study reports population-level prevalence estimates and patterns of physical activity
in a diverse set of countries, using a comparable, reliable
and validated survey instrument. In this study, the IPAQ
short form was administered to over 52,000 adults aged
18–65 years, using a standard protocol in 20 countries.
The results show substantial variation in the population
estimates of meeting the IPAQ "high active" category, a
threshold developed to reflect an amount greater than
than standard recommended levels, but more suited for
use with a multiple domain measure such as IPAQ. Eight
of the 20 countries had "high activity" rates over 50%, and
these countries came from several continents. We also
observed different patterns by gender and age, with most
countries showing younger men more active than younger
women, but this gender difference was less marked
among older adults. Further, in these countries, age-
related declines in physical activity were much more fre-
quently observed among men than among women.
As shown in Figure 1, countries achieved high physical
activity in different ways, with four of the most activeTable 3: Gender specific Prevalence* of In ternational Physical Activity Questionnair e categories among 18–65 year-olds by count ry†;
International Prevalence Study, 2002–2004
Country Weighted
Valid
n ##Men (%) Women (%)
Low active Moderate Activit y High active Low active Mode rate activity High active
Argentina 1189 27.1 (24–31) 35.4 (32–39) 37.5 (34–41) 26.3 (23–30) 34.9 (31–39) 38.6 (35–42)
Australia 2642 14.3 (12–16) 20.0 (18–22) 65.8 (63–68) 20.1 (18–22) 28.5 (26–31) 51.4 (49–54)
Belgium 1922 37.3 (34–40) 25.4 (23–28) 37.2 (34–40) 48.7 (46–52) 29.4 (27–32) 21.9 (19–25)
Brazil 981 25.6 (22–29) 34.9 (31–39) 39.5(35–44) 34.3 (30–38) 52.7 (48–57) 13.0(10–16)
Canada 2626 12.3 (10–14) 23.2 (21–26) 64.4 (62–67) 15.1 (13–17) 30.1 (28–33) 54.8 (52–58)
China 1593 7.4 (6–9) 33.4 (30–37) 59.1 (56–63) 6.4 (5–8) 37.4 (34–41) 56.2 (53–60)
Colombia 2974 16.5 (15–18) 23.7 (22–26) 59.7 (57–62) 23.1 (21–25) 31.2 (29–34) 45.7 (43–48)
Czech Rep 7468 9.8 (9–11) 22.1 (21–23) 68.2 (67–70) 10.0 (9–11) 32.2 (31–34) 57.7 (56–59)
Hong Kong 4657 13.8 (12–15) 46.5 (44–48) 39.8 (38–42) 16.8 (15–18) 54.6 (53–57) 28.6 (27–30)
India 1004 22.5 (19–26) 37.8 (34–42) 39.8 (36–44) 24.3 (21–28) 39.6 (35–44) 36.1 (32–40)
Japan 4618 41.1 (39–43) 33.1 (31–35) 25.8 (24–28) 45.6 (44–48) 37.8 (36–40) 16.7 (15–18)
Lithuania 2210 15.9 (14–18) 28.3 (26–31) 55.7 (53–59) 14.0 (12–16) 37.5 (35–40) 48.4 (45–51)
New Zealand 1449 8.0 (6–10) 18.0 (15–21) 74.0 (71–77) 16.5 (14–19) 31.3 (28–35) 52.2 (49–56)
Norway 1625 25.1 (22–28) 29.2 (26–32) 45.8 (42–49) 27.2 (24–30) 38.1 (35–41) 34.7 (31–38)
Portugal 1435 28.9 (26–32) 27.0 (24–30) 44.1 (40–48) 23.4 (20–27) 30.1 (27–33) 46.4 (43–50)
Saudi Arabia 974 42.8 (38–47) 36.8 (33–41) 20.2 (17–24) 37.3 (33–42) 30.7 (27–35) 32.2 (28–36)
Spain 1541 24.3 (21–27) 29.8 (27–33) 45.9 (42–49) 24.1 (21–27) 42.7 (39–46) 33.3 (30–37)
Sweden 1254 25.6 (22–29) 31.8 (28–35) 42.5 (39–46) 22.2 (19–25) 42.7 (39–47) 34.9 (31–39)
Taiwan 4773 41.3 (39–43) 28.2 (26–30) 30.5 (29–32) 43.3 (41–45) 37.6 (36–40) 19.1 (18–21)
USA 4587 13.6 (12–15) 19.2 (18–21) 67.2 (65–69) 18.2 (17–20) 25.0 (23–27) 56.7 (55–59)
* Age and gender standardised to the world population 2002 [US Census Bureau 2002 [16]; Doll 1966, [17].
† Australia: Age 18–64 only; Hong Kong: Age 20–64 only; Japan: Age 18–39 only; Portugal: Age 40–65 only
## note that sample sizes differ from Table 1 due to mini mal missing data on some physical activity questions

International Journal of Behavioral Nutrition and Physical Activity 2009, 6:21 http://www.ijbnpa.org/content/6/1/21
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(page number not for citation purposes)countries (Australia, Canada, New Zealand, USA) show-
ing a greater volume of vigorous-intensity physical activity
relative to moderate-intensity activity and walking. These
same countries seem to have relatively well developed
facilities for recreational activity and a history of long-
term promotion of exercise. Four of the countries with
substantial rates of high physical activity had more than
30% of overall physical activity derived from walking
(Canada, China, Colombia, Czech Republic) suggesting
that countries with an infrastructure or culture that sup-
ports walking can achieve high levels of physical activity
with lesser contribution from vigorous activity. However,
substantial proportions from walking (Hong Kong SAR,
Japan, Spain, Taiwan) and vigorous activity (Belgium,
Brazil, Taiwan) were also found in countries with low
overall physical activity prevalence rates (< 30% in the
'high' category), so there is no indication that an emphasis
on promoting one domain of activity will lead to high lev-
els of overall physical activity at the population level. Oneconclusion from these results is that different patterns of
physical activity are associated with high prevalence esti-
mates, so countries could tailor physical activity promo-
tion strategies to local infrastructure, available programs,
and culture.
There are a few European multi-country physical activity
surveys that provide a context for interpreting present
results. The 2002 Eurobarometer study used the IPAQ
instrument [13] and identified low prevalence estimates
for Belgium and Sweden, similarly to IPS and reported the
highest levels of physical activity in the Netherlands and
Germany (these two countries did not participate in IPS).
However, earlier European-only studies had observed
slightly different rankings [14,23]. A Pan-European Union
Survey on Consumer Attitudes to Physical Activity had
found a similar low prevalence of activity in Belgium and
Portugal, but reported a high prevalence rate in Sweden
[23]. Another study used information from the 2002–3Table 4: Prevalence* of International Physical Activity Qu estionnaire categories by age group by gender and country†; International
Prevalence Study, 2002–2004.
Country % Prevalence
Male Female
18–39 40–65 18–39 40–65
Low Mod High # Low Mod High Low Mod High Low Mod High
A r g e n t i n a 2 63 2 4 1 2 84 03 32 13 44 53 43 63 0
Australia 13 17 70 16 23 61 19 28 53 21 30 49
B e l g i u m 3 32 7 4 1 4 32 43 34 43 32 35 42 52 1
Brazil 17 36 46 36 33 31 31 54 15 38 51 11
Canada 10 22 69 15 25 59 13 30 57 18 31 51
China 7 30 63 8 37 55 8 40 53 5 35 60
Colombia 14 17 69 20 32 48 22 30 49 25 33 42
Czech Rep 7 20 73 13 25 62 9 31 60 12 34 55
Hong Kong 14 45 42 14 48 38 19 57 25 15 52 33
I n d i a 2 52 2 5 3 1 95 72 32 72 84 52 15 42 5
Japan 41 33 26 – – – 46 38 17 – – –
L i t h u a n i a 1 22 4 6 3 2 13 34 61 33 65 11 54 04 5
N e w Z e a l a n d 7 1 7 7 6 9 1 97 11 63 25 31 83 15 2
Norway 21 28 51 30 30 40 27 36 37 28 41 31
Portugal – – – 29 27 44 – – – 23 30 46
Saudi Arabia 38 35 27 49 39 12 35 32 32 39 29 32
S p a i n 1 73 1 5 2 3 42 83 82 44 13 62 44 53 0
Sweden 23 30 47 29 34 37 20 40 40 25 46 29
Taiwan 42 27 31 41 30 29 45 36 19 41 39 20
U S A 1 11 6 7 2 1 62 36 11 82 65 61 92 45 7
# low, moderate [mod] and high active IPAQ categories
* Age-and gender – standardized to the world population 2002 [US Census Bureau 2002 [16]; Doll 1966, [17].
† Australia: Age 18–64 only; Hong Kong: Age 20–64 only; Japan: Age 18–39 only; Portugal: Age 40–65 only

International Journal of Behavioral Nutrition and Physical Activity 2009, 6:21 http://www.ijbnpa.org/content/6/1/21
Page 8 of 11
(page number not for citation purposes)WHO World Health Survey to collect IPAQ short-form
physical activity data from 51 countries, mostly from pop-
ulation samples in developing countries [24]. Physical
inactivity prevalence data from the four comparable coun-
tries were remarkably similar to the findings in this IPS
study; for example, inactivity rates were low for China and
the Czech Republic [around 10% in both the IPS and the
World Health Survey], and high levels of inactivity
reported in both surveys for Brazil [close to 30% inactive
in both studies], and close to 25% for Spanish adults in
both studies. The similarity of these estimates was note-
worthy, despite different survey methods, suggesting that
IPAQ data may be consistent, at least within country.
One interesting further comparison can be made from
representative cross sectional data of adolescents in
Europe and North America through the contemporaneous
2001–2002 Health Behaviour in School-aged children
survey (HBSC) [25]. Looking at the group closest to the
IPS age group (the 15 year old samples) the countries with
the most active boys and girls included USA, Canada,
Czech Republic and Lithuania in the upper quartile, and
Belgium, Norway and Portugal in the lowest quartile. This
distribution for physical activity among adolescents wassimilar to that observed in the IPS among adults from the
same countries.
The findings from this study indicate that the majority of
the population in most participating countries or regions
appeared to undertake at least a moderate amount of
physical activity when assessed using the multi-domain
IPAQ. This suggests that most adults in these countries are
obtaining some activity, yet the global problem of rising
prevalence of obesity remains. Thus, it appears total phys-
ical activity in most countries remains insufficient to
ensure energy balance and prevent obesity [26] or that the
ratio of energy expenditure to dietary intake is unbalanced
to maintain weight stability.
Strengths of IPAQ include its measurement of multiple
domains, and the separate assessment of walking behav-
iour, compared to many current PA surveillance systems
[27]. There are some limitations with IPAQ, including dif-
ficulties with respondents in distinguishing moderate and
vigorous activities. It is also well recognised that self-
reported measures can over-estimate physical activity
[28], and the IPAQ may do this more than other surveys
[29-31]. Although there is a benefit in IPAQ assessingPrevalence of high activity, and proporti ons of total physical activity for each coun try derived from walking, moderate- and vi g- orous-intensity activityFigure 1
Prevalence of high activity, and proportions of total ph ysical activity for each co untry derived from walking,
moderate- and vigorous-intensity activity .0%10%20%30%40%50%60%70%80%90%100%
Argentina
Australia
Belgium
Brazil
Canada
China
Colombia
Czech Rep
Hong Kong
India
Japan
Lithuania
New Zealand
Norway
Portugal
Saudi Arabia
Spain
Sweden
Taiwan
USA
38.0 58.6 29.6 26.3 59.6 57.7 52.7 62.9 34.1 37.9 21.2 52.1 63.1 40.3 45.3 26.2 39.6 38.8 24.8 62.0Vigorous Moderate Walking
% High active

International Journal of Behavioral Nutrition and Physical Activity 2009, 6:21 http://www.ijbnpa.org/content/6/1/21
Page 9 of 11
(page number not for citation purposes)multiple domains of physical activity as part of global sur-
veillance, it could contribute to higher overall PA esti-
mates than previous surveys that captured leisure-time
activity alone [15]. There is also the possibility of differen-
tial measurement error using IPAQ, with some countries
or population subgroups potentially giving relatively
accurate estimates of their behaviour, while other popula-
tions may over-estimate or under-estimate their physical
activity; this between-country variability appeared even
greater in the World Health Survey, which was comprised
of mostly developing countries [24]. The samples here
were large-scale population samples, but eight of them
were regional, not national samples, so these prevalence
estimates cannot be generalised to the country level (for
example, to all of China or Argentina). Based on educa-
tion level (Table 1), these samples showed similar or
slightly higher educational attainment to national or
regional levels for those countries, suggesting comparabil-
ity on this attribute.
Other methodological issues in the IPS included the vari-
ations in response rates across countries, and despite
many efforts to standardize protocols, there were
undoubtedly important differences in implementation.
While all surveys were reviewed for consistency in the
translation and cultural adaptation for participating coun-
tries, variations in how respondents understood the sur-
vey may have contributed to difficulties in interpreting
findings of this international prevalence study. Though it
is likely impossible to eliminate all challenges to the com-
parability of survey results across countries, subsequent
surveillance studies could benefit from additional train-
ing of investigators, development of more rigorous trans-
lation and adaptation procedures, on-site inspections for
quality control of data collection, centralized data entry
system, and other methods for enhancing data quality.
Furthermore, in low literacy populations, standardised
showcards or illustrations should be used to depict types
or intensity of different physical activities, but these can-
not be used with telephone-based survey administration.
In addition to the abovementioned methodological
issues, concerns remain with self report measures. Whilst
they remain the most feasible and affordable instruments
for global surveillance, objective population measures of
physical activity, such as pedometers [32] or accelerome-
ters [33,34], may be beneficial to determine if differences
across countries and between groups revealed in the
present study represent true differences in physical activity
behaviour.
The International Prevalence Study on Physical Activity
provided data that allow 20 countries to be compared on
physical activity behaviours for the first time. For some
countries, these data represent their first large scale meas-
urement of physical activity. Several countries have
adopted the IPAQ and IPS methods as their national orregional surveillance system, and these data contribute to
current WHO and European surveillance systems. A major
contribution of IPS was to produce internationally com-
parable physical activity prevalence estimates and to dem-
onstrate the feasibility of standardised data collection on
physical activity using a common protocol. Though ques-
tions remain about the precision of the derived prevalence
estimates, an important next step is the continued use of
established instruments for the collection and monitoring
of physical activity as part of ongoing non-communicable
disease risk factor surveillance systems. Ongoing research
will compare the IPAQ results with the Global Physical
Activity Questionnaire (GPAQ), the World Health Organ-
ization's instrument also being used for international sur-
veillance [21,35], and compare both of these against
objective measures.
The results from this international surveillance study on
physical activity can provide useful baseline data, at least
within countries, and studies could be repeated to ascer-
tain population trends in physical activity. One important
feature of a useful health monitoring system is the use of
consistent measures over time [36]. Country-specific data
and trends can be used to monitor efforts to promote
physical activity and improve public health. Although sur-
veillance data alone are not sufficient to motivate or guide
the implementation of national policy, consistent trend
data are an essential underpinning of the case for public
health action.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
AB supervised the data collection and management, con-
ceptualized the paper, and carried out primary writing
and interpretation of the paper, and is guarantor for it. FB
coordinated the recruitment of countries and the IPS
group, contributed to the conceptualization of the study,
primary drafting and interpretation of the paper. CLC and
BEA were responsible for country inclusion and study pro-
tocols, IPAQ translation and contributed to the conceptu-
alization of the study, writing and interpretation of the
paper. JFS, MH, MS, MP contributed to the conceptualiza-
tion of the study, assisted with the writing and interpreta-
tion of the paper. TC and HRB analyzed the data, and
assisted with interpretation and writing. IPS centers coor-
dinated study implementation, IPAQ translation and data
collection in each country, following standard protocols.
Appendix 1
IPS Collaborating research groups in each country
Country level authors
Argentina: Díaz Colodrero G, Bazan N, Kunic H; Asoci-
ación Metropolitana de Medicina del Deporte, Buenos
Aires

International Journal of Behavioral Nutrition and Physical Activity 2009, 6:21 http://www.ijbnpa.org/content/6/1/21
Page 10 of 11
(page number not for citation purposes)Australia: Bauman A, Merom D, Smith B. Centre for Phys-
ical Activity and Health, University of Sydney
Belgium: De Bourdeaudhuij I, Lefevre J., Philippaerts R
Department of Movement and Sport Sciences, Ghent Uni-
versity and Faculty of Kinesiology and Rehabilitation Sci-
ences, K.U. Leuven
Brazil: Matsudo SM, Matsudo VR, CELAFISCS – Physical
Fitness Research Center (Celfasics), São Caetano do Sul,
São Paulo.
Canada: Craig CL, Cameron C, Canadian Fitness and Life-
style Research Institute, Ottawa
China PRC: Yang Li, Hua Fu, Department of Preventive
Medicine, School of Public Health, Fudan University,
Shanghai
Colombia Gómez LF, Health Division, Fundacion Fes
Social, Bogota.
Czech Republic: Fromel K, Mitas J. Centre for Kinanthro-
pology Research, Palacky University
Hong Kong SAR China: Macfarlane D, Bacon-Shone J, The
University of Hong Kong, Pokfulam.
India: Reddy SK, Joshi P, Goenka S, Prabhakaran D, All
India Institute of Medical Sciences, New Delhi
Japan: Katsumura T, Murase N. Department of Sports
Medicine for Health Promotion, Tokyo Medical Univer-
sity
Lithuania: Volbekiene V, Baubliene R. Lithuanian Acad-
emy of Physical Education (LAPE)
New Zealand: McLean G, Sport and Recreation New Zea-
land (SPARC), Carr H, Ministry of Health, Wellington
Norway: Tomten H, Directorate for Health and Social
Affairs; Anderssen SA, Norwegian School of Sport Sci-
ences, Oslo
Portugal: Sardinha L, Technical University of Lisbon.
Mota J, Faculty of Sports-University of Porto
Saudi Arabia: Al-Hazzaa HM Exercise Physiology Labora-
tory, King Saud University, Riyadh
Spain: Serra Majem L, Roman B, Community Nutrition
Research Center, Barcelona Science Park, University of
Barcelona;Sweden: Sjöström M, Hagströmer M, Bergman P. Depart-
ment of Biosciences and Nutrition, Karolinska Institutet,
Sweden
Taiwan: Yiing Mei Liou, National Yang-Ming University;
Yung-Tai Hung, National Taiwan University.
USA: Ainsworth BE, Department of Exercise and Wellness,
Arizona State University; Hipp D, Physical Activity and
Health Branch, U.S. Centers for Disease Control and Pre-
vention Atlanta, Georgia USA
Appendix 2 – Criteria for inclusion in the IPS
project
Sample Population and sample size
A representative population sample of at least 1500 adults
aged 18 to 65 years was suggested. This sample should be
representative of national populations or of a sizeable
portion or region(s) within a country (defined as a popu-
lation of over one million). In some circumstances sam-
ples which did not meet either of these criteria but that
which the country itself would regard as representing the
national population were considered acceptable. Samples
were to be selected using simple random sampling and
simple random sampling proportional to size.
Data Collection timeframes
Data collection was planned for Spring or Fall (Autumn)
seasons in 2002/03 (if data were collected across 12
months only these months would be used) as these sea-
sons were deemed most comparable across countries and
less likely to be affected by extreme weather. In special
cases, other months were accepted because meteorologi-
cal data were examined and weather conditions were con-
sidered comparable.
Response Rates and Sample Characteristics
To assess representativeness, response rates were required,
as well as the most recent Census data providing informa-
tion on age, sex, education and ethnicity for the sample
population (country or region).
Questionnaire Administration
Telephone interview, face-to-face interview, or self-
administration were permitted. No proxy interviews were
accepted.
Obtaining Informed Consent
Informed consent (using local established procedures)
must be obtained.
Questionnaire
IPAQ short form was mandatory and must be used with
core demographic questions. Details of the context of data

International Journal of Behavioral Nutrition and Physical Activity 2009, 6:21 http://www.ijbnpa.org/content/6/1/21
Page 11 of 11
(page number not for citation purposes)collection (e.g., embedded in a health survey or a stand
alone physical activity survey) were required as well as
question order and details of any other additional ques-
tions on physical activity. No changes to the short IPAQ
form other than cultural adaptations were permitted. Any
other physical activity questions were to occur after the
IPAQ short form was completed (otherwise the sample
should be randomly split in half with one half the sample
receiving the IPAQ questions first and the second half
receiving any other physical activity questions first). Core
demographic information comprised: age, gender, educa-
tion, current employment status, and city size.
Translation and Cultural Adaptation
Guidelines for cultural adaptation and translation were
provided and are available at http://www.ipaq.ki.se . A
copy of the final survey and English back-translation was
required.
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