ABSTRACT

Objectives.

To characterize how physical activity and sedentary behavior have been measured in national health surveys in South American countries.

Methods.

An extensive search was made for national health surveys from all 12 South American countries through health websites, national statistical offices, and contact with researchers and policy-makers. The following eligibility criteria were used to select surveys: conducted in a South American country; used a nationally representative sample ≥ 18 years; coordinated by the public, private or mixed private–public sector; and assessed physical activity and/or sedentary behavior. Data were extracted on general information about the surveys, specific details about the physical activity and sedentary behavior assessment, and additional questions related to activity behavior.

Results.

In total, 36 surveys were included, two of which were multicountry surveys; all surveys assessed physical activity and 27 assessed sedentary behavior. Most surveys (23/36; 64%) were based on previously validated international questionnaires, but 13 (57%) of these deviated from the reference tools, introducing changes and adaptations. Sedentary behavior was assessed mostly through questions on screen time and/or daily sitting time in the same physical activity questionnaires. No survey used device-based measures to generate data on these behaviors.

Conclusions.

Differences between instruments used and modifications limit the comparability of data across countries. This highlights the importance of standardizing assessment within South America for physical activity and sedentary behavior sections in national surveys, with the broader aim of contributing to establishing a standardized strategy for the surveillance of physical activity and sedentary behavior in South America.

Keywords
Exercise; sedentary behavior; health surveys; population surveillance; South America

RESUMEN

Objetivos.

Describir cómo se han medido la actividad física y el sedentarismo en las encuestas nacionales de salud en los países de América del Sur.

Métodos.

Se llevó a cabo una extensa búsqueda de encuestas nacionales de salud de los doce países sudamericanos en sitios web de salud, oficinas nacionales de estadística y mediante el contacto con investigadores y responsables de formular políticas. Para escoger las encuestas se emplearon los siguientes criterios de selección: realizada en un país sudamericano; muestra representativa a nivel nacional de ≥ 18 años; coordinada por el sector público, el sector privado o mixto público-privado; y evaluación de la actividad física o el sedentarismo. Se extrajeron datos como información general de las encuestas, detalles específicos de la evaluación de la actividad física y el sedentarismo, y otras preguntas relacionadas con la actividad física.

Resultados.

En total, se incluyeron 36 encuestas, dos de las cuales se realizaron en varios países. Todas las encuestas evaluaron la actividad física; 27, el sedentarismo. La mayoría de las encuestas (23/36; 64%) se basaron en cuestionarios internacionales anteriormente validados, de los cuales 13 (57%) se desviaron de las herramientas de referencia al tener cambios y adaptaciones. El sedentarismo se evaluó principalmente en los mismos cuestionarios de actividad física mediante preguntas sobre el tiempo invertido delante de pantallas o el tiempo diario sentado. Ninguna encuesta aplicó medidas basadas en dispositivos para obtener datos sobre estos comportamientos.

Conclusiones.

Las diferencias entre los instrumentos empleados y las modificaciones limitan la comparabilidad de los datos en todos los países. Esto pone de relieve la importancia de estandarizar la evaluación en América del Sur de las secciones dedicadas a la actividad física y al sedentarismo en las encuestas nacionales, con el objetivo general de contribuir a la creación de una estrategia estandarizada para la vigilancia de la actividad física y el sedentarismo en América del Sur.

Palabras clave
Ejercicio físico; conducta sedentaria; encuestas epidemiológicas; vigilancia de la población; América del Sur

RESUMO

Objetivos.

Caracterizar como a atividade física e o comportamento sedentário têm sido medidos em pesquisas nacionais de saúde em países sul-americanos.

Métodos.

Foi realizada uma busca extensa de pesquisas nacionais de saúde de todos os 12 países sul-americanos em sites de saúde e órgãos nacionais de estatística, e pelo contato com pesquisadores e formuladores de políticas. Foram usados os seguintes critérios de elegibilidade para selecionar as pesquisas: conduzida em um país sul-americano; que tenha usado uma amostra nacionalmente representativa ≥ 18 anos; coordenada pelo setor público, privado ou público-privado; e que tenha avaliado a atividade física e/ou o comportamento sedentário. Os dados extraídos eram sobre informações gerais das pesquisas, detalhes específicos sobre a avaliação da atividade física e do comportamento sedentário e questões adicionais relacionadas ao comportamento na atividade.

Resultados.

Ao todo, 36 pesquisas foram incluídas, duas das quais foram conduzidas em vários países. Todas as pesquisas avaliaram a atividade física e 27 avaliaram o comportamento sedentário. A maioria das pesquisas (23/36; 64%) baseou-se em questionários internacionais previamente validados e 13 (57%) delas se desviaram das ferramentas de referência, introduzindo mudanças e adaptações. O comportamento sedentário foi avaliado principalmente por meio de perguntas sobre tempo de tela e/ou tempo diário sentado nos mesmos questionários sobre atividade física. Nenhuma pesquisa utilizou medições realizadas por dispositivos para gerar dados sobre esses comportamentos.

Conclusões.

As diferenças entre os instrumentos usados e as modificações limitam a comparabilidade dos dados entre os países, o que destaca a importância de padronizar a avaliação na América do Sul para as seções de atividade física e comportamento sedentário em pesquisas nacionais, com o objetivo mais amplo de contribuir para o estabelecimento de uma estratégia padronizada para a vigilância da atividade física e do comportamento sedentário na América do Sul.

Palavras-chave
Exercício físico; comportamento sedentário; inquéritos epidemiológicos; vigilância da população; América do Sul

Physical inactivity and sedentary behavior are associated with negative health outcomes and elevated costs in health systems, representing a challenge in public health for countries of all income levels (¹1. Hafner M, Yerushalmi E, Stepanek M, Phillips W, Pollard J, Deshpande A, et al. Estimating the global economic benefits of physically active populations over 30 years (2020–2050). Br J Sports Med. 2020;54(24):1482–87.–⁴4. Heron L, O'Neill C, McAneney H, Kee F, Tully MA. Direct healthcare costs of sedentary behaviour in the UK. J Epidemiol Community Health. 2019;73(7):625–29.). Despite the benefits of both increasing physical activity and reducing sedentary behavior, Latin America and the Caribbean have the highest levels of physical inactivity worldwide (⁵5. Guthold R, Stevens GA, Riley LM, Bull FC. Worldwide trends in insufficient physical activity from 2001 to 2016: a pooled analysis of 358 population-based surveys with 1·9 million participants. Lancet Glob Health. 2018;6(10):e1077–e86.). About 40% of adults in South America do not achieve 150 minutes a week of physical activity, and nearly half of all adults spend more than 4 hours a day sitting (⁶6. Werneck AO, Baldew SS, Miranda JJ, Díaz Arnesto O, Stubbs B, Silva DR. Physical activity and sedentary behavior patterns and sociodemographic correlates in 116 982 adults from six South American countries: the South American physical activity and sedentary behavior network (SAPASEN). Int J Behav Nutr Phys Act. 2019;16(1):68.). Given these alarmingly high rates, several South American countries have created specific national health agendas targeting physical activity, but they have not necessarily placed equal emphasis on reducing sedentary behavior (⁷7. Varela AR, Pratt M, Powell K, Lee IM, Bauman A, Heath G, et al. Worldwide surveillance, policy, and research on physical activity and health: the Global Observatory for Physical Activity. J Phys Act Health. 2017;14(9):701–9.).

Alongside the development and implementation of effective strategies to stimulate physical activity and reduce sedentary behavior, it is essential to have well established nationwide surveillance of these two behaviors. Monitoring activities could help countries identify the prevalence, distribution, potential determinants and trends over time of physical activity and sedentary behavior, and the effectiveness of public health interventions to address them (⁸8. Tolonen H, Koponen P, Al-Kerwi A, Capkova N, Giampaoli S, Mindell J, et al. European health examination surveys – a tool for collecting objective information about the health of the population. Arch Public Health. 2018;76:38.–¹¹11. Kohl HW, 3rd, Craig CL, Lambert EV, Inoue S, Alkandari JR, Leetongin G, et al. The pandemic of physical inactivity: global action for public health. Lancet. 2012;380(9838):294–305.).

Regional surveillance of physical activity has already been initiated and implemented, and could serve as example for other regions (¹²12. Guthold R, Louazani SA, Riley LM, Cowan MJ, Bovet P, Damasceno A, et al. Physical activity in 22 African countries: results from the World Health Organization STEPwise approach to chronic disease risk factor surveillance. Am J Prev Med. 2011;41(1):52–60.). For instance, the European Union developed and implemented the European Health Interview Survey – Physical Activity Questionnaire (EHIS-PAQ) to be used by all European Union member states, which will make it possible to make regional comparisons and evaluations of health targets (¹³13. Finger JD, Tafforeau J, Gisle L, Oja L, Ziese T, Thelen J, et al. Development of the European Health Interview Survey – Physical Activity Questionnaire (EHIS-PAQ) to monitor physical activity in the European Union. Arch Public Health. 2015;73:59.). A similar endeavor would also benefit South America (¹⁴14. Werneck AO, Baldew SS, Miranda JJ, Incarbone Ó, Silva DR. The South American Physical Activity and Sedentary Behavior Network (SAPASEN). Glob Health Promot. 2020;27(3):171–6. Bull FC, Maslin TS, Armstrong T. Global physical activity questionnaire (GPAQ): nine country reliability and validity study. J Phys Act Health. 2009;6(6):790–804.). To date, no analysis has explored the similarities and differences between the various South American surveys that have been used for the assessment of physical activity and sedentary behavior. Therefore, the present study aimed to characterize how physical activity and sedentary behavior have been measured in national health surveys in South American countries.

METHODS

The selection of the national surveys was conducted in three phases. First, we searched for surveys on the websites of health and national statistical offices of each South American country. Second, the identified surveys were presented to the members of the South American Physical Activity and Sedentary Behavior Network (¹⁴14. Werneck AO, Baldew SS, Miranda JJ, Incarbone Ó, Silva DR. The South American Physical Activity and Sedentary Behavior Network (SAPASEN). Glob Health Promot. 2020;27(3):171–6. Bull FC, Maslin TS, Armstrong T. Global physical activity questionnaire (GPAQ): nine country reliability and validity study. J Phys Act Health. 2009;6(6):790–804.) in order to verify them. In addition, in this phase, representatives of the health sectors of South American countries were contacted asking for any additional surveys. All the websites consulted and contacts of the health sectors of the countries are available from the authors on request.

From all the surveys provided, we selected those that met the following eligibility criteria: (i) conducted in a South American country, with no date restrictions; (ii) used a nationally representative sample of adults (≥ 18 years); (iii) coordinated by the public, private or mixed private–public sector, including academic research groups; and (iv) included assessment of physical activity and/or sedentary behavior. Surveys that also included people younger than 18 years in their age range were eligible.

In the third phase, two of the authors summarized all extraction forms in tables that were checked by the co-authors. Data extracted included: general information about the surveys (country, year, name of the survey, data collection strategy and sample age range); specific details about the physical activity and sedentary behavior assessment (questionnaires/questions used, time reference and domains/context assessed); and additional questions related to the activity behaviors (e.g. reasons for and perceptions of physical activity and sports practice). We conducted a narrative review to synthesize information of each survey.

RESULTS

We identified 34 surveys across all 12 South American countries and two multicountry surveys with data from more than one country. General information on each national health survey that assessed physical activity is presented in Table 1. Surveys were conducted between 2003 (Chile) and 2020 (Venezuela), and the number of surveys conducted over this period in each country ranged from one (Guyana, Paraguay, and Suriname) to six (Peru). Among the countries with more than one survey, Argentina, Bolivia, Chile, and Venezuela had conducted only one type of survey, whereas Brazil, Colombia, Ecuador, Peru, and Uruguay had more than one type of survey. In addition, two multicenter surveys were conducted at one time point each. Data were collected by personal interview in 35 surveys (six reported the use of an electronic collector or personal digital assistants, four in Brazil, and one each in Chile and Paraguay); it was not clear how data were collected in one survey (Uruguay).

Of the questionnaires used, nine surveys used the Global Physical Activity Questionnaire (GPAQ) (¹⁵15. Bull FC, Maslin TS, Armstrong T. Global physical activity questionnaire (GPAQ): nine country reliability and validity study. J Phys Act Health. 2009;6(6):790–804.), six used the short version of the International Physical Activity Questionnaire (IPAQ), and six used the long version of the IPAQ (¹⁶16. Craig CL, Marshall AL, Sjöström M, Bauman AE, Booth ML, Ainsworth BE, et al. International physical activity questionnaire: 12-country reliability and validity. Med Sci Sports Exerc. 2003;35(8):1381-95.). Three surveys used only specific domains of the IPAQ long version and one survey used another questionnaire including all four physical activity domains. Thirteen surveys from six countries (Argentina, Colombia, Ecuador, Guyana, Peru, and Suriname) and a multicountry survey used questionnaires that deviated from the reference ones (description, examples, or sections). Surveys generally followed the reference time of the questionnaires (GPAQ: typical week; IPAQ: last 7 days). Among the multicenter surveys, the Latin American Study of Nutrition and Health used the transport and leisure domains of the IPAQ long version and included a device-based measure through accelerometers, in part of their samples (about 30%). The World Health Survey used the IPAQ short version.

We found that some surveys adapted questions from the reference physical activity instruments. Argentina’s survey (which used the IPAQ short version) included binary questions about the domains in its 2013 version. The surveys in Brazil (Pesquisa Nacional por Amostra de Domicílios 2015), Colombia (Encuesta Nacional de Salud 2007), and Chile (Encuesta Nacional de Salud 2003) used independent questions for leisure physical activity only. Bolivia used questions on achieving 30 minutes a day of physical activity regardless of the domain. Brazil (Pesquisa Nacional por Amostra de Domicílios 2008), Paraguay, and Peru (Encuesta Demográfica y de Salud Familiar 2011, 2012 and 2013) adopted independent questions for specific domains of physical activity. The Encuesta Nacional de Salud in Uruguay adopted a general question considering all domains.

Of the 36 surveys, 27 also assessed for sedentary behavior (Table 2). The assessment of sedentary behavior was generally included in the physical activity questionnaires. The short version of the GPAQ and IPAQ consider a single question about the total time (hours and minutes) spent sitting on a typical day or during the last 7 days, respectively. The long version of the IPAQ is similar to the short version but separates responses into week and weekend days. The Encuesta Nacional de Demografía y Salud, (Bolivia), the Pesquisa Nacional por Amostra de Domicílios 2008 (Brazil), the Pesquisa Nacional de Saúde 2019 (Brazil), the Encuesta Nacional de Salud (Uruguay), and the Latin American Study of Nutrition and Health were the only surveys that considered more than one type of sitting time (e.g. television-viewing, computer or video games, reading a newspaper, and listening to the radio). Some minor wording and structure changes were noted in questions on sedentary behavior (e.g. sedentary activity instead of sitting time – Primera Encuesta Nacional de Factores de Riesgo de Enfermedades No Transmisibles in Paraguay).

Additional questions about physical activity were included in 14 national surveys (available from authors on request). The reasons for doing or not doing physical activity were asked in surveys in Argentina and Uruguay, and in the two Brazilian surveys. Bolivian surveys asked about the perception of the benefits of physical activity and the Brazilian surveys included information about sports practice (past and present), as well as the environment, public policies and programs for physical activity. The first survey in Chile (2003) included a general question about the perception of the respondent’s own behavior during the day, and the last survey in Chile (2016–2017) had complementary questions on characteristics of specific domains and activities (transport). The Guyana survey used questions on access to information about physical activity. The Latin American Study of Nutrition and Health adopted specific information on environmental correlates of movement behaviors.

DISCUSSION

Information on physical activity does exist and is available from representative samples across all 12 South American countries. Although most of the surveys used the GPAQ or IPAQ (23/36, 64%), about half of them (13/23, 57%) did not use the reference version of the questionnaires and used only domain-specific questions or changed reference questions. The use of GPAQ and IPAQ was why information about sedentary behavior was available for all countries. With few exceptions, the surveys did not investigate the full spectrum of sedentary activities, such as lying down or reclining, but used instead single questions about sitting time of the physical activity questionnaires (¹⁷17. McLaughlin M, Atkin AJ, Starr L, Hall A, Wolfenden L, Sutherland R, et al. Worldwide surveillance of self-reported sitting time: a scoping review. Int J Behav Nutr Phys Act. 2020;17(1):111.). This may be because evidence on the role of sedentary behaviors as a risk factor for physical and mental diseases is more recent compared with the evidence on physical inactivity (¹⁸18. Tremblay MS, Aubert S, Barnes JD, Saunders TJ, Carson V, Latimer-Cheung AE, et al. Sedentary Behavior Research Network (SBRN) – terminology consensus project process and outcome. Int J Behav Nutr Phys Act. 2017;14(1):75.).

On a global level, a nationwide surveillance of physical activity and sedentary behavior allows for international comparisons and adequate monitoring of whether targets for these behaviors are attained or not (¹⁹19. Strain T, Wijndaele K, Garcia L, Cowan M, Guthold R, Brage S, et al. Levels of domain-specific physical activity at work, in the household, for travel and for leisure among 327 789 adults from 104 countries. Br J Sports Med. 2020;54(24):1488–97.). However, surveillance efforts vary across countries and depend on country priorities. While some high-income countries are already using wearable devices to objectively measure physical activity and sedentary time in their populations (²⁰20. Strain T, Wijndaele K, Brage S. Physical activity surveillance through smartphone apps and wearable trackers: examining the UK potential for nationally representative sampling. JMIR Mhealth Uhealth. 2019;7(1):e11898., ²¹21. LaMunion SR, Fitzhugh EC, Crouter SE. Challenges and opportunities related to the objective assessment of physical activity within U.S. health surveys. Ann Epidemiol. 2020;43:1–10.), most low- and middle-income countries still rely on self-reporting methods as the main way to collect such data in their national health surveys.

Although South American countries have included questionnaires and/or questions about physical activity in their national surveys, the way this information has been generated deserves careful attention. Both the GPAQ and the IPAQ (short and long versions), although widely used and accepted, tend to show mixed psychometric properties depending on the region in the world and population subgroup (¹⁵15. Bull FC, Maslin TS, Armstrong T. Global physical activity questionnaire (GPAQ): nine country reliability and validity study. J Phys Act Health. 2009;6(6):790–804., ²²22. Lee PH, Macfarlane DJ, Lam TH, Stewart SM. Validity of the international physical activity questionnaire short form (IPAQ-SF): a systematic review. Int J Behav Nutr Phys Act. 2011;8(1):115.–²⁵25. Hallal PC, Gomez LF, Parra DC, Lobelo F, Mosquera J, Florindo AA, et al. Lessons learned after 10 years of IPAQ use in Brazil and Colombia. J Phys Act Health. 2010;7(Suppl 2):S259–64.). In addition, using adapted versions, selecting some questions from each questionnaire and rephrasing them, adapting the question, or not including all domains of the questionnaires (i.e. leisure, work, household, and transport) could affect the psychometric properties of the instruments and thus affect their validity and reliability. Furthermore, the changes introduced through adaptations made to the reference tools and the addition of questions, as evidenced by our results, could potentially undermine comparisons between countries (²⁶26. Mindell JS, Moody A, Vecino-Ortiz AI, Alfaro T, Frenz P, Scholes S, et al. Comparison of health examination survey methods in Brazil, Chile, Colombia, Mexico, England, Scotland, and the United States. Am J Epidemiol. 2017;186(6):648–58.–³²32. Strath SJ, Kaminsky LA, Ainsworth BE, Ekelund U, Freedson PS, Gary RA, et al. Guide to the assessment of physical activity: clinical and research applications: a scientific statement from the American Heart Association. Circulation. 2013;128(20):2259–79.). Given these characteristics, further investigation on the psychometric properties of the adapted instruments should be conducted in the South American context in order to assess the quality of the measures generated.

Some countries also assessed complementary information about physical activity, such as reasons for practising specific types of sports (or not) and past practices. This assessment does not seem to follow any standard and appears to be more related to the interests and expectations of each surveillance system and policy-makers.

Since one of the main aims of monitoring physical activity and sedentary behavior is to assess the prevalence of these behaviors at the population level (active versus inactive; sedentary versus non-sedentary), instruments are not always able to capture all aspects of physical activity and sedentary behavior. Similar to most countries (³³33. Milton K, Varela AR, Strain T, Cavill N, Foster C, Mutrie N. A review of global surveillance on the muscle strengthening and balance elements of physical activity recommendations. J Frailty Sarcopenia Falls. 2018;3(2):114–24.), muscle strengthening and balance exercises are not specifically assessed in the South American surveys, although this has been recommended in public health guidelines on physical activity (³⁴34. Bull FC, Al-Ansari SS, Biddle S, Borodulin K, Buman MP, Cardon G, et al. World Health Organization 2020 guidelines on physical activity and sedentary behaviour. Br J Sports Med. 2020;54(24):1451–62.). Until recently, research on sedentary behavior has relied on self-report measures and has primarily been examined through screen-based behaviors, which explains the questions used by the surveys. Although consensus is lacking on cut-offs for sedentary behavior, interest in its specific manifestations (e.g. TV-viewing, smartphone use, and reading) and their patterns (e.g. timing, duration of bouts, and frequency of breaks) are growing (¹⁸18. Tremblay MS, Aubert S, Barnes JD, Saunders TJ, Carson V, Latimer-Cheung AE, et al. Sedentary Behavior Research Network (SBRN) – terminology consensus project process and outcome. Int J Behav Nutr Phys Act. 2017;14(1):75., ³⁵35. Prince SA, Butler GP, Roberts KC, Lapointe P, MacKenzie AM, Colley RC, et al. Developing content for national population health surveys: an example using a newly developed sedentary behaviour module. Arch Public Health. 2019;77:53.). Previous work suggests that despite the importance of screen time, it alone may not be a good marker for sedentary behavior, which highlights the need to assess a variety of sedentary behaviors (³⁶36. Biddle SJ, Gorely T, Marshall SJ. Is television viewing a suitable marker of sedentary behavior in young people? Ann Behav Med. 2009;38(2):147–53.).

Surveys can also be used to identify trends over time. Most of the countries, except for Guyana and Suriname, conducted at least two surveys in different years allowing time trend analysis of physical activity and sedentary behavior in nine and five countries, respectively. However, in some countries, differences between the questionnaires used in the different surveys did not allow valid analysis of time trends. However, in Argentina, Brazil, Bolivia, Chile, Colombia, Peru, Uruguay, and Venezuela the same surveys were used at different times, thus allowing time comparisons within the countries, but not necessarily across countries since they used different tools.

As recommendations derived from international physical activity guidelines may change over time, attention should also be given to preserving the time comparability (evaluation of public health practice) (³⁷37. Ki JS, Kim H. Comparison of estimates and time series stability of Korea Community Health Survey and Korea National Health and Nutrition Examination Survey. Epidemiol Health. 2019;41:e2019012.) or adjusting questionnaires (data generation) to new guidelines. For example, the interest in the integrative view of behaviors during the 24 hours of the day, the incorporation of different physical activity intensities, sedentary behaviors and sleep (³⁸38. Tremblay MS, Carson V, Chaput J-P, Connor Gorber S, Dinh T, Duggan M, et al. Canadian 24-hour movement guidelines for children and youth: an integration of physical activity, sedentary behaviour, and sleep. Applied Physiology, Nutrition, and Metabolism. 2016;41(6 Suppl 3):S311–27.–⁴⁰40. Rollo S, Antsygina O, Tremblay MS. The whole day matters: understanding 24-hour movement-guideline adherence and relationships with health indicators across the lifespan. J Sport Health Sci. 2020;9(6):493–510.), as well as the removal of the criterion that physical activity should be performed in bouts of at least 10 minutes in the most recent guidelines on physical activity and sedentary behavior of the World Health Organization (⁴¹41. Troiano RP, Stamatakis E, Bull FC. How can global physical activity surveillance adapt to evolving physical activity guidelines? Needs, challenges and future directions. Br J Sports Med. 2020;54(24):1468–73.) can demand adjustments on the surveillance systems.

In view of the multiple dimensions of physical activity and sedentary behaviors (e.g. frequency, intensity, pattern, context, type, and reasons for a particular behavior), public health systems are faced with hard decisions on their priorities and the costs associated with surveys to be conducted at the population level. In addition, although indicators of sedentary behavior are slightly more consistent, the comparability of physical activity indicators from national health surveys from South American countries can be affected by the different measures used. For example, the IPAQ questionnaire overestimates physical activity compared with the GPAQ and it is possible to create a correction (⁵5. Guthold R, Stevens GA, Riley LM, Bull FC. Worldwide trends in insufficient physical activity from 2001 to 2016: a pooled analysis of 358 population-based surveys with 1·9 million participants. Lancet Glob Health. 2018;6(10):e1077–e86.) based on the differences between IPAQ and GPAQ. However, the use of other less known questionnaires which contain only part of domains or even domain-specific questions are a major challenge for harmonization of the physical activity data. To increase between-country comparability, countries should discuss the adoption of standardized measures within their national health surveys, or at least consistently use the reference questionnaires.

This comprehensive narrative review has limitations. We focused on the assessment of movement behaviors and individual methodological characteristics of the national surveys were not considered, e.g. sampling design, age ranges of participants, training of personnel, or response rates. Since this review considered only nationally representative surveys, it is possible that further surveys exist that are less comprehensive but which could provide additional evidence of physical activity and sedentary behavior for specific municipalities or regions in South America; for example the VIGITEL which represents states capitals in Brazil and provides different indicators of movement behaviors (⁴²42. Cruz MSd, Bernal RTI, Claro RM. Tendência da prática de atividade física no lazer entre adultos no Brasil (2006–2016) [Trends in leisure-time physical activity in Brazilian adults (2006–2016)]. Cad Saúde Pública. 2018;34(10):e00114817.). However, this is the first review of physical activity and sedentary behavior surveillance among adults from South American countries and it aimed to improve our understanding of the assessment of physical activity and sedentary behavior in the continent (⁴³43. Stamatakis E, Bull FC. Putting physical activity in the "must-do" list of the global agenda. Br J Sports Med. 2020;54(24):1445–6.). Our review points to the importance of standardizing assessment within South America when considering future national surveys and/or future implementation/modification of the physical activity and sedentary behavior sections in national surveys, with the broader aim of contributing towards establishing a standardized strategy for the surveillance of physical activity and sedentary behavior in the South American region.

In conclusion, information about physical activity and sedentary behavior derived from national surveys from all South American countries is available. Although assessment instruments vary among surveys, the most used were GPAQ, IPAQ or questions/specific domains of these questionnaires. Sedentary behavior has not been assessed as an independent behavior, but through single questions in physical activity questionnaires. These findings will help inform the strengths and weaknesses of comparison efforts of existing data on physical activity and sedentary behaviors in the region. Similarly, this study points to essential minimum requirements for future standardization efforts to generate meaningful comparable data across countries to enable broader monitoring and evaluation of physical activity and sedentary behaviors, which have such important public health relevance.

Disclaimer.

The authors are solely responsible for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the Revista Panamericana de Salud Pública/Pan American Journal of Public Health and/or those of the Pan American Health Organization, nor those of the institutions to which the authors are affiliated.

REFERENCES

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