Assessing Physical Activity Levels in Filipino Americans With Hypertension Using the Rapid Assessment of Physical Activity Questionnaire

Abstract

Regular physical activity decreases the risk of cardiovascular disease and premature death. Little research has been conducted among Filipino Americans about their level of physical activity. Using the validated Rapid Assessment of Physical Activity questionnaire, we examined the activity level of Filipino Americans (N = 108) from the southwest region of the United States and compared the findings with national physical activity guidelines. The sample mean age was 65 years, 98% were born in the Philippines, 31% had some college education, 71% were married, and 40% had incomes less than $25,000. The mean blood pressure was 140/85 mmHg. The mean score for physical activity level was 5 (max. score 7) and for strength and flexibility 1 (max. score 3), which is less than the recommended guidelines. Lifestyle strategies to increase physical activity and reduce obesity and hypertension in this high-risk, understudied population are warranted.

Keywords

hypertension Filipino Americans obesity physical activity physical function Rapid Assessment of Physical Activity (RAPA)

Introduction

Filipino Americans are the second largest Asian subgroup and one of the fastest growing immigrant populations in the United States.^1
-3 There are approximately 3.4 million Filipino Americans in the United States, with a population growth increase of 38.9% between 2000 and 2010.² Hypertension is a significant problem in this population and its complications are the leading cause of death.⁴

The American Heart Association recommends that all adults participate in moderate to vigorous physical activity at least 3 to 5 days per week to reduce the risk of hypertension and other cardiovascular-related diseases.⁵ Regular physical activity is associated with a reduction in blood pressure.^6
-8 Aerobic activities have been shown to lower systolic blood pressure by 3.4 to 10.5 mmHg and diastolic blood pressure by 2.4 to 7.6 mmHg.^9
-13 Even low-intensity physical activities have been shown to reduce systolic blood pressure by 11 mmHg and diastolic blood pressure by 6 mmHg.¹⁴ Physical activity has also been shown to decrease markers of inflammation associated with the development of hypertension such as C-reactive protein and interleukin-6.¹⁵ It also suppresses the pro-inflammatory transcription nuclear factor κ B and aortic stiffness responsible for the development of hypertension.¹⁶ Moreover, there is strong evidence that physical activity reduces weight gain and depression, and improves balance, bone density, sleep quality, and cognitive function.¹⁷

To date, studies on physical activity and overall health of Filipino Americans are limited. Understanding the level of physical activity among Filipino Americans is an important starting point prior to recommending and initiating physical activity interventions for this population.

Several physical activity assessment measures have been tested in both clinical and community settings. One tool is the brief, easy-to-administer Rapid Assessment of Physical Activity (RAPA) questionnaire.¹⁸ The aim of this study was to examine the physical activity level of Filipino Americans with hypertension using the RAPA questionnaire, and whether it meets the recommended national guidelines for physical activity.^19,20

Methods

We secured approval to conduct this study from the University of Nevada, Las Vegas, Institutional Review Board prior to research activities and used flyers, posters, and word of mouth to recruit research participants.

Study Design, Sample, and Setting

Our study used a cross-sectional research design. We recruited Filipino Americans from a primary care clinic in the southwest region of the United States between April and May 2015. The clinic had a total of 15,348 patients. Among those patients, 82% were Filipinos, 7% Caucasians, 5% Hispanics, 3% African Americans, and 3% were other Asians. To recruit participants, we distributed flyers, and posters were displayed inside the clinic’s lobby and in each patient’s room. The inclusion criteria were Filipino Americans who could speak and understand English, read and write, and had a diagnosis of hypertension or were taking antihypertensive drugs. The exclusion criteria were patients with cognitive impairment or severe illness.

RAPA Questionnaire

We used the RAPA questionnaire in a clinical setting to assess the physical activity level and the strength and flexibility level of Filipino Americans with hypertension. RAPA is a nine-item, self-administered questionnaire that requires only 2 to 5 minutes to complete, is easily understood, and readable at the sixth-grade level.^21,22 The questions are based on the Centers for Disease Control and Prevention, 2008 Physical Activity Guidelines for Americans.¹⁹ RAPA has been used in several research studies and is considered valid and reliable.¹⁸ RAPA has an 81% sensitivity, 69% specificity, and 77% positive predictive value, and is significantly correlated with the Community Healthy Activities Model Program for Seniors physical activity questionnaire.^21,23,24 Many clinicians use this questionnaire to rapidly capture patients’ physical activity levels and determine compliance to the activity based on the national physical activity guidelines.

The RAPA questionnaire has two sections: RAPA₁ and RAPA₂ (Table 1). RAPA₁ includes seven questions about the physical activity level of leisure-time aerobic activity based on pictures of light, moderate, and vigorous activities.^21,22 The questions are categorized as either sedentary, under-active, or active. The question with the highest number with an affirmative response is selected for scoring. For example, if question 1, “I rarely or never do any physical activities” is marked “yes,” it is scored “1” and regarded as sedentary. Questions 2 through 5, “I do some light or moderate physical activities, but not every week,” to “I do vigorous physical activities every week, but less than 20 minutes a day or 3 days a week,” are considered under-active. Questions 6 through 7, “I do 30 minutes or more a day of moderate physical activities, 5 or more days a week,” and “I do 20 minutes or more a day of vigorous physical activities, 3 or more days a week,” are considered active. According to Topolski and colleagues,¹⁸ a RAPA score less than 6 is suboptimal and is used as a benchmark for not meeting the standard recommendations for physical activity.²⁴ RAPA₂ has two questions and evaluates strength and flexibility training: “I do activities to increase muscle strength such as lifting weights once a week or more” and “I do activities to improve flexibility such as stretching or yoga once a week or more.” Any score less than 3 is considered suboptimal.

Table 1.

RAPA Questionnaire.

Score question	Yes	No
RAPA₁
1. I rarely or never do any physical activities	□	□
2. I do some light or moderate physical activates, but not every week	□	□
3. I do some light physical activity every week	□	□
4. I do moderate physical activities every week, but less than 30 minutes a day or 5 days a week	□	□
5. I do vigorous physical activities every week, but less than 20 minutes a day or 3 days a week	□	□
6. I do 30 minutes or more a day of moderate physical activities, 5 or more days a week	□	□
7. I do 20 minutes or more a day of vigorous physical activities, 3 or more days a week	□	□
RAPA₂
1. I do activities to increase muscle strength, such as lifting weights or calisthenics, once a week or more	□	□
2. I do activities to improve flexibility, such as stretching or yoga, once a week or more	□	□

Note. RAPA = Rapid Assessment of Physical Activity.

Procedures

The questionnaires were completed in a private room inside the primary care clinic. Two research-trained Filipino Americans (registered nurse and undergraduate student) assisted in the recruitment and data collection. They met with the participants, explained the purpose and procedure of the study, obtained informed consent, and administered the questionnaires. A total of 108 participants completed the questionnaires. Each participant received a gratuity of $10 for participating.

Data Analysis

We analyzed all data with the IBM Statistical Program for the Social Sciences (SPSS) 20 for Windows, including descriptive statistics and frequencies.

Results

The mean age of the sample was 65 (35-80) years. There were 64 females (59%) and 44 males (40%) and 98% were born in the Philippines. Of these, 31% completed high school and had at least 2 years of college; 71% were married, 73% had adult children living with them, and 40% had incomes less than $25,000 (Table 2).

Table 2.

Demographic Characteristics of Participants (N = 108).²⁶

Characteristic	Category	n	%
Place of birth	Philippines	108	100
Gender	Female	64	59.3
Gender	Male	44	40.7
Age (years)	<30	2	1.9
	31-40	7	6.4
	41-50	10	9.2
	51-60	28	25.7
	61-70	41	37.6
	71-80	17	15.6
	>80	3	2.8
Education (years)	<10	9	8.3
	10-12	38	35.1
	13-16	53	49.1
	17-18	8	7.41
Marital status	Single	16	14.8
	Married	77	71.3
	Separated/divorced	15	13.9
No. of children younger than 18 years old living in the same house	0	79	73.1
	1	14	13.0
	2	6	5.6
	3	6	5.6
	4 or more	3	2.8
Household annual income	<$25,000	43	39.8
	$25,000-$49,999	25	23.1
	$50,000-$74,999	20	18.5
	$75000-$99,999	12	11.1
	>$100,000	7	6.5

Table 3 outlines the participants’ blood pressure and number of medications. The mean blood pressure was 140/85 mmHg: 37% had prehypertension, 39% had Stage 1 hypertension, and 13% had Stage 2 hypertension. Ninety percent were on antihypertensive drugs and 43.5% reported taking two or more of these medications.

Table 3.

Participants’ Blood Pressure and Number of Medications.²⁵

Characteristic	Category	n	%
Blood pressure (mmHg)	Normal	12	11.0
	Prehypertension	40	37.0
	Hypertension, Stage 1	42	39.0
	Hypertension, Stage 2	14	13.0
Taking antihypertensive drugs	No	11	10.2
Taking antihypertensive drugs	Yes	97	89.8
No. of antihypertensive drugs	0	1	0.9
	1	61	56.5
	2	23	21.3
	3	11	10.2
	4 or more	3	2.8

Note. SBP = systolic blood pressure; DBP = diastolic blood pressure. Joint National Committee (JNC) 7 Classification of Blood Pressure in Adults (3). Prehypertension (SBP 120-139 mmHg or DBP 80-89 mmHg); hypertension, Stage 1 (SBP 140-159 mmHg or DBP 90-99 mmHg); hypertension, Stage 2 (SBP ≥160 mmHg or DBP ≥100 mmHg).

Table 4 presents the anthropometric measurements of participants. The mean weight was 68.9 kg (151 lbs), body mass index was 27.08 kg/m², waist circumference was 89.72 cm, and hip circumference was 97.79 cm.

Table 4.

Anthropometric Measurements.

Measurement	Female	Male	Total
Measurement	M	M	M
Height (m)	1.54	1.67	1.59
Weight (kg)	62.56	78.33	68.98
Body mass index (kg/m²)	26.38	28.11	27.08
Waist circumference (cm)	86.63	94.21	89.72
Hip circumference (cm)	97.62	98.03	97.79
Waist/hip ratio	0.89	0.96	0.92
Waist/height ratio	0.56	0.56	0.56

The mean RAPA₁ score for aerobic training was 5 (max. score 7) and the mean RAPA₂ score for strength and flexibility was 1 (max. score 3; not shown in the table). This indicates that the sample in this study was under-active and not meeting the standard recommendations for physical activity.

The RAPA scores based on individual question are presented in Tables 5 and 6.

Table 5.

RAPA₁ Scores in Percentage (N = 108).

RAPA₁ questions	Yes	No
I rarely or never do any physical activities	22	78
I do some light or moderate physical activates, but not every week	73	27
I do some light physical activity every week	65	35
I do moderate physical activities every week, but less than 30 minutes a day or 5 days a week	0	40
I do vigorous physical activities every week, but less than 20 minutes a day or 3 days a week	69	31
I do 30 minutes or more a day of moderate physical activities, 5 or more days a week	45	55
I do 20 minutes or more a day of vigorous physical activities, 3 or more days a week	39	61

Note. RAPA = Rapid Assessment of Physical Activity.

Table 6.

RAPA₂ Scores in Percentage (N = 108).

RAPA₂ questions	Yes	No
I do activities to increase muscle strength, such as lifting weights or calisthenics, once a week or more	38	62
I do activities to improve flexibility, such as stretching or yoga, once a week or more	43	57

Note. RAPA = Rapid Assessment of Physical Activity.

Discussion

Physical activity is an important component of health. It should be monitored routinely in a clinical setting like other modifiable cardiovascular risk factors such as hypercholesterolemia, diabetes, and smoking.²⁶ RAPA questionnaire has a demonstrated acceptability and quickly estimated the physical activity level of Filipino Americans with hypertension in a primary care clinic. In our study, participants reported a low level of physical activity and strength and flexibility training, not meeting the recommended national guidelines. Most participants reported they engaged in light to moderate physical activities such as walking, vacuuming, or doing light yard work, but they spent less than 30 minutes a day or less than 5 days a week performing these activities. More than half of the sample did not engage in strength or flexibility training such as lifting, stretching, or yoga. Those who did this training did so only once a week.

RAPA provided a rapid self-report and an overview of the physical activity level of our participants. Although our study did not assess factors related to physical inactivity, it is possible that the reasons for not adopting an active lifestyle are similar to those reported in the literature. According to the Centers for Disease Control and Prevention,²⁷ the most common reasons for physical inactivity are lack of awareness about the benefits of physical activity; lack of time, motivation, and confidence; fear of injury; inconvenience; not enjoyable; and weather conditions. Understanding these barriers and developing strategies to overcome them may also apply to individuals with hypertension and help them engage in regular physical activity. Suggestions for overcoming these barriers may also apply to Filipino Americans. Strategies specific to this population include teaching and counseling about the benefits of physical activity through social media; monitoring and logging daily activities to increase awareness and be mindfully attuned to active behavior; starting slow and increasing the time and amount of activity to avoid injury and prevent added stress to their daily routines; using peer and family support; increasing motivation by joining social clubs or a dance group; starting the activity early in the morning when energy and mental focus are highest; and teaching how to warm up and cool down to prevent injury.^25,27
-32 The availability of transportation reduces the need to walk, and technologies such as the television and smart phone promote sedentary behaviors. In addition, the lack of fitness centers for adults and community centers with culturally based programs may be barriers to physical activity. Dirige and colleagues³⁰ studied the effects of an 18-month culturally based physical activity intervention among 528 older Filipino Americans living in San Diego, California. Following the intervention, which encompassed nutrition, counseling, and physical activities, there was a significant increase in the level of physical activity and program involvement among the participants. The researchers suggested that culturally specific programs encouraging physical activity interventions and a healthy lifestyle among Filipino Americans be emphasized. These recommendations may be a way of motivating Filipino Americans to engage in regular physical activity.

Limitations

This study used convenience sampling, which limits the generalizability of the study findings. Participants were a small non-random sample of volunteers with hypertension from a primary care clinic. The results may only reflect the Filipino American adult population with hypertension, making generalizations challenging. It was also a self-report study and subject to misreporting due to personal or social desirability bias, poor memory, misunderstandings, or other reasons. Despite the limitations, our study contributes to both home health care and clinical practice by providing insights to nurses, clinicians, and other health care providers about the physical level of Filipino Americans with hypertension or other chronic disease and the usefulness of the RAPA questionnaire in capturing the physical activity level of individuals.

Conclusions

RAPA has a demonstrated acceptability, was easy to use, and quickly captured the physical activity level of Filipino Americans with hypertension in our study. The participants did not meet the recommended national guidelines for physical activity, or strength and flexibility training. Lifestyle strategies that increase physical activity and reduce the incidence or severity of hypertension in this high-risk, understudied population are warranted. Findings from our study can be used by health care providers in advocating an active lifestyle for Filipino Americans as part of an overall health and wellness program.

Footnotes

Acknowledgements

The authors thank Dr. Benito Calderon, MD; Dr. Tari D. Topolski; Ms. Amanda Aldana, RN; and Mr. Audwin C. Angosta, BSPsy student for assistance with recruitment and data collection; and all the participants who took part in this study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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