Relationship between meeting the recommendations for physical activity and health-related quality of life in adult Chinese Internet users

doi:10.4236/ojpm.2011.13014

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Vol.1, No.3, 94-100 (2011)

doi:10.4236/ojpm.2011.13014

Open Journal of Preventive Medicine

Relationship between meeting the recommendations for

physical activity and health-related quality of life in adult

Chinese Internet users

Jia-Meng Ma1,2*, Ai Shibata3, Isao Muraoka3

1Graduate School of Sport Sciences, Waseda University, Tokyo, Japan; *Corresponding Author: jiameng2011@gmail.com

2School of Physical Education, Sendai University, Sendai, Japan;

3Faculty of Sport Sciences, Waseda University, Tokyo, Japan; aishibata@aoni.waseda.jp, imuraoko@aoni.waseda.jp

Received 10 September 2011; revised 17 October 2011; accepted 29 October 2011.

ABSTRACT

Background: The benefits of a recommended

level of physical activity on physiological health

indicators such as morbidity and mortality are

well-accepted, but few researches has addressed

whether or not the association between the re-

commended level of physical activity and a

health-related quality of life (HRQOL) exists in

the Chinese adults. Purpose: The present study

examined whether the recommended physical

activity (PA) would be associated with HRQOL

in the Chinese adults. Methods: Cross-sectional

data were collected through an internet-based

survey. Total of 1394 Chinese adults responded

the International Physical Activity Question-

naire-Chinese version examining whether indi-

viduals met the recommended ACSM/AHA PA

guideline. Demographic data were also obtained.

HRQOL was assessed with the Medical Out-

comes Survey Shor t Form-3 6 que sti onnair e (SF -

36). Multivariate analyses of covariance were

utilized to examine differences in multidimen-

sional scales of the SF-36. Results: In both gen-

ders, the recommended group had significantly

higher physical functioning, vitality, and mental

health scores than the inactive group. Signifi-

cant differences in role physical, general health,

social functioning scores were only found among

the recommended and insufficient male groups.

Conclusion: Individuals w ho attained the recom-

mended level of PA had better scores on some

dimensions of HRQOL than those who did not.

Keywords: Behavior Science; Health Promotion;

HRQOL; Physical Activity

1. INTRODUCTION

In its focus on healthy living, the World Health Or-

ganization (WHO) places an emphasis not simply on

preventing chronic diseases, but on preserving or im-

proving quality of life (QOL) through the maintenance

of a good state of physical independent function and

mental health in daily life. Health-related quality of life

(HRQOL) is defined as individual and community per-

ceptions of physical and mental health, and is considered

an important indicator in evaluating health status [1]. It

is also a basic tool used to evaluate self-awareness of the

physical and mental aspects of health status in daily life

[2,3].

Sufficient physical activity is already known to reduce

the risk of mortality and morbidity of chronic conditions

such as coronary artery disease, diabetes mellitus, or

hypertension [4-7]. It is also well-documented that as

well as having such physical effects, physical activity

also has mental effects. Previous studies have reported

that people who are physically inactive in their daily

lives have lower HRQOL than active people [8-10], and

that the mental aspect of HRQOL in those who engage

in regular exercise is superior to that of those with a

sedentary lifestyle [11]. Based on these findings, health

care providers and health promotion workers recom-

mend engaging in regular physical activity as a means to

maintain or improve HRQOL.

In the United States (US), the American College of

Sports Medicine/American Heart Association (ACSM/

AHA) published guidelines encouraging people to par-

ticipation physical activity in order to prevent chronic

diseases and maintain or improve health [12]. These

guidelines recommend engaging in ≥150 minutes per

week of at least physical activity of moderate-intensity,

and the guidelines are currently in widespread use

around the world [13,14]. In a study using the Medical

Outcomes Study short form 36 (SF-36) to investigate the

J.-M. Ma et al. / Open Journal of Preventive Medicine 1 (2011) 94-100

relationship between meeting the recommended amount

of physical activity and HRQOL in French adults, those

who met the recommended amount scored higher than

those who did not in five of the eight SF-36 domain

scales: physical functioning, vitality, general health, so-

cial functioning, and mental health [12,15]. Thus, reports

mainly from the US and Europe indicate that meeting

the recommended amount of physical activity not only

reduces the prevalence of chronic diseases or the mortal-

ity rate from such diseases, but is also beneficial in in-

creasing the HRQOL[10].

China also has the same emphasis on HRQOL as

other countries. In the Healthy China 2020 Strategy an-

nounced by the Ministry of Health of the People’s Re-

public of China, the ultimate goal of health promotion is

to increase HRQOL [16]. While there have been occa-

sional studies in China of the relationship between

HRQOL and physical activity focusing on specific groups

such as people suffering a particular disease [17,18],

there have been no studies investigating this relationship

in Chinese adults across a wide range of age-groups

[19].

There has been tremendous socioeconomic growth in

China in recent, particularly in urban areas, and lifestyles

are becoming westernized at an ever-increasing rate.

According to a 2009 survey report of the development of

the Internet in China, the number of Internet users in

urban areas is increasing every year. Internet penetration

in China is 31.8%, and 72.6% of Internet users are urban

dwellers. Health problems among these urban Internet

users are expected to increase as a result of increasing

Westernization of their lifestyles and decreased physical

activity. In order to build the measures to address physic-

cal inactivity, it would be useful to survey physiccal

activity and HRQOL among urban dwellers in China,

who are at particularly high risk of physical inactivity.

The present study examined that the relationship be-

tween recommended amount of physical activity and

HRQOL among adult Chinese Internet users.

2. METHODS

2.1. Participants

The survey was carried out from December 2009 to

January 2010. The participants were Chinese adults reg-

istered as monitors (approx. 1,950,000 people as of No-

vember, 2009) with a Japanese company specializing in

overseas surveys. The goal was to have responses from

1,300 people, and after stratifying the participants to

ensure equal numbers of each gender and age group (30

- 39 years, 40 - 49 years, 50 - 59 years), 39,000 adults

from across China were randomly selected. The survey

company sent an e-mail to each person requesting their

cooperation with the questionnaire survey. The final num-

ber of respondents was 1501, a response rate of 3.8%.

By way of remuneration, the participants who responded

to the questionnaire survey were awarded Internet points

by the survey company according to the number of sur-

vey items to which they responded. The present study

was approved by the institutional review board by the

Waseda University (approved number 2009-145, Dec. 7.

2009).

2.2. Measures

2.2.1. Physical Activity

The Chinese version of the International Physical Ac-

tivity Questionnaire–Short Version (IPAQ–SV) [20] was

used to estimate the amount of physical activity. The

IPAQ–SV was designed for the purpose of identifying

the frequency and duration of walking, moderate and

vigorous physical activity, and sedentary activity during

the past week The reliability and validity of the Chinese

version of the IPAQ–SV have already been investigated

in a previous study, with a test-retest reliability coeffi-

cient of r = 0.779 and validity shown by a good correla-

tion of r = 0.598 with the daily energy expenditure cal-

culated from the physical activity log [20]. This is a

similar result to verification of the reliability and validity

of the International Physical Activity Questionnaire car-

ried out in 12 countries [21].

The total amount of physical activity (hours/week)

was weekly minutes of walking, moderate-intensity and

vigorous-intensity activity were calculated by multiply-

ing the number of days/week by the frequency of physic-

cal activity. On the basis of the ACSM/AHA guidelines,

participants with a total weekly amount of physical ac-

tivity (including walking and moderate-intensity and

vigorous intensity physical activity) of 150 minutes or

more were classified into the sufficient group, and those

with a total of less than 150 min were classified into the

insufficient group.

2.2.2. HRQOL

The Chinese version of the SF-36 [22] was used to

measure HRQOL. The validity and reliability of apply-

ing this instrument to Chinese people have been con-

firmed [23]. It has also been shown that the electronic

version, used over media such as the Internet, has the

same levels of validity and reliability as the paper self-

reporting version [24]. The questionnaire has 36 items,

organized into the following eight domain scales: physic-

cal functioning (PF), role-physical (RP), bodily pain

(BP), general health (GH), vitality (VT), social func-

tioning (SF), role-emotional (RE), and mental health

(MH). Each domain scale is calculated as a score from 0

J.-M. Ma et al. / Open Journal of Preventive Medicine 1 (2011) 94-100

to 100, with higher scores indicating better levels of sub-

jective health and functioning.

2.3. Statistical Analysis

Of the 1501 respondents, 107 were excluded on the

basis of the data exclusion criteria established in the

IPAQ-SV protocol, including cases in which the total

physical activity exceeded 960 minutes (16 hours) and

cases for which data were lost. The remaining 1,394

subjects (92.9%) were analyzed. All analyses were per-

formed after stratification by gender. A t-test and a

one-way analysis of variance (ANOVA) were used to

investigate the relationships between demographic vari-

ables and differences in the SF-36 domain scales. The

differences in scale scores between the two groups clas-

sified according to whether they met the recommended

amount of physical activity (sufficient group, insuffi-

cient group) were investigated using a multivariate

analysis of covariance (MANCOVA), with the demo-

graphic variables for which a significant relationship

with the domain scales was found in the ANOVA (age,

marital status, employment status) as covariates. The

significance level was set at p < 0.05. The analysis soft-

ware was SPSS ver. 17.0.

3. RESULTS

3.1. Basic Characteristics of Respondents

The mean age of subjects was 43.0 ± 8.0 years, and

50.2% were male. The participants were 91.7% married,

97.8% employed, and 67.6% had university or higher

educational status. In addition, 62.3% had a personal

annual household income of 50,000 yuan or more and

63.7% had a body mass index within the standard range.

As for walking, total minutes were 280.2 ± 319.2 min

per week in male, while females accumulated totally

294.8 ± 373.2 min per week. Also, males spent 250.6 ±

348.5 min in moderate-intensity activity, whereas females

spent 254.8 ± 346.6 minutes. In addition, weekly time of

vigorous-intensity activity in males and females were

180.7 ± 279.0 minutes and 160.9 ± 281.6 minutes respect-

tively. Of the total attributes, 87.3% met the recom-

mended amount of physical activity (Table 1). Of these,

89.0% of males and 85.6% of females met the recom-

mended amount of physical activity. Moreover, there

were 2.6% of participants were found to be inactive.

Table 1. Basic characteristics and physical activity level for male and female Chinese respondents.

Participants

Men Women

n (%) mean(SD ) n (%) mean (SD) Total n (%)

Total 700 (50.2) 694 (49.8) 1394 (100)

Age

30 - 39 234 (33.4) 235 (33.9) 469 (33.6)

40 - 49 234 (33.4) 232 (33.4) 466 (33.4)

50 - 59 232 (33.1) 227 (32.7) 459 (32.9)

Marital status

married 650 (92.9) 628 (90.5) 1278 (91.7)

unmarried 50 (7.1) 66 (9.5) 116 (8.3)

Employment status

employed 688 (98.3) 701 (97.5) 1364 (97.8

not employed 12 (1.7) 18 (2.5) 30 (2.2)

Educational status

≤high school graduate 4 (7.0) 53 (7.6) 102 (7.3)

2years college or equivalent 160(22.9) 189 (27.2) 349 (25.0)

≥college graduate 491(70.0) 452 (65.1) 943 (67.6)

Income level (RMB)

<30,000 90 (12.9) 78 (11.2) 168 (12.1)

30,000 - 40,000 75 (10.7) 69 (9.9) 144 (10.3)

>40,000 - 50,000 105 (15.0) 108 (15.6) 213 (15.3)

>50,000 430 (61.4) 439 (63.0) 869 (62.3)

BMI (kg/m²)

<18.5 10 (1.4) 49 (7.1) 59 (4.2)

18.5 - 23.9 398 (56.9) 490 (70.7) 888 (63.7)

24.0 - 27.9 252 (36.0) 136 (19.6) 388 (27.8)

≥28.0 40 (5.7) 19 (2.7) 59 (4.2)

Physical activity level

Recommendeda 623 (89.0) 594 (85.6)

Walking (min/week)b 280.2 (319.2) 294.8 (373.2)

Moderate-intensity activity (min/week)b 250.6 (348.5) 254.8 (346.6)

Vigorous-intensity activity (min/week)b 180.7 (279.0) 160.9 (281.6)

MB = China yuan. a. Met the recommended amount of physical activity. b. Mean (SD).

J.-M. Ma et al. / Open Journal of Preventive Medicine 1 (2011) 94-100

3.2. Effects of Physical Activity Level on

HRQOL

Regarding the 8-domain scales scores, a one-way

ANOVA was conducted to examine the group differ-

ences in the SF-36 measures for each demographic vari-

able. In both genders the differences of PF, BP, and GH

with meeting the required amount were lowest in the 50

- 59 years age group and highest in the 30 - 39 years age

group. For marital status, unmarried males only showed

higher RP than married males. For employment status,

PF, RP, GH, VT, and MH were higher among employed

males than unemployed males, and BP and GH were

higher among employed females than unemployed fe-

males. Also, a MANCOVA was performed with these

influential variables (age, marital status, and employ-

ment status) as covariants, the scores on the eight do-

main scales as dependent variables, and the physical

activity groups as independent variables. Multivariate

effects for PF, RP, GH, VT, SF, and MH were found

among males and for PF, VT, and MH among females

(males; Wilk’s  = 0.934, p = 0.000; females: Wilk’s  =

0.934, p = 0.000). Moreover, a univariate analysis

showed that PF, VT, and MH were significantly higher

in the sufficient group than the insufficient group for

both genders. In the insufficient group, RP, GH, and SF

were significantly higher in both genders (Table 2 ).

4. DISCUSSION

The present study investigated the relationship be-

tween meeting the recommended amount of physical

activity and HRQOL among Chinese adults that use the

Internet. Overall, 87.3% of participants met the recom-

mended amount of physical activity. A previous study of

physical activity among Chinese adults using the

IPAQ-SV found that 88.8% of adults carried out ≥150

minutes of physical activity per week [25], so the results

of the present study were consistent with this previous

study. Moreover, with regard to HRQOL, the overall

results of the present study were slightly lower than a

previous survey of Chinese adults using the SF-36 [26],

but the trends in scores for each scale were similar.

Meeting the recommended amount of physical activity

had a significant relationship with better scores for al-

most all domain scales (PR, RP, GH, VT, SF, and MH)

among males, even after adjustment for demographic

factors. Among females, meeting the recommended

amount was significantly related to with better scores for

PF, VT, and MH. The findings of the present study thus

imply that engaging in the recommended amount of

physical activity is associated with both physical and

mental aspects of HRQOL. The SUVIMAX epidemiol-

ogical cohort study in France also reported that partici-

Table 2. Aadjusted HRQOL measures in respondents among

physical activity groups stratified by gender.

Physical Activity Group

Male mean (SD)Recommended Insufficient F P

PF 88.44 (14.6) 80.71 (20.3) 16.45<0.001

RP 84.70 (19.6) 78.99 (23.2) 5.700.017

BP 77.90 (16.8) 76.86 (15.0) 0.180.676

GH 67.71 (19.7) 56.40 (22.8) 19.82<0.001

VT 68.64 (16.0) 58.79 (18.3) 22.29<0.001

SF 77.12 (17.6) 70.94 (18.5) 8.050.005

RE 79.95 (20.3) 75.76 (22.2) 2.720.100

MH 67.17 (15.3) 62.14 (18.4) 5.410.020

Female mean (SD )

PF 88.36 (12.4) 83.30 (17.0) 13.75<0.001

RP 85.98 (18.1) 86.32 (19.8) 0.010.934

BP 77.55 (16.7) 80.28 (18.0) 1.960.163

GH 67.46 (20.2) 64.22 (19.9) 2.690.102

VT 69.08 (15.2) 64.40 (17.9) 8.330.004

SF 78.72 (17.1) 81.50 (17.0) 1.970.161

RE 81.47 (18.5) 81.67 (21.8) 0.000.951

MH 67.59 (14.8) 63.05 (18.1) 7.110.008

Comparison in multidimensional scales of SF-36 among physical activity

levels withcovariate of age, marital status, employment status. Bonferroni-

adjusted univariate multiple comparison.

pants engaging in the recommended amount of physical

activity showed greater values for PF, RP, GH, RE, VT,

SF, and MH than the control group [15]. Furthermore,

the Behavioral Risk Factor Surveillance System (BRFSS),

a large-scale survey of physical activity conducted in the

US, reported that a significantly lower proportion of

people who subjectively evaluated themselves as un-

healthy for 14 or more days in a month met the recom-

mended amount of physical activity than other people

[27]. It therefore appears that meeting the recommended

amount of physical activity is associated with better

HRQOL among adult Internet users in China in the same

way as in developed countries.

Of the eight domain scales, no significant relationship

was found between BP or RE and physical activity in

males, or between RP, BP, GH, SF, or RE and physical

activity in females. In a previous study, vigorous-inten-

sity physical activity is associated with all domains of

the SF-36 scale, and that vigorous-intensity activity has

a greater effect on all domains in females than in males

J.-M. Ma et al. / Open Journal of Preventive Medicine 1 (2011) 94-100

[28]. Another previous study also found that vigor-

ous-intensity leisure-time physical activity was more

strongly associated with all of the domains than moder-

ate-intensity physical activity [15]. With the present

study, it is not possible to make direct mention to any

amount-response relationship between the intensity or

amount of physical activity and HRQOL, as the survey

examined the relationship between HRQOL and engage-

ing in ≥150 minutes per week of at least physical activity

of moderate-intensity. Nonetheless, in light of the pre-

vious studies, the present results suggest the possibility

that higher intensity or greater amount of physical active-

ity are required in order to have an effect on the domains

in which no relationship with meeting the recommended

amount was found, and that carrying out the recom-

mended amount of physical activity of 150 minutes per

week of physical activity of moderate-intensity or vig-

orous-intensity may not be sufficient.

Furthermore, while a significant relationship between

physical activity and the SF domain was found among

males, no relationship was found among females. In a

previous study, a longitudinal study found that five years

of continual leisure-time activity had a favorable effect

in raising SF in females [29]. The present study was

cross-sectional, and, moreover, physical activity habits

and period of duration were not surveyed, but it seems

that engaging in a constant amount and duration of

physical activity has an effect on SF in females. There is

therefore a need to investigate this point using a longitu-

dinal study.

Moreover, in the present study, female found a weaker

relationship between the physical aspects of HRQOL in

particular and meeting the recommended amount of

physical activity. A previous study that examined the

relationship between long-term physical activity and

HRQOL reported that the more intense the physical ac-

tivity, the stronger the relationship between physical

activity and the physical aspects of HRQOL [30]. This

suggests that engaging in high-intensity activity has an

effect on the physical aspects of HRQOL. There is also a

trend for males to favor high-intensity activity, while

females generally engaging in moderate-intensity physic-

cal activity [31]. Consequently, in the present study, it is

likely that, among those engaging in 150 min or more

physical activity per week, the males were engaging in

high-intensity activity, while more females were engage-

ing in moderate-intensity activity. It would probably be

desirable to recommend that female engaging in high-

intensity activity in order to achieve more effective im-

provement of the physical aspects.

In a previous study, engaging in leisure-time physical

activity of moderate or greater intensity for 150 min or

more per week showed a strong relationship to the

HRQOL domain scales (except BP) [15]. In the present

study, however, evaluation of the relationship to

HRQOL of physical activity of moderate or greater in-

tensity that includes activities of daily life observed sev-

eral domain scales for which no relationship was found.

From this, it may be conjectured that leisure-time physic-

cal activity has a greater relation to HRQOL than the

general activity of daily life. Moreover, as leisure-time

physical activity has a positive effect on overall health,

while physical activity from commuting or work has a

negative effect on subjective well-being, it has been

suggested that physical activity engaging in a passive

condition has a great effect on psychological factors [32].

In China, one-third of all people commuting to work go

by bicycle or on foot. One would therefore expect that

the participants of the present study included many peo-

ple met physical activity recommendation by such active

commuting. Therefore, the finding of the present study

that there was no relationship between physical activity

and the psychological domains RE and SF was probably

due at least in part to differences in the type of exercise

being engaging in by participants.

There are a number of limitations to the present study.

First, the cross-sectional design of the study makes it

impossible to mention a causal relationship between

engaging in the recommended amount of physical active-

ity and HRQOL. Second, there is the presence of sam-

pling bias. Subjects were selected after stratifying by

gender and age group, but it has been pointed out that

sampling error can occur when subjects are selected by

random sampling from monitors registered with a survey

company [33]. Comparing the characteristics of the sub-

jects of the present survey with the adult population of

China as whole using information released by the Na-

tional Bureau of Statistics of China in 2008, the survey

participants were better educated and had higher income.

Adult Chinese people who use the Internet are those

with higher socioeconomic status, so there is probably a

bias toward people with the same attributes in the moni-

tors of the survey company. According to a survey by

the China Internet Network Information Center (CNNIC),

at least 70% of Internet users are urban dwellers, so that

the subjects of the present study were probably a largely

urban group. These points mean that caution must be

exercised in any attempt to generalize the results of the

present survey to the adult population of China as a

whole. Furthermore, with regard to the amounts of

physical activity of moderate or greater intensity and of

walking assumed in the IPAQ, it is impossible to avoid

bias due to inaccurate assumptions or recollections on

the part of the subjects because of the self-reporting na-

ture of the study. In a previous study of physical activity

evaluation methods with Chinese subjects [34], the IPAQ

J.-M. Ma et al. / Open Journal of Preventive Medicine 1 (2011) 94-100

gave a higher evaluation of physical activity amount

than a heart rate monitor, an accelerometer, and a ques-

tionnaire relating to a daily physical activity log. There-

fore, the IPAQ may overestimate the amount of physical

activity.

5. CONCLUSIONS

Since a relationship was found between meeting the

amount of physical activity recommended in the ACSM/

AHA guidelines and HRQOL, it is likely that engaging

in the recommended amount of physical activity has an

important effect on health. However, as discussed above,

further studies should be done to determine more accu-

rately the association between HRQOL and the recom-

mended physical activity level using a representative

sample and a larger sample size. Participants should not

be only restricted to the internet user sample. HRQOL

may possibly be related to other characteristics of the

Chinese population. Moreover, the association between

HRQOL with specific domains of physical activity (such

as leisure-time household, occupational and transport)

should be examined further. Furthermore, effective sup-

port strategies are needed for promoting physical activity

with the goal of improving HRQOL.

6. ACKNOWLEDGEMENTS

This work was supported by a Global COE program “Sport Sciences

for the Promotion of Active Life” from the Japan Ministry of Educa-

tion, Culture, Sports, Science, and Technology.

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