Physical activity and health-related quality of life among adult women in Cali, Colombia: a...

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Quality of Life ResearchAn International Journal of Quality ofLife Aspects of Treatment, Care andRehabilitation - Official Journal of theInternational Society of Quality of LifeResearch ISSN 0962-9343 Qual Life ResDOI 10.1007/s11136-013-0378-9

Physical activity and health-relatedquality of life among adult women in Cali,Colombia: a cross-sectional study

Luis F. Gómez, José Moreno, OlgaL. Gómez, Rocio Carvajal & DianaC. Parra

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Physical activity and health-related quality of life among adultwomen in Cali, Colombia: a cross-sectional study

Luis F. Gomez • Jose Moreno • Olga L. Gomez •

Rocio Carvajal • Diana C. Parra

Accepted: 19 February 2013

� Springer Science+Business Media Dordrecht 2013

Abstract

Objectives To examine the associations of leisure-time

physical activity (LTPA) and walking for transportation

(WT) with the physical and mental dimensions of health-

related quality of life (HR-QOL) among women.

Methods A cross-sectional study was carried out in 2009

among 1,263 women ages 18–59 years living in neighbor-

hoods with low and middle-low socioeconomic status in the

urban area of Cali. HR-QOL was assessed using the Short

Form 8 (SF-8). LTPA and WT were measured using the long

version of the International Physical Activity Questionnaire

(IPAQ). Associations were assessed using linear regression

models adjusting for potential confounders.

Results Low (10–149 min) and medium–high (at least

150 min) levels of WT were negatively associated with the

mental and physical dimensions of HR-QOL. Low

(10–149 min of moderate intensity PA, or 10–74 min of

vigorous intensity PA) and medium–high (at least 150 or

75 min of moderate or vigorous intensity PA, respectively)

levels of LTPA were positively associated with both

dimensions. Significant interactions were observed between

education level and perceived safety from traffic.

Conclusions This study found that WT and LTPA were

associated with HR-QOL both in the physical and mental

dimensions; however, the direction and magnitude of the

association varied by domain. These results highlight the

need to better understand the links between PA and HR-

QOL in urban contexts from Latin America.

Keywords Physical activity � Health-related quality of

life � Urban environment

Background

The promotion of physical activity (PA) is starting to be

recognized as a cornerstone of public health policies [1]. A

compelling number of studies have consistently found that

those who engage in regular physical activity are less likely

to develop chronic diseases such as type 2 diabetes, cancer

and heart disease [2–4]. In addition, physical activity has

been linked with a lower risk of depression symptoms and

cognitive decline [5, 6].

Health-related quality of life (HR-QOL) is a multidi-

mensional concept which includes overall aspects of life

closely linked with physical and mental well-being [7–10].

Although several studies have shown a consistent positive

association between physical activity and HR-QOL [11–15],

the majority of them have only measured physical activity

during leisure time or overall physical activity [11–15].

Jurakic et al. conducted one of the few studies measuring

L. F. Gomez (&)

Departamento de Medicina Preventiva y Social, Facultad de

Medicina, Pontificia Universidad Javeriana, Bogota, Colombia

e-mail: [email protected]

J. Moreno

Instituto Nacional de Salud Publica de Mexico, INSP,

Cuernavaca, Mexico

J. Moreno

Escuela de Salud Publica de Mexico, Cuernavaca, Mexico

O. L. Gomez

Escuela de Salud Publica, Universidad del Valle, Cali, Colombia

R. Carvajal

Fundacion FES Social, Pontificia Universidad Javeriana, Cali,

Colombia

D. C. Parra

Washington University in St. Louis, Prevention Research Center,

St. Louis (MO), USA

123

Qual Life Res

DOI 10.1007/s11136-013-0378-9

Author's personal copy

several domains of physical activity and their association

with HR-QOL and found that while those who engaged in

LTPA were more likely to have higher HR-QOL, transpor-

tation and domestic PA domains were negatively associated

[16].

There is not a clear understanding about the relation-

ships between different domains of PA and HR-QOL

among women who reside in social contexts with large

gender and social disparities, such as those seen in Latin

America. In consequence, the objective of this study is to

examine the associations of two domains of PA: leisure-

time physical activity (LTPA) and walking for transporta-

tion (WT) with the physical and mental dimensions of HR-

QOL among adult women. The results of this study may

contribute to improve understanding of this relevant issue

for public health in the context of Latin America.

Methods

Study setting

Cali is the third largest city in Colombia with a population

of approximately 2,200,000 inhabitants and is an important

economic and cultural urban center of the southwest region

of the country [17]. Its Gini coefficient was 0.53 in 2010,

being very close to the national average (0.56) [18].

As in other Latin American countries, gender disparities

are very notorious in Colombia where 33 % of Colombian

homes have a female head of household. In addition,

34.6 % of women 15 years and older residing in urban

settings do not have an economic income, compared with

17.2 % among men. In addition, unemployment rates are

significantly higher among women (15.8 %) compared to

men (9.4 %) [19].

According to the National Nutrition Survey from 2010,

19.8 % of adults living in Cali engaged in at least 150 min

of LTPA per week and 28.2 % walked for at least 150 min

per week for transportation purposes [20].

Study and sampling design

This was a cross-sectional study conducted in 2010 which

was part of a broader study aimed at assessing the acces-

sibility conditions to mental health services in the city.

Using a multistage probabilistic sampling design, 221

urban segments from low and middle-low socioeconomic

status neighborhoods were selected as primary sample units

(PSU) considering an unequal probability of selection

proportional to the population size. On average, 10

households were selected in each PSU using a random

systematic selection procedure. Finally, an adult 18 years

and older was selected in each household using Kish tables

for respondent selection. For the present study, data from

1,263 adult women were used. The response rate in this

subpopulation group was 83.1 %.

General measurement procedures

A face-to-face questionnaire was administered by inter-

viewers with experience conducting population surveys

and who received a standardized training of 5 days prior to

data collection. The average duration of the interviews was

25 min. All participants were asked to provide written

informed consent. The study was approved by the Institu-

tional Review Board from FES Foundation.

HR-QOL

The official and licensed Spanish version of the Short Form-

8 (SF-8) was used to assess HR-QOL among selected par-

ticipants. This validated questionnaire allows establishing

separate scorings for mental health and physical health,

which were calculated based on the procedures suggested by

QualiMetrics [21]. These two variables were treated as

continuous scores. The value of Cronbach’s alpha was 0.80

for the participant’s responses obtained in the study.

Physical activity

Two domains of physical activity were assessed in this

study using the selected items of a cultural adapted version

of the Long Form of the International Physical Question-

naire (IPAQ): WT and LTPA. In a previous study con-

ducted in Bogota, this version of IPAQ was validated with

accelerometers obtaining a spearman correlation of 0.42

(p = 0.006) when comparing the accelerometer measures

and the scoring in metabolic equivalents (MET). In addi-

tion, the test–retest reliability was 0.69 (p \ 0.001) [22].

These domains were included in this study based on

their relevance for public health and prior recommenda-

tions for the Latin American region [23].

WT was classified in three categories following the 2008

Physical Activity Guidelines for Americans (PAGA) [24]:

(a) inactive: reporting less than 10 min of WT in the last

7 days, (b) low: reporting between 10 and 149 min of WT

in the last 7 days and (c) medium–high: reporting at least

150 min of WT in the last 7 days. The PAGA considers

separately the categories medium (150–300 min a week)

and high (more than 300 min a week) but these were col-

lapsed in order to increase cell size and improve precision

in the statistical analysis. Participants classified in this

category meet the physical activity recommendations

according with PAGA.

Categories of LTPA patterns were as follows: (a) inac-

tive: reporting less than 10 min of physical activity of

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moderate or vigorous intensity in the last 7 days, (b) low:

reporting between 10 and 149 min of physical activity of

moderate intensity, or between 10 and 74 min of physical

activity of vigorous intensity in the last 7 days and

(c) medium or high: reporting at least 150 min of moderate

intensity or at least 75 min of vigorous physical activity in

the last 7 days.

Covariates

Sociodemographic covariates included age groups (18–29,

30–49 and 50–59 years), education levels (less than sec-

ondary education and secondary education completed or

more), marital status (married or living together, separated

or divorced, and single or widow), household domestic

activities defined as the main occupation during the last

30 days (yes or not) and socioeconomic status of the

neighborhoods. This last variable was established using the

criteria of the municipality of Cali which consider the

characteristics of the surrounding urban environments (i.e.

street and sidewalk infrastructure) and physical attributes

of housing (i.e. construction type and materials) [25].

Finally, the perception of safety from traffic was assessed

using the following question: ‘‘How safe from traffic do

you or will you feel crossing the streets of the place where

you reside?’’ and response options were as follows: ‘‘very

unsafe’’, ‘‘unsafe’’, ‘‘neither unsafe nor safe’’, ‘‘safe’’ and

‘‘very safe’’.

Table 1 Descriptive

characteristics of the study

population (n = 1,263)

a Number of observation

Variables na % or mean (SD)

Age in years 1,263 37.5 (11.6)

Education levels

None 322 25.5 %

Primary and incomplete secondary education 768 60.8 %

Secondary education completed or more 173 13.7 %

Marital status

Married or living together 781 61.8 %

Separated or divorced 112 8.9 %

Single 329 26 %

Widow 41 3.3 %

Household activities as their main occupation

Yes 923 73 %

No 340 27 %

Socioeconomic status of neighborhood

Low 773 61 %

Middle-low 490 39 %

How safe from traffic do you or will you feel crossing the streets of

the place where you reside?

Very unsafe 168 13.3 %

Unsafe 488 38.6 %

Neither safe nor unsafe 264 21.0 %

Safe 336 26.6 %

Very safe 6 0.5 %

Levels of walking for transportation in the last 7 days

Inactive: less than 10 min 304 24 %

Low: 10–149 min 765 60.6 %

Medium–high: 150 min or more 194 15.4 %

Levels of leisure-time physical activity in the last 7 days

Inactive: less than 10 min 824 65.2 %

Low: 10–149 min (moderate activities) or 10–74 min (vigorous

activity)

246 19.5 %

Medium–high: 150 min and over (moderate activities) or 75 min

or more (vigorous activity)

193 15.3 %

Mental dimension of health-related quality of life 1,263 50.8 (8.7)

Physical dimension of health-related quality of life 1,263 50.1 (8.0)

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Statistical analysis

Two multiple linear regression models were conducted to

examine the associations between the physical activity

patterns of WT and LTPA and HR-QOL: one for the

mental dimension and another one for the physical

dimension.

The following sets of statistical interaction terms were

explored in the models based on a previous study con-

ducted in Colombia exploring the links between urban

environments and physical activity and HR-QOL [26]:

• Education level and walking for transportation interac-

tions (Secondary education completed or more * walk-

ing for transportation 10–149 min; and secondary

education completed or more * walking for transpor-

tation 150 min or more)

• Education level and leisure-time physical activity

interactions (Secondary education completed or mor-

e * leisure-time physical activity 10–149 min of mod-

erate activity or 10–74 min vigorous activity; and

secondary education completed or more * leisure-time

physical activity 150 min or more of moderate activity

or 75 min or more of vigorous activity)

• Perception of safety when crossing streets and walking

for transportation interactions (Safe or very safe *

walking for transportation 10–149 min; and safe or

very safe * walking for transportation 150 min or

more)

Therefore, it was hypothesized that the extent to which

physical activity patterns (inactive, low and medium–high)

of LTPA and WT were associated with HR-QOL may vary

according to education level and perceived safety from

traffic.

Models were adjusted by age groups, education levels,

socioeconomic status of neighborhood, marital status,

household activity and interaction terms. Variance inflation

factors were calculated in the step-by-step variable’s

selection process to examine multicollinearity among

variables included in the models. All the statistical analyses

took into account the unequal probability of selection and

the complexity of sampling design using Stata 12.

Results

Characteristics of the study population

Table 1 shows descriptive characteristics of the 1,263

women surveyed in this study. Mean age of the sample was

37.5 (SD = 11.6). Eighty-six percent had less than sec-

ondary education, 61,8 % reported being married or living

together and 73 % reported household activities as their

main occupation. Sixty-one percent belonged to low

socioeconomic status. Slightly more than 15 % reported a

medium–high pattern of WT or LTPA in the last 7 days.

The SF-8 mean scores for the mental and physical health

dimensions were 50.8 (SD = 8.7) and 50.1 (SD = 8.0),

respectively.

WT and LTPA patterns and its associations with HR-

QOL

Tables 2 and 3 show the associations of WT and LTPA

patterns with the mental and physical health dimensions of

HR-QOL.

Low and medium–high levels of WT were negatively

and significantly associated with the mental dimension of

HR-QOL (b = -0.81 and b = -0.91, p \ 0.001, respec-

tively; p trend \ 0.001). Low and medium–high levels of

LTPA were significantly and positively associated with the

mental dimension of HR-QOL (b = ?0.51 and b =

?0.92, respectively; p trend \ 0.001) (Table 2).

Similarly, low and medium–high levels of WT were

negatively associated with the physical dimension of HR-

QOL (b = -1.15 and b = -1.75, respectively; p trend

\ 0.001). Low and medium–high levels of LTPA were

positively associated with the physical dimension of HR-

QOL (b = ?2.51 and b = ?1.84, respectively; p trend

\ 0.001) (Table 3).

Significant interaction terms were found between the

selected PA domains and education level and perception of

safety when crossing the streets. Achieving low and med-

ium–high levels of LTPA among those with complete

secondary education or more was positively associated

with the mental dimension of HR-QOL. Likewise,

achieving low and medium–high levels of WT among

those with complete secondary education or more was

positively associated with the physical dimension of HR-

QOL. Finally, women who walked above the inactive level

(10–149 min or 150 min or more) and reported being safe

or very safe when crossing the streets tended to report

higher scorings of HR-QOL in the mental and physical

dimensions (Tables 2, 3).

Both models achieved low levels of explained variation

with determination coefficients not exceeding 6 %.

Discussion

This study found that WT and LTPA were associated with

HR-QOL both in the physical and mental dimensions;

however, the direction and magnitude of the associations

varied by domain. LTPA patterns were positively associ-

ated with the mental and physical dimension of HR-QOL,

whereas WT was negatively associated with both

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Table 2 Linear regression

analysis of mental dimension of

the HR-QOL by walking for

transportation and leisure-time

physical activity among 1,263

adult women

a Model adjusted by age

groups, education levels,

socioeconomic status of

neighborhood, marital status,

household domestic activities,

walking for transportation,

physical activity in leisure time

and interaction terms

R2: Model with

sociodemographic

variables = 0.025, model with

sociodemographic variables and

physical activity

patterns = 0.030, model with

sociodemographic variables,

physical activity patterns and

interaction terms = 0.032

Variables Mean Modela

b (SE) p

Covariates

Age groups (years)

18–29 51.2 Ref

30–49 51.6 ?0.91 (0.07) \0.001

50–59 52.1 ?1.83 (0.10) \0.001

Education levels

Less than secondary education 51.5 Ref

Secondary education completed or more 52.3 1.53 (0.13) \0.001

Marital status

Married or living together 52.0 Ref

Separated or divorced 51.9 -1.50 (0.09) \0.001

Single or widow 51.3 -0.76 (0.07) \0.001

Household domestic activities

Not 52.5 Ref

Yes 51.5 -0.21 (0.07) 0.004


Low 51.8 Ref

Middle-low 52.0 ?0.23 (0.06) 0.001

How safe from traffic do you feel while crossing the streets

of the place where you reside?

Very unsafe, unsafe, neither safe nor unsafe 51.3 Ref

Safe and very safe 53.1 ?1.31 (0.13) \0.001

Physical activity levels p trend


Inactive: less than 10 min 52.6 Ref

Low: 10–149 min 51.5 -0.81 (0.13) \0.001

Medium–high: 150 min and over 52.1 -0.91 (0.16)

Level of leisure-time physical activity in the last 7 days

Inactive: less than 10 min 51.3 Ref

Low: 10–149 min (moderate activities) or 10–74 min

(vigorous activity)

52.5 ?0.51 (0.12) \0.001

Medium–high: 150 min or more (moderate activities)

or 75 min or more (vigorous activity)

52.8 ?0.92 (0.13)

Interactions effects p

Education level (Secondary education completed or more)

* walking for transportation (10–149 min)

– -0.57 (0.15) \0.001


* walking for transportation (150 min or more)

– ?0.19 (0.19) 0.299


* leisure-time physical activity (10–149 min of moderate

activity or 10–74 min vigorous activity)

– ?1.03 (0.18) \0.001


* leisure-time physical activity (150 min and over of moderate

activity or 75 min or more of vigorous activity)

– ?0.38 (0.18) 0.035

Perception of safety when crossing streets (safe or very safe)


– ?0.95 (0.15) \0.001



– ?1.54 (0.20) \0.001

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Table 3 Linear regression

analysis of physical dimension

of the HR-QOL by walking for

transportation and leisure-time

physical activity among 1,263

adult women

a Model adjusted by age

groups, education levels,

socioeconomic status of

neighborhood, marital status,

household domestic activities,

walking for transportation,

physical activity in leisure time

and interaction terms

R2: Model with

sociodemographic

variables = 0.039, model with

sociodemographic variables &

physical activity

patterns = 0.051, model with

sociodemographic variables,

physical activity patterns and

interaction terms = 0.055

Variables Mean Modela

b (SE) p

Covariates

Age groups (years)

18–29 52.0 Ref

30–49 50.6 -1.15 (0.07) \0.001

50–59 49.8 -2.23 (0.10) \0.001

Education levels

Less than secondary education 48.9 Ref

Secondary education completed or more 52.0 -0.05 (0.14) 0.748

Marital status

Married or living together 50.7 Ref

Separated or divorced 48.1 -0.50 (0.13) \0.001

Single or widow 50.6 -0.90 (0.08) \0.001

Household domestic activities

Not 51.0 Ref

Yes 49.7 -0.14 (0.08) 0.048


Low 50.0 Ref

Middle-low 49.7 ?0.10 (0.06) 0.091

How safe from traffic do you feel while crossing the streets of the

place where you reside?

Very unsafe, unsafe, neither safe nor unsafe 49.6 Ref

Safe and very safe 51.9 ?1.45 (0.12) \0.001

Physical activity levels p trend


Inactive: Less than 10 min 49.3 Ref

Low active: 10–149 min 50.6 -1.15 (0.10) \0.001

Medium or high active: 150 min or more 50.6 -1.75 (0.15)

Minutes of leisure-time physical activity in the last 7 days

Inactive: Less than 10 min 49.3 Ref

Low: 10–149 min (moderate activities) or 10–74 min

(vigorous activity)

51.6 ?2.51 (0.10) \0.001

Medium–high: 150 min and over (moderate activities) or

75 min or more (vigorous activity)

51.8 ?1.84 (0.12)

Interactions effects p



– ?2.18 (0.13) \0.001

Education level (Secondary completed education or more)


– ?1.95 (0.18) \0.001

Education level (Secondary completed education or more)

* leisure-time physical activity (10–149 min of moderate

activity or 10–74 min vigorous activity)

– -0.67 (0.14) \0.001


* leisure-time physical activity (150 min and or more of

moderate activity or 75 min or more of vigorous activity)

– ?0.06 (0.16) 0.692



– ?0.55 (0.18) \0.001



– ?1.41 (0.13) \0.001

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dimensions. In addition, this study found significant vari-

ation of the effects once adjusted by education level and

perception of safety when crossing the streets.

The positive associations between LTPA and HR-QOL

are similar to those found in studies conducted in devel-

oped and developing countries and enhance the relevance

of this PA domain on health and well-being [11–15]. On

the other hand, to our knowledge, the study conducted by

Jurakic et al. in Croatia was the only previous study that

reported a negative association between PA for transpor-

tation and HR-QOL [16].

These findings highlight the need to better understand

the links between active transportation and HR-QOL in

contexts characterized by social, gender and urban

inequalities. In a society with pronounced gender and

social disparities such as Colombia, walking for transpor-

tation may be linked with burdensome utilitarian activities

culturally assigned to women, such as caregiving, and

household chores [12]. In addition, the mobility patterns of

Latin American women are specially conditioned by

security circumstances such as the risk of robbery and

sexual harassment [27]. All of these factors might have

deleterious associations between well-being and functional

health which should be explored in future studies. Fur-

thermore, it is relevant to note that at the moment of

conducting this study, the municipality of Cali was

undertaking several mega public works which may have

affected urban mobility, access to public transportation and

environmental and well-being perceptions of walkers. For

this reason, it is possible that the beneficial effects of

physical activity in HR-QOL, in particular, walking for

transportation, may not be present in such a context.

The interactions between education level and WT and

LTPA were significant but did not have consistent patterns,

which highlight the need for a deeper exploration in further

studies. Results of the interaction term between perception

of safety when crossing the streets are in some way

expected and may show the relevance of improving

pedestrian safety and other urban attributes, not only to

promote active transportation, but also to increase the

perception of quality of life [26].

Several limitations can be identified in this study. First,

the cross-sectional designed does not allow to track over

time the influence of the selected PA domains on HR-QOL.

Second, residual confusion cannot be ruled out due to

several potential cofounders that were not measured, such

as family composition and income. Third, several studies

have shown that IPAQ overestimates PA levels [26, 28–

30]; however, this limitation has been shown to be more

problematic for the short form of IPAQ [31]. Also, results

can be only statistically inferred to the sampling frame of

women who reside in low and middle-low neighborhoods

in Cali. Finally, although SF-8 has shown appropriate

psychometric properties, the self-perception assessment of

HR-QOL may have limitations due to differences in social

experiences among participants [31]. For instance, people

who have lived in adverse and deprived social conditions

may have a tendency to report fair or good perceptions of

HR-QOL as a coping strategy to face their daily lives [32].

Even with these limitations, our study provides useful

information about the relationship between physical

activity and HR-QOL and could guide the development of

public policies to improve the social and urban environ-

ment conditions linked with PA patterns. Future studies

should explore the interactive role of environmental factors

in the association of physical activity and HR-QOL.

Conclusions

This study found that WT and LTPA were associated with

HR-QOL both in the physical and mental dimensions;

however, the direction and magnitude of the association

varied by domain. These results highlight the need to better

understand the links between PA and HR-QOL in urban

contexts from Latin America.

Acknowledgments This research was supported by a grant from the

Departamento Administrativo de Ciencia, Tecnologıa e Innovacion,

COLCIENCIAS, Grant # 620449326152 - Contract # 565-2009.

Many individuals contributed to this research, and their assistance is

acknowledged.

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