Objectives-The gestation-adjusted projection method extrapolates birth weight using third-trimester sonography. This technique is shown to be more accurate for sonographic examinations from 34 weeks to 36 weeks 6 days than 37 weeks to 38 weeks 6 days. Our objective was to determine whether even earlier sonographic examinations (31 weeks-33 weeks 6 days) further improves birth weight prediction in patients with diabetes.Methods-We conducted a retrospective cohort analysis of 388 pregnant women with pregestational or gestational diabetes who delivered at 37 weeks or later and had a sonographic examination performed between 31 weeks and 36 weeks 6 days. Sonographic examinations were categorized as "early" if performed at 31 weeks to 33 weeks 6 days or "late" if performed at 34 weeks to 36 weeks 6 days. We estimated birth weight using the gestation-adjusted projection method, compared errors in prediction of birth weight using the t test and Mann-Whitney U test, and performed a 2-sample test of proportions to compare prediction of macrosomia (birth weight >4000 g).Results-The early and late groups had similar mean gestational ages at birth (38 weeks 4 days versus 38 weeks 5 days; P = .13) and rates of macrosomia (10.7% versus 12.4%; P = .63). The early group had a greater mean absolute error (336 versus 297 g; P = .03) and percent error (9.9% versus 7.9%; P = .01) in birth weight prediction but a lower mean birth weight (3303 versus 3426 g; P = .02). Sensitivity for prediction of macrosomia was 19% in the early group versus 45% in the late group (P = .07), whereas specificity was similar (98% versus 96%; P = .27).Conclusions-Using the gestation-adjusted projection method in our patients with diabetes, we found that sonographic examinations performed at 34 weeks to 36 weeks 6 days better predicted birth weight than those performed at 31 weeks to 33 weeks 6 days.

Study objective: The study objectives are to (1) assess prevalence of congenital heart disease (CHD), (2) describe outcomes of pregnancies in women with CHD, (3) compare outcomes in women with and without CHD, and (4) characterize neonatal outcomes in pregnancies complicated by CHD.Design: This was a retrospective cohort study of women who delivered at the University of Colorado Hospital. Diagnosis of CHD was identified based on history of cardiac disease, pulmonary disease, or subacute bacterial endocarditis prophylaxis during labor and confirmed with echocardiogram when available. Comprehensive retrospective review of anesthetic, obstetric, and neonatal outcomes was performed.Setting: University of Colorado Hospital.Patients: 18,226 women.Interventions: Medical record review.Measurements: Valvular abnormalities, New York Heart Failure Association classification scores, types of CHD, maternal age, race, gravidity, parity, maternal prepregnancy body mass index, cigarette use, type of delivery, type of analgesia used, early initiation of neuraxial analgesia, arrhythmias, need for peripartum diuretics, prolonged maternal hospital stay, preterm birth, small for gestational age, neonatal CHD, neonatal or maternal intensive care unit (ICU) admissions, and maternal or neonatal death.Main results: We identified 117 pregnancies in 110 women with CHD. Parturients with CHD were more likely to have operative vaginal delivery (P<.0001), neonatal ICU admissions (P=.003), and had prolonged hospital stays. Occurrence of CHD in neonates was 6%. Moderate-to-severe valvular disease was associated with increased rates of operative vaginal delivery, early initiation of neuraxial labor analgesia, cardiac complications (including arrhythmia and use of diuretics), prolonged hospital stay, and maternal ICU admission. However, most deliveries and births were uncomplicated; and there were one case each of maternal mortality and fetal death after birth.Conclusion: Operative abdominal deliveries and neonatal ICU admissions are more common in women with CHD, but these pregnancies are generally well tolerated with low mortality rates. (C) 2015 Elsevier Inc. All rights reserved.

ObjectivePregnancies complicated by diabetes are associated with increased risk of macrosomia (birth weight ≥4000gm) and shoulder dystocia. Estimating fetal weight at delivery can assist in delivery decision-making. In previous studies, ultrasound (U/S) estimated fetal weight (EFW) at 34w-36w6d more accurately predicted birth weight (BW) than at 37w-38w6d. Our objective was to determine whether earlier U/S, specifically 31w-33w6d, further improves BW prediction in diabetic pregnancies.Study DesignSingleton non-anomalous pregnancies delivered at ≥37w were identified among women with pre-gestational or gestational diabetes from the University of Colorado Perinatal Database (2005-2010). Women who underwent an U/S between 31w and 36w6d were included (n=388). If a subject had more than one U/S during this time period, only the earlier was included. We calculated the predicted BW using the gestation-adjusted prediction (GAP) model (Best, 2002). Ultrasounds were categorized as "early" (31w-33w6d, n=196) or "late" (late: 34w-36w6d, n=162). We used the Wilcoxon 2-sample test to compare absolute error and absolute percent error between predicted and actual BW. We performed Chi-square analysis to compare sensitivity and specificity for prediction of macrosomia.ResultsThe early and late U/S groups had a similar mean gestational age at birth (38w4d vs 38w5d; p=0.13), macrosomia rate (10.7 vs 12.4%; p=0.63), and proportion of gestational diabetics (73 vs 72%, p=0.78). However, mean BW was smaller in the early group (3303 vs 3426g; p=0.02). The early U/S group had a greater mean absolute error (335.7 vs 296.3g, p=0.03) and percent error (9.9 vs 7.9%, p=0.01) compared with late U/S. Sensitivity for prediction of macrosomia was 45% in the late group as compared to 19% in the early group (P=0.07), while specificity was similar in both groups (98 vs 96%; p=0.27).ConclusionUsing the GAP model in this population of diabetic patients, we found that U/S at 34w-36w6d better predicted birth weight as compared to U/S at 31w-33w6d. ObjectivePregnancies complicated by diabetes are associated with increased risk of macrosomia (birth weight ≥4000gm) and shoulder dystocia. Estimating fetal weight at delivery can assist in delivery decision-making. In previous studies, ultrasound (U/S) estimated fetal weight (EFW) at 34w-36w6d more accurately predicted birth weight (BW) than at 37w-38w6d. Our objective was to determine whether earlier U/S, specifically 31w-33w6d, further improves BW prediction in diabetic pregnancies. Pregnancies complicated by diabetes are associated with increased risk of macrosomia (birth weight ≥4000gm) and shoulder dystocia. Estimating fetal weight at delivery can assist in delivery decision-making. In previous studies, ultrasound (U/S) estimated fetal weight (EFW) at 34w-36w6d more accurately predicted birth weight (BW) than at 37w-38w6d. Our objective was to determine whether earlier U/S, specifically 31w-33w6d, further improves BW prediction in diabetic pregnancies. Study DesignSingleton non-anomalous pregnancies delivered at ≥37w were identified among women with pre-gestational or gestational diabetes from the University of Colorado Perinatal Database (2005-2010). Women who underwent an U/S between 31w and 36w6d were included (n=388). If a subject had more than one U/S during this time period, only the earlier was included. We calculated the predicted BW using the gestation-adjusted prediction (GAP) model (Best, 2002). Ultrasounds were categorized as "early" (31w-33w6d, n=196) or "late" (late: 34w-36w6d, n=162). We used the Wilcoxon 2-sample test to compare absolute error and absolute percent error between predicted and actual BW. We performed Chi-square analysis to compare sensitivity and specificity for prediction of macrosomia. Singleton non-anomalous pregnancies delivered at ≥37w were identified among women with pre-gestational or gestational diabetes from the University of Colorado Perinatal Database (2005-2010). Women who underwent an U/S between 31w and 36w6d were included (n=388). If a subject had more than one U/S during this time period, only the earlier was included. We calculated the predicted BW using the gestation-adjusted prediction (GAP) model (Best, 2002). Ultrasounds were categorized as "early" (31w-33w6d, n=196) or "late" (late: 34w-36w6d, n=162). We used the Wilcoxon 2-sample test to compare absolute error and absolute percent error between predicted and actual BW. We performed Chi-square analysis to compare sensitivity and specificity for prediction of macrosomia. ResultsThe early and late U/S groups had a similar mean gestational age at birth (38w4d vs 38w5d; p=0.13), macrosomia rate (10.7 vs 12.4%; p=0.63), and proportion of gestational diabetics (73 vs 72%, p=0.78). However, mean BW was smaller in the early group (3303 vs 3426g; p=0.02). The early U/S group had a greater mean absolute error (335.7 vs 296.3g, p=0.03) and percent error (9.9 vs 7.9%, p=0.01) compared with late U/S. Sensitivity for prediction of macrosomia was 45% in the late group as compared to 19% in the early group (P=0.07), while specificity was similar in both groups (98 vs 96%; p=0.27). The early and late U/S groups had a similar mean gestational age at birth (38w4d vs 38w5d; p=0.13), macrosomia rate (10.7 vs 12.4%; p=0.63), and proportion of gestational diabetics (73 vs 72%, p=0.78). However, mean BW was smaller in the early group (3303 vs 3426g; p=0.02). The early U/S group had a greater mean absolute error (335.7 vs 296.3g, p=0.03) and percent error (9.9 vs 7.9%, p=0.01) compared with late U/S. Sensitivity for prediction of macrosomia was 45% in the late group as compared to 19% in the early group (P=0.07), while specificity was similar in both groups (98 vs 96%; p=0.27). ConclusionUsing the GAP model in this population of diabetic patients, we found that U/S at 34w-36w6d better predicted birth weight as compared to U/S at 31w-33w6d. Using the GAP model in this population of diabetic patients, we found that U/S at 34w-36w6d better predicted birth weight as compared to U/S at 31w-33w6d.

OBJECTIVE:The purpose of this study was to examine associations between the prepregnancy maternal body mass index (BMI) across the 3 clinical presentations of preterm birth (PTB).STUDY DESIGN:We conducted a retrospective cohort study of the records of 11,726 women. The World Health Organization International Classification was used to categorize BMI. The primary outcome of the study was PTB (<37 weeks' gestation) presenting as spontaneous preterm labor, preterm premature rupture of the membranes, or a medical indication. We used univariable and multivariable logistic regression analysis to analyze the data (P < .05).RESULTS:We found (1) a significant increase in the overall incidence of PTB at the extremes of BMI, (2) a higher risk for PTB from spontaneous preterm labor at the lower extremes (low plus moderate thinness) of BMI (adjusted odds ratio [aOR], 2.4; 95% confidence interval [CI], 1.4-4.2; P = .003), (3) a higher risk for preterm premature rupture of the membranes at the upper extremes (obese class II plus III) of BMI (aOR, 1.6; 95% CI, 1.1-2.3; P = .02), and (4) a higher risk for a medically indicated PTB at the lower (aOR, 2.8; 95% CI, 1.4-5.6; P = .004) and upper (aOR, 1.5; 95% CI, 1.1-2.2; P = .02) extreme of BMI.CONCLUSION:Women at the extremes of prepregnancy BMI are at risk for PTB.

OBJECTIVE: To evaluate whether women with known risk factors for preterm birth will manifest different rates of cervical shortening preceding a spontaneous preterm birth. METHODS: We conducted a secondary analysis of data from the Maternal--Fetal Medicine Units Network Preterm Prediction Study. Known risk factors for preterm birth were recorded. Cervical lengths were measured between 22+0 weeks and 24+6 weeks, and again 4 weeks later. Cervical slope was defined as the change in cervical length between these visits divided by time (millimeters per week). Preterm birth was defined as preterm premature rupture of membranes or spontaneous preterm labor leading to delivery before 37 weeks of gestation. We analyzed the data for 2,584 women using logistic regression and tested for interaction between risk factors in the model to determine whether cervical shortening preceded preterm births in all variable groups. RESULTS: Cervical slope was not significantly associated with preterm birth (P=.9) in women with vaginal bleeding. Cervical slope was significantly associated with preterm birth in women without a history of vaginal bleeding (odds ratio 1.2, 95% confidence interval 1.1–1.4). CONCLUSIONS: Pregnancies without vaginal bleeding have a 20% increase in the risk of preterm birth for each additional millimeter per week increase in cervical slope. Pregnancies with vaginal bleeding are at risk for preterm birth but do not appear to undergo progressive cervical shortening. This suggests that women with vaginal bleeding undergo a different mechanism leading to preterm birth. LEVEL OF EVIDENCE: II

To construct updated birthweight reference standards using a large, contemporary, and race/ethnically diverse sample in Colorado in order to: 1) provide clinicians with an updated tool for fetal growth assessment and 2) provide updated norms for determination of small- and large for gestational age (SGA and LGA). In this cross-sectional study, weight-for-gestational age curves for neonates were constructed from birthweight measurements of 57,826 singleton infants (48.6% female). Neonates were born between 20 and 42 weeks gestation during 1999-2010 in the Denver metropolitan area. Gestational age was based on the best obstetrical estimate, which included ultrasound examination in the majority of cases. Sex-specific and combined-sex growth charts were constructed using the 10th, 25th, 50th, 75th, and 90th percentiles. A locally-weighted regression procedure was applied to the empirical weight-for- gestational age percentiles. To investigate trends in intrauterine growth, we compared our data to the Lubchenco growth data (Lubchenco, Pediatrics, 1963), which were derived from birthweights of infants born during 1948-1961 in Denver, CO. The updated curves are presented in the figure. On average, male neonates weighed 3284 grams and females weighed 3181 grams. For gestational ages 24-28 weeks, contemporary neonates weighed 182 grams less than the historical neonatal population. Birthweights for gestational ages 29 and 30 weeks were similar between the two populations. For gestational ages 31-42 weeks, contemporary neonates weighed 282 grams more than the historical population. We demonstrate changes in birthweights during the past 5 decades in Colorado, including a lower mean weight at early gestational ages and a higher mean weight at later gestational ages. Use of historical growth standards will likely increase misclassification of SGA and LGA in contemporary neonates. These updated norms for intrauterine growth can facilitate monitoring of fetal growth.

Bleeding in the first and second trimester of pregnancy is a well-documented risk factor for preterm birth (PTB), but the pathophysiology by which this occurs is uncertain. Better understanding of this could lead to future interventions. We and others have previously described progressive cervical shortening in women who later experienced spontaneous PTB. In this analysis, we hypothesize that women with unexplained vaginal bleeding also manifest progressive cervical shortening leading to PTB. We conducted a secondary analysis of data from the Maternal Fetal Medicine Unit Network Preterm Prediction Study, an observational cohort study of women receiving prenatal care at one of 10 sites. Maternal report of vaginal bleeding was recorded at study visits scheduled at 2 week intervals between enrollment and 32 weeks. Cervical lengths were measured by transvaginal sonography between 22+0 weeks and 24+6 weeks and again 4 weeks later. Cervical slope was defined as the change in cervical length between these visits divided by time (mm/week). PTB was defined as preterm premature rupture of membranes or spontaneous preterm labor leading to a delivery prior to 37 weeks gestation. We analyzed the prospectively collected data for 2584 women using logistic regression and tested for interaction between risk factors in the model to determine whether cervical shortening preceded preterm births complicated by unexplained vaginal bleeding. Cervical slope was a significant predictor of PTB only among women without a history of vaginal bleeding during the first or second trimester of pregnancy (P<.0001). There was no relationship between cervical slope and PTB (P=.92) in women with vaginal bleeding (n = 662). Pregnancies with vaginal bleeding are at risk for PTB but do not appear to undergo progressive cervical shortening manifested by cervical slope. We therefore postulate that there is a different pathophysiologic mechanism leading to PTB in women with vaginal bleeding. This may have an effect on the efficacy of interventions for PTB including progesterone supplementation.

The prepregnancy body mass index (BMI, kg/m2) is one of the few modifiable risk factors for preterm birth (PTB). The objective of this study was to determine the relationship between WHO categories of BMI and spontaneous preterm birth (SPTB). From our perinatal database (2005 - 2010), we analyzed data on 11,967 women who delivered singleton births after excluding women who had a medically indicated PTB or delivered < 20 weeks. SPTB was defined as a PTB resulting from PPROM or spontaneous preterm labor. We used the WHO international classification of BMI (see figure). We analyzed the data using univariable and multivariable logistic regression analysis, adjusting for maternal age, race/ethnicity, parity, cigarette smoking, history of PTB, chronic medical disease, uterine anomalies, cervical incompetence and infertility. SPTB accounted for 65% of all PTBs. The incidence of SPTB was highest among women who had severe or moderate thinness, 28% and 22%, respectively. Compared to women with normal range BMI, the categories significantly associated with an increased risk of SPTB were: severe thinness (AOR = 2.7, 95% CI = 1.3 to 5.8, P = 0.01) and moderate thinness (AOR = 2.1, 95% CI 1.3 to 3.5, P = 0.003). We also found that obese class I was associated with a decreased risk (AOR = 0.75, 95% CI = 0.60 to 0.93, P = 0.01). Women with BMI < 17 are more than twice as likely to have SPTB compared to women with normal range BMI. Because severe and moderate thinness prior to pregnancy is potentially modifiable, interventions for women in these categories to achieve a healthy preconception weight should be evaluated.

BACKGROUND: With the emergence of H1N1 pandemic (pH1N1) influenza, the CDC recommended that pregnant women be one of five initial target groups to receive the 2009 monovalent H1N1 vaccine, regardless of prior infection with this influenza strain. We sought to compare the immune response of pregnant women to H1N1 infection versus vaccination and to determine the extent of passive immunity conferred to the newborn. METHODS/FINDINGS: During the 2009-2010 influenza season, we enrolled a cohort of women who either had confirmed pH1N1 infection during pregnancy, did not have pH1N1 during pregnancy but were vaccinated against pH1N1, or did not have illness or vaccination. Maternal and umbilical cord venous blood samples were collected at delivery. Hemagglutination inhibition assays (HAI) for pH1N1 were performed. Data were analyzed using linear regression analyses. HAIs were performed for matched maternal/cord blood pairs for 16 women with confirmed pH1N1 infection, 14 women vaccinated against pH1N1, and 10 women without infection or vaccination. We found that pH1N1 vaccination and wild-type infection during pregnancy did not differ with respect to (1) HAI titers at delivery, (2) HAI antibody decay slopes over time, and (3) HAI titers in the cord blood. CONCLUSIONS: Vaccination against pH1N1 confers a similar HAI antibody response as compared to pH1N1 infection during pregnancy, both in quantity and quality. Illness or vaccination during pregnancy confers passive immunity to the newborn.

We examined vaccination rates during pregnancy against both seasonal and pandemic H1N1 influenza and reasons for nonadherence to recommended guidelines during the 2009 through 2010 influenza season. Demographic and vaccination data were collected using a cross-sectional approach. Among 813 postpartum women, 520 (64%) reported receiving the seasonal influenza vaccination and 439 (54%) reported receiving the H1N1 influenza vaccination during pregnancy. Most received vaccinations at their obstetrician's office. Major reasons for not receiving vaccination were: not knowledgeable about the vaccine importance (25%), concerns for effects on fetal and maternal health (18% and 9%, respectively), and not knowledgeable about where to obtain vaccination (9%). Reported H1N1 influenza vaccination rates were significantly lower in blacks (37%) compared with non-Hispanic whites, Hispanics, and Asian/other (57%, 59%, and 58%, respectively; P < .0001). Subsequent campaigns for improving vaccination rates in pregnancy should focus on educating patients about vaccine importance and safety.

OBJECTIVE: To estimate whether it is possible to define clinically a subgroup of women who have so high a cesarean delivery rate as to avoid spontaneous onset of labor or induced labor. METHODS: We conducted a retrospective cohort study (October 2005 to January 2010) on a data set of women who had premature rupture of membranes (PROM) at greater than 24 weeks of gestation, a singleton pregnancy, and a viable fetus without congenital anomalies. Patients were treated in a common way regarding indications for delivery. The primary outcome was cesarean delivery. RESULTS: We identified 1,026 women (comprising 7.9% of all deliveries) who had PROM and met the inclusion criteria. There were 404 with preterm deliveries. One hundred thirty-seven (13.4%) had a contraindication to either labor or vaginal delivery. For women with induction (n=355), vaginal delivery occurred in 82%, whereas for those with spontaneous labor (n=534), vaginal delivery occurred in 87% (P=.03). No clinically defined subgroup had an observed cesarean delivery rate greater than 27%, and in most subgroups, it was lower, even when we built in multiple risk factors, including gestational age less than 34 weeks, chorioamnionitis, abruption, and nulliparity. CONCLUSION: In the absence of a contraindication to labor or to vaginal delivery, the likelihood of vaginal delivery after PROM, with either spontaneous or induced labor, is high, even when we included multiple risk factors for cesarean delivery. LEVEL OF EVIDENCE: II

In Brief OBJECTIVE: To estimate whether it is possible to define clinically a subgroup of women who have so high a cesarean delivery rate as to avoid spontaneous onset of labor or induced labor. METHODS: We conducted a retrospective cohort study (October 2005 to January 2010) on a data set of women who had premature rupture of membranes (PROM) at greater than 24 weeks of gestation, a singleton pregnancy, and a viable fetus without congenital anomalies. Patients were treated in a common way regarding indications for delivery. The primary outcome was cesarean delivery. RESULTS: We identified 1,026 women (comprising 7.9% of all deliveries) who had PROM and met the inclusion criteria. There were 404 with preterm deliveries. One hundred thirty-seven (13.4%) had a contraindication to either labor or vaginal delivery. For women with induction (n=355), vaginal delivery occurred in 82%, whereas for those with spontaneous labor (n=534), vaginal delivery occurred in 87% (P=.03). No clinically defined subgroup had an observed cesarean delivery rate greater than 27%, and in most subgroups, it was lower, even when we built in multiple risk factors, including gestational age less than 34 weeks, chorioamnionitis, abruption, and nulliparity. CONCLUSION: In the absence of a contraindication to labor or to vaginal delivery, the likelihood of vaginal delivery after PROM, with either spontaneous or induced labor, is high, even when we included multiple risk factors for cesarean delivery. LEVEL OF EVIDENCE: II For women with premature rupture of membranes and no contraindications to labor, the vaginal delivery rate is high regardless of risk factors.

Purpose: To determine whether respondents share researchers' understandings of concepts and questions frequently used in the assessment of usual physical activity (PA) behavior. Methods: As part of On the Move, a study aimed at reducing measurement error in self-reported physical activity (PA), we conducted cognitive interviews with 19 men and 21 women, ages 45-65, regarding their responses to the PA questionnaires used in two large, population-based studies, Life After Cancer Epidemiology and California Men's Health study. One questionnaire asks about the frequency, the duration, and the perceived intensity of a range of specific activities in several different domains over the past 12 months. The second questionnaire asks about frequency and duration of specific, mostly recreational activities, grouped by intensity (i.e., moderate or vigorous) over the past 3 months. We used verbal probing techniques to allow respondents to describe their thought processes as they completed the questionnaires. All interviews were tape-recorded and transcribed, and the transcripts were then analyzed using standard qualitative methods. Results: Cognitive interviews demonstrated that a sizable number of respondents understood "intensity" in terms of emotional or psychological intensity rather than physical effort. As a result, the perceived intensity with which a participant reported doing a specific activity often bore little relationship to the MET value of that activity. Additionally, participants often counted the same activity more than once, overestimated work-related PA, and understood activities that were grouped together in a single category to be definitive lists rather than examples. Conclusion: Cognitive interviews revealed significant gaps between respondents' interpretations of some PA questions and researchers' assumptions about what those questions were intended to measure. Some sources of measurement error in self-reported PA may be minimized by additional research that focuses on the cognitive processes required to respond to PA questionnaires.

PURPOSE: To determine if respondents understand concepts and questions frequently used to assess usual physical activity behavior in the ways intended by researchers. METHODS: As part of the On the Move pilot study a project aimed at reducing measurement error in self-reported physical activity measures, we conducted cognitive interviews with 20 men and 20 women, ages 40–65, regarding their responses to 2 physical activity questionnaires currently in use in large, population-based studies. One questionnaire, used in the LACE (Life After Cancer Epidemiology) study, a cohort study of breast cancer survivors, asks about the frequency, duration, and perceived intensity of various activities in several different domains over the past 12 months. The second questionnaire, used in the California Men's health Study (CMHS), a prospective study of etiologic factors for prostate and other cancers, asks about frequency and duration of specific, mostly recreational activities, grouped by intensity (i.e. moderate or vigorous) over the past 3 months. We used verbal probing techniques to allow respondents to describe their thought processes as they completed the questionnaires. All interviews were tape recorded and transcribed. We coded and analyzed the transcripts using modified grounded theory techniques. RESULTS: The cognitive interviews demonstrated that a sizable number of respondents understood “intensity” in terms of emotional or psychological intensity, rather than physical effort. As a result, the perceived intensity with which a participant reported doing a specific activity often bore little relationship to the MET value of that activity. Additionally, participants understood activities that were grouped together in a single category to be definitive, limited lists rather than examples, and they had difficulty dividing an activity, such as walking, into separate domains (i.e. walking for transportation vs. walking for exercise). CONCLUSION: Cognitive interviews reveal significant gaps between researchers' assumptions about what is being measured in physical activity questionnaires and some respondents' answers. Additional research and questionnaire redesign should be undertaken to address these gaps.