Objectives: To validate parent-reported child habitual total physical activity against accelerometry and three existing step-count thresholds for classifying 3h/day of total physical activity in pre-schoolers from 13 culturally and geographically diverse countries. Design: Cross-sectional validation study. Methods: We used data involving 3- and 4-year-olds from 13 middle- and high-income countries who participated in the SUNRISE study. We used Spearman's rank-order correlation, Bland-Altman plots, and Kappa statistics to validate parent-reported child habitual total physical activity against activPAL™-measured total physical activity over 3?days. Additionally, we used Receiver Operating Characteristic Area Under the Curve analysis to validate existing step-count thresholds (Gabel, Vale, and De Craemer) using step-counts derived from activPAL™. Results: Of the 352 pre-schoolers, 49.1% were girls. There was a very weak but significant positive correlation and slight agreement between parent-reported total physical activity and accelerometer-measured total physical activity (r: 0.140; Kappa: 0.030). Parents overestimated their child's total physical activity compared to accelerometry (mean bias: 69min/day; standard deviation: 126; 95% limits of agreement: -179, 316). Of the three step-count thresholds tested, the De Craemer threshold of 11,500 steps/day provided excellent classification of meeting the total physical activity guideline as measured by accelerometry (area under the ROC curve: 0.945; 95% confidence interval: 0.928, 0.961; sensitivity: 100.0%; specificity: 88.9%). Conclusions: Parent reports may have limited validity for assessing pre-schoolers' level of total physical activity. Step-counting is a promising alternative - low-cost global surveillance initiatives could potentially use pedometers for assessing compliance with the physical activity guideline in early childhood.
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