COVID-19 AND THE INFLUENCE OF SOCIAL RESTRICTION ON PHYSICAL ACTIVITY AMONG CHILDREN AND ADOLESCENTS

COVID-19 E INFLUÊNCIA DA RESTRIÇÃO SOCIAL NA ATIVIDADE FÍSICA DE CRIANÇAS E ADOLESCENTES

ABSTRACT

The objectives of this study were to verify the influence of the procedures adopted to contain the Covid-19 pandemic on the levels of physical activity (PA) of children and adolescents, as well as to check if there are any differences between the sexes and age groups. A quick literature review was carried out by means of a search in journals available in the PubMed, Scopus and Web of Science databases, using the following keywords: Children, Adolescents, Physical Exercise, Physical Activity, and Covid-19. Of the 449 studies identified, 17 were selected by the criterion of containing data referring to before and during the social restriction period in the same study. With the exception of one article, the synthesis of results indicated a decrease in PA levels and an increase in time spent on screen activities during the social restriction period, in greater proportions for adolescents and for females. Results are similar among countries in the same region than comparing different continents, due to differences in the sociocultural environment in which young people live, mainly encouraged by their guardians. From a public health point of view, there should be a concern about the continuity of this pattern of behavior after the end of the pandemic, which would further increase the risk of already existing problems, such as delays in motor development, overweight, obesity, cardiovascular diseases and diabetes in adulthood.

Keywords: Childhood; Adolescence; Physical Activity; Sedentary Behavior; Coronavirus

RESUMO

Os objetivos deste estudo foram verificar a influência dos procedimentos adotados para conter a pandemia da Covid-19 nos níveis de atividade física (AF) de crianças e adolescentes e verificar se há diferenças entre os sexos e faixas etárias. Foi realizada uma revisão rápida de literatura, com busca em periódicos disponíveis nas bases de dados PubMed, Scopus e Web of Science, utilizando as palavras-chaves: Crianças, Adolescentes, Exercício Físico, Atividade Física e Covid-19. Dos 449 estudos identificados, 17 foram selecionados pelo critério de conter dados referentes a antes e durante o período de restrição social no mesmo estudo. Com exceção de um artigo, a síntese dos resultados indicou diminuição dos níveis de AF e aumento do tempo em atividades de tela durante o período de restrição social, em maior proporção para adolescentes e para o sexo feminino. Os resultados são mais próximos entre países da mesma região do que entre diferentes continentes, devido às diferenças no ambiente sociocultural em que os jovens vivem, incentivados principalmente pelos seus responsáveis. Do ponto de vista da saúde pública, deve existir uma preocupação com a continuidade desse padrão de comportamento após o término da pandemia, o que aumentaria ainda mais o risco de problemas já existentes, como atrasos no desenvolvimento motor, sobrepeso, obesidade, doenças cardiovasculares e diabetes na vida adulta.

Palavras-chave: Infância; Adolescência; Atividade Física; Sedentarismo; Coronavírus

Introduction

In March 2020, the World Health Organization (WHO) declared the pandemic state for Covid-19, a disease caused by the SARS-CoV-2¹ virus. The virus can be easily transmitted through respiratory droplets, saliva or other contact routes and cause acute respiratory distress and other complications². Although healthy children and adolescents are not part of the risk group³, any individual can develop symptoms of the disease, from the mildest to the lethal ones; in rare cases, children can develop Multisystem Inflammatory Syndrome (MIS-C)⁴, which affects the airways and lungs shortly after infection with the SARS-CoV-2 virus and can cause great difficulty in breathing, requiring intubation in some cases. In addition, there is concern about contagion, for instance, from their guardians and those considered as a risk group, that is, people over 60 years old and/or with other pathologies and comorbidities, such as heart diseases, diabetes, hypertension, etc.¹

For this reason, many countries have adopted social restriction measures¹, with the closing of schools and daycare centers, as well as parks, gyms and environments considered non-essential, thus changing the routine of children and adolescents around the world, particularly in relation to the possibilities of engaging in PA. Actually, even before the pandemic, low rates of PA among children and adolescents were already considered a serious public health issue^5),(6, with girls, in general, having even lower PA levels compared to boys, especially with the increase in chronological age^{7),(8),(9),(10}. With the adoption of social isolation measures, there is a high probability of this situation worsening, thus resulting in a great effect on global public health. Recent studies indicate that there was a reduction in PA among adults and children during the social restriction period^11),(12.

However, scientific evidence about the effect of social restriction on PA levels is still scarce, particularly because the duration, frequency and type of restriction were different in each country/region. Furthermore, a greater understanding of the influence of age and sex is needed. Therefore, due to the possible effect of social restriction on health, and taking into account the importance of PA in childhood and adolescence, there is a need for information aimed at the formulation of public policies applied to the resumption of face-to-face activities, both in the school context and in leisure. The objectives of this review research were: (i) to synthesize evidence from studies that have verified the influence of social restrictions resulting from the Covid-19 pandemic on the PA levels of children and adolescents; and (ii) to verify possible differences between the sexes and age groups. The hypothesis is that there has been a reduction in PA levels among children and adolescents of both sexes, which would lead to risks to public health becoming worse.

Methods

A quick literature review was conducted from the recommendations of the World Health Organization (WHO)¹³, in which a quick review is described as a way to synthesize literature in a few weeks, without losing quality criteria, such as transparency, reproducibility and systematization. Thus, such studies are justified by the fact that systematic reviews require long periods of time (months/years) and costs related to the team of researchers, while quick responses are desirable in practical contexts of public policy formulation, especially during crises¹³. In this sense, the present text uses this resource to verify the effects of the pandemic on the engagement in PA of children and adolescents in the world, from the following scientific article databases: Pubmed, Scopus and Web of Science.

Figure 1
Quick review flowchart

Eligibility criteria

Based on the research question, the search comprised original articles published in peer-reviewed scientific journals, in English, Portuguese and Spanish. More specifically, based on the “PICOS”¹⁴ strategy, the following items were established, considering:

Population

Samples of children and adolescents aged between 3 and 19 years old (without disabilities and/or specific clinical conditions, except for samples specifically composed of overweight and/or obese children).

Exposure/outcome

Observational studies that have analyzed the effect of the procedures adopted to contain the pandemic, which include distancing, social isolation, lockdown, quarantine, and strict or relaxed confinement in engagement in PA, having as basis Covid-19 for exposure variable and/or PA for outcome variable, provided that there were comparisons between current and pre-pandemic levels. No restrictions were imposed as to PA intensity (light/moderate/vigorous), domains (e.g., leisure, school or commuting), and instruments used to measure PA (e.g., questionnaires or motion sensors).

Study design

Cross-sectional and longitudinal studies that presented analyses on Covid-19 and PA were included, regardless of the protocol used (e.g., univariate or multivariate analyses). Case studies, reviews, meta-analyses, and event summaries were excluded.

Sources of information and search strategy

A search for journals available in the PubMed, Web of Science and Scopus databases was carried out, using the terms “Child”, “Adolescent”, “Physical Exercise”, “Physical Activity” and “Covid-19”. The terms “Children” and “Adolescents”, as well as “Physical Exercise” and “Physical Activity”, were joined in each database through the Boolean operator “OR” and their respective results; the term “Covid-19” was later connected through the Boolean operator “AND”. One author (RPAJ) performed the initial search for articles, having December 31, 2020, as maximum date of publication, and introduced all retrieved articles in the Rayyan platform (https://rayyan.ai/reviews/231130)¹⁵, where duplicates were identified and removed.

Subsequently, two authors (SAM, JVBXR), independently, reviewed, in the platform, the available articles by their titles and abstracts. Results were compared, and inconsistencies were discussed until consensus was reached. When no consensus was reached, a third author (GS) determined the eligibility of the study. After this phase ended, the same authors evaluated the full texts of the remaining articles. Data were independently extracted by two authors (SAM, JVBXR) in an electronic spreadsheet, which was organized into two levels of information: (1) descriptive (location, sample and age) and (2) methodological (design, characteristics of the procedures adopted to contain the pandemic, type and measure of PA, form of analysis, and main results). Data were extracted from the total sample only if data by sex were not available. Considering the heterogeneity among the designs and methods adopted, a descriptive synthesis of the available data was chosen.

Results

A total of 449 articles were identified in the selected databases (Pubmed = 105; Web of Science = 118; Scopus = 226), of which 158 were excluded in the duplicate removal phase. After the titles and abstracts of the remaining 291 articles were read, 22 articles were selected for full reading, and 17 were included for data synthesis, as shown in the flowchart displayed in Figure 1.

Among the 17 selected studies, 8 were cross-sectional, 8 were longitudinal, and only one was experimental. The sample size ranged from 41¹⁶ to 1,711¹⁷ participants. Most studies (n = 11) were conducted on the European continent^16)-(26. All studies used questionnaires to measure PA, and only one study²⁶ used smartphone sensors, pedometer and motion-based activity recognition (MBAR). Regarding the characteristics of the procedures adopted to contain the pandemic, nine studies classified them as lockdown^{16),(17),(19),(20),(22),(23),(26),(28),(29}, two studies classified them as isolation or quarantine^18),(30, five classified them as social distancing^{24),(25),(27),(31),(32}, and one study classified them as strict or relaxed confinement²¹. Despite different applications and concepts, the studies had similar results, regardless of the restriction model adopted (social isolation, lockdown, quarantine, confinement or social distancing). For this reason, we defined the use of “social restriction” as a single term to refer to the seclusion period during the pandemic.

With the exception of the study from Germany¹⁷, all studies reported a decrease in PA levels during the pandemic period compared to the pre-pandemic period. Among the studies that differentiated sex in the sample (n = 8), two found no difference between boys and girls^17),(22, and six showed statistically significant differences in PA levels between the groups^{18),(19),(20),(28),(30),(31}. Among the articles that showed differences between the sexes (n = 6), three studies showed that there was a decrease for both sexes and that boys had higher PA levels than girls did^18),(19),(30; two studies showed that, for the female sex, there was no significant difference in PA level before and during the pandemic^28),(31, and one study showed that, among those who were active during the pandemic, girls were more active, and among those who were inactive, they were also more inactive than boys were²⁰.

Among the total number of studies that established some relationship with age (n = 7), only one study found no difference between ages²², and five observed that the older the age, the lower the PA levels found when compared to younger ages in the same sample^{17),(19),(28),(29),(30}. One study showed the opposite (the younger the age, the lower the PA levels)²¹.

Chart 1
Main descriptive results of the publications included

Chart 1
continuation

Chart 1
continuation

Discussion

The initial hypothesis was confirmed, as there was a decrease in PA levels among children and adolescents due to social restriction in 16 of the 17 analyzed studies (94%). Girls had a lower PA level than boys did, although some studies^25),(31) have not found significant differences in PA for girls before and during the pandemic, probably because the latter already had low PA levels in the pre-pandemic period^33),(34. Most studies (n=4) comparing children and adolescents reported that the decrease or lower adoption of PA recommendations (PA ≥ 60 minutes daily) was greater in adolescents than in children.

To control the increase in cases of Covid-19, restrictive measures such as the closing of schools, as well as PA and sports programs, brought about drastic changes in family routine and raised the likelihood of sedentary behavior and of parents’ having trouble balancing responsibilities with education, health, PA time and work. Evidence prior to the pandemic^{33),(35),(36),(37)} has already reported lower PA levels among girls and a reduction in PA for both sexes in early adolescence³⁷, a phenomenon that remained during the social isolation period. Additionally, the results of the present study showed that, both in childhood and adolescence, boys who were more active in the pre-pandemic period were more likely to maintain the same PA levels during social isolation^18),(19),(30. These findings reinforce the perspective that children/adolescents who were more active before the pandemic tend to remain more active during the pandemic, when compared to the less active in the pre-pandemic period. That is, engagement in PA before the pandemic was a protective factor for the maintenance (or smaller reduction) of PA during the pandemic.

The results show that changes in PA levels due to the pandemic were similar across countries in the same region. The consequences of social isolation have shown adverse effects on the movement and playful behaviors of Canadian children and adolescents²⁹ in activities such as walking/cycling, outdoor and indoor physical exercise, and outdoor play. Many young people were not meeting PA recommendations during the pandemic, which could be related not only to the closing of schools and PA places, but also to a lack of adequate space at home or even a lack of family encouragement. In research involving different continents, Brazil and Chile had a higher rate of inactive adolescents during the isolation, compared to Italy and Spain²⁰. In Brazil, a single study showed that there was also a significant reduction in weekly physical activity among children and adolescents of both sexes³², with most of the sample being inactive during the social restriction.

In countries on the European continent, similar results have been found during the period in which social restriction measures were implemented. In a systematic review, Hesketh et al.³⁸ pointed out some barriers to children’s PA in studies conducted in Europe, the United States, Canada and other countries, with highlight to climate, safety and interaction between parents and daycare teachers in PA-related care; within this context, social restriction can be considered a potentiating factor for these barriers. Most studies have not described or considered physical activity in housework or gardening, which may be the reason for the increase in PA that has occurred in Germany, where these tasks were considered in the applied questionnaire¹⁷.

From a public health point of view, there is a risk that the increase in sedentary lifestyle and screen time will remain post-pandemic, which would increase the prevalence of existing problems, such as delays in motor³⁷ and social-cognitive³⁹ development, in addition to greater risks of overweight, obesity, cardiovascular diseases, diabetes and physical inactivity in adulthood⁴⁰. Thus, the data of the present review justify the need for integrated public policies on education and health, aimed at families, schools and the use of leisure areas, such as parks and squares. Among the limitations of the present research, it is worth mentioning the relatively small number of studies and the use of recall questionnaires to measure PA. Moreover, information about sedentary behavior, such as screen time, was not found in all articles, which can be extremely important, since, during social restriction, Remote Learning was adopted, increasing the need to be immobile in front of screens. With the continuity of research (post-pandemic), a greater understanding of the effect of social restriction on the PA and motor development of children and adolescents is necessary, taking into account the sociocultural context and the application of public policies and/or intervention programs.

Conclusion

Low PA rates among children and adolescents were already evident before the pandemic, particularly among girls. Social restriction measures have contributed to decreasing PA during the pandemic, with a greater effect on adolescents and girls. Encouragement towards and evaluation of PA in the family environment, at school and in leisure time should be considered in further research. It is paramount that other health professionals promote PA as a tool for the biopsychosocial development of young people, also with a view to minimizing the negative effects resulting from the Covid-19 pandemic and consequent social restriction.

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Data availability

Data citations

World Health Organization. Coronavirus disease (‎COVID-19). 2020[ Cited on 2021 Jul 02 ]. Available from:<Available from:https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-a-detail/coronavirus-disease-Covid-19 (site OMS) >.

Publication Dates

• Publication in this collection
  19 Dec 2022
• Date of issue
  2022

History

• Received
  15 Sept 2021
• Reviewed
  01 June 2022
• Accepted
  25 June 2022