Abstract
[Purpose] The purpose of this study was to determine the factors associated with decreased physical activity levels among community residents over a long-term observation period during the coronavirus disease 2019 (COVID-19) pandemic. [Participants and Methods] We conducted a cross-sectional study using a self-administered questionnaire and daily steps as an indicator of physical activity levels. The study population consisted of 704 community-dwelling residents aged 40 years and older who participated in the health program from 2019 to 2020. We compared the daily steps from March–December 2019 to March–December 2020 and performed multivariate analysis to identify the factors associated with decreased daily steps. [Results] Of all participants, 447 (63.5%) returned the questionnaire and 309 (43.9%) were included in the analysis. During the COVID-19 pandemic, 133 (43.0%) respondents had decreased physical activity levels. The multivariate analysis showed that working (odds ratio, 2.08; 95% confidence interval, 1.10–3.94) was significantly associated with decreased daily steps during the COVID-19 pandemic. [Conclusion] There was a significant association between decreased physical activity levels and working during the COVID-19 pandemic. When restrictive measures such as teleworking are implemented, it may be necessary to take measures to prevent a decline in physical activity levels.
Keywords: Physical activity levels, Coronavirus disease 2019 (COVID-19), Working
INTRODUCTION
Physical activity is important for maintaining health; it has been associated with morbidity1, 2), including cardiovascular disease, diabetes, cancer, and osteoporosis, falls in the elderly3), and immune response4, 5). Previous studies have shown associations between physical activity and a variety of factors, including physical6) and psychological status7, 8), living environment9, 10), social networks11), and health literacy12, 13). Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic in 2020, restrictive measures such as self-restraint in social activities and social distancing have been taken worldwide to reduce spread of the virus. These measures are necessary to prevent the spread of COVID-19, but they have been reported to decrease the overall amount of physical activity14,15,16). Therefore, we need to determine which factors are associated with reduced physical activity during the COVID-19 pandemic and effectively prevent such a decline.
Factors associated with physical activity levels during the COVID-19 pandemic include frailty14); psychological health conditions such as depression, anxiety, and decreased sense of well-being17); resilience18); levels of exercise or sports activity; health-related quality of life19); and working status20, 21). However, the outcomes evaluated in these studies were limited to short-term changes during lockdown. There are no studies examining the impact over the long term. It is important to investigate factors associated with decreased physical activity over the long term, as prolonged decline in physical activity levels can have a negative impact on health.
This study assessed the association between physical activity levels and health literacy. Health literacy is defined as the ability to gather, understand, and use appropriate information from a large amount of information. Health literacy has been reported to be related to various health behaviors, including physical activity12, 13). Since the beginning of the COVID-19 pandemic, a large amount of information about the virus, risk of infection, and infection prevention methods has been disseminated. Health literacy might have an impact on physical activity levels during these situations.
The purpose of this study was to determine which factors, including health literacy, are associated with decreased physical activity levels among community residents over a long-term observation period during the COVID-19 pandemic. If this study can identify such factors, it might provide information that is helpful for health promotion and maintaining physical activity levels in a prolonged COVID-19 pandemic.
PARTICIPANTS AND METHODS
We conducted a cross-sectional study using a self-administered questionnaire and data from the city authority in Kitaibaraki City, Ibaraki Prefecture, Japan. Kitaibaraki City is located approximately 160 km north of the capital, Tokyo. The population was 41,400 and 35.0% of the population was aged 65 years or older, higher than the national average of 28.4%22). Ibaraki Prefecture was subject to a state of emergency declaration from April 16 to May 14, 2020. Unlike a lockdown that prohibits people from going out, the state of emergency declaration was not mandatory. It depended on the voluntary cooperation of the residents. Once the state of emergency was declared, residents were required to refrain from going out except for work or daily shopping. They were restricted from using schools, department stores, and movie theaters. In Ibaraki Prefecture, the first case of COVID-19 was reported on March 17, 2020. The total number of cases by the end of December 2020 was reported to be 2,446. In Kitaibaraki City, the first case of COVID-19 was reported on October 26, 2020. There were five cases reported by the end of December 202022). Since the first COVID-19 case in Ibaraki Prefecture occurred in March 2020, we defined the period from March to December 2020, as the COVID-19 pandemic period. The same period in the previous year, March to December 2019, was defined as the non-COVID-19 pandemic period.
Kitaibaraki City has conducted a health program aimed at promoting healthy behaviors among citizens aged 40 years or older since 2017. Participants in the health program were given pedometers by Kitaibaraki City at the time of registration. The study population consisted of 704 community residents aged 40 years or older who participated in the health program in both 2019 and 2020. Residents who did not give consent for study participation and those who had an illness or injury that affected physical activity between January and December 2020 were excluded.
The survey items included physical activity levels, participant characteristics (age, gender, height, weight, body mass index (BMI), educational history, household size, medical history, smoking history, and working status), subjective health, health behaviors and perceptions regarding COVID-19, health literacy, and resilience.
We used daily steps, which was data obtained from the health program, as the indicator of physical activity levels. The daily steps is related to energy expenditure during physical activity, indicating its validity as an indicator of physical activity levels23). The daily steps was measured using a tri-axial accelerometer (AM-150; Tanita, Tokyo, Japan).
We developed questionnaire items related to health behaviors and perceptions regarding COVID-19 based on prior research24, 25). We investigated the effect of COVID-19 on health behaviors and perceptions regarding COVID-19, which included daily steps, awareness of exercise and walking for health, understanding of how to exercise safely during the COVID-19 pandemic, and fear of the virus that causes COVD-19 when exercising outside. We asked the question about the effect of COVID-19 on daily steps using a 4-point Likert scale from “no effect at all” to “significant effect”. We asked the question about awareness of exercise and walking for health using a 4-point Likert scale from “not at all” to “quite a bit”. We asked the other questions using a 4-point Likert scale ranging from “almost never” to “quite a bit”. We assessed health literacy using the 14-item health literacy scale for Japanese adults (HLS-14)26) developed by Suga et al., which is a comprehensive measure of health literacy for Japanese adults. We assessed resilience using the Brief Resilience Scale-Japanese version (BRS-J)27).
We distributed the self-administered questionnaires to the individuals by mail between December 3 and December 23, 2020. We collected questionnaires at four public facilities in the city, including the city hall and libraries. We obtained steps data from Kitaibaraki City only for those who agreed to participate in the study.
Study participants were included in the analysis if steps data were recorded for at least 4 days per month during the study period28, 29). We excluded days of poor compliance with wearing the pedometer when the pedometer recorded less than 300 steps28) and rainy days30) based on previous studies. We calculated the average number of steps per day by dividing the total number of steps taken during the period of analysis by the number of days for which data were recorded.
We defined the group whose average daily steps decreased during the COVID-19 pandemic period compared with the non-COVID-19 pandemic period as the decreased step count group. The group whose average daily steps did not decrease during the COVID-19 pandemic period compared with the non-COVID-19 pandemic period was defined as the non-decreased step count group. We treated age, height, weight, BMI, HLS-14, and BRS-J as continuous variables. We treated the remaining variables as categorical variables. We classified educational history into two categories: graduated from high school or higher. We classified household size into two categories: “single” or “non-single”. We classified working status into two categories: “working” if the respondent was working full time, part-time, or in another arrangement; and “not working”. We classified subjective health into two categories: “good” for very good or good, and “poor” for not so good or poor. We classified health behaviors and perceptions regarding COVID-19 into two groups based on the median response, which required responses on a 4-point Likert scale.
We conducted univariate analyses to examine the association between each variable and step count group status. Categorical variables were analyzed using the χ2 test. Continuous variables were compared using the t-test. We also performed forced-entry binomial logistic regression to identify factors associated with decreased daily steps. Independent variables consisted of age, gender, HLS-14, and variables with p<0.1 in the univariate analysis. Significance level was set at p<0.05. All analyses were conducted with SPSS 25.0 for Mac (IBM Crop, Armonk, NY, USA).
All participants were informed about the study in writing. They provided written informed consent prior to enrollment in the study. We conducted the study in accordance with the Declaration of Helsinki and with the approval of the University of Tsukuba Medical Ethics Board (no. 1602).
RESULTS
Figure 1 shows the study flow. Of 704 potential study participants, 447 (63.5%) completed the questionnaire. The final analysis included 309 (43.9%) respondents, excluding those who had an illness or injury that affected their steps in 2020 and those with missing steps data. Figure 2 shows the distribution of changes in daily steps in 2020 compared with 2019. Of these 309 respondents, 133 (43.0%) were in the decreased step count group and 176 (57.0%) were in the non-decreased step count group (Table 1). The mean daily steps in the decreased step count group was 7,824.5 ± 3,451.8 in 2019 and 6,973.9 ± 2,728.1 in 2020, representing 850.6 fewer steps in 2020 compared with 2019. The mean daily steps in the non-decreased step count group was 7,963.6 ± 2,699.8 in 2019 and 9,162.8 ± 3,078.9 in 2020, representing 1,199.2 more steps in 2020 than in 2019. There were no significant differences in daily steps in 2019 between the two groups.
Fig. 1.
Flowchart of the participant selection.
Fig. 2.
Distribution of changes in daily steps in 2020 compared with 2019.
Table 1. Characteristics of study participants with and without decreased daily steps in univariate analysis.
| Overall | Decreased step count group | Non-decreased step count group | |
| (n=309) | (n=133) | (n=176) | |
| Number of steps per day, mean ± SD | |||
| 2019 | 7,903.7 ± 3,047.1 | 7,824.5 ± 3,451.8 | 7,963.6 ± 2,699.8 |
| 2020 | 8,220.6 ± 3,126.9 | 6,973.9 ± 2,728.1 | 9,162.8 ± 3,078.9*** |
| The COVID-19 pandemic had an effect on the daily steps, n (%) | |||
| Yes | 83 (26.9) | 45 (33.8) | 38 (21.6)* |
| No | 226 (73.1) | 88 (66.2) | 138 (78.4) |
| Gender, n (%) | |||
| Female | 201 (65.0) | 84 (63.2) | 117 (66.5) |
| Male | 108 (35.0) | 49 (36.8) | 59 (33.5) |
| Age, mean ± SD, years | 67.6 ± 8.5 | 66.5 ± 9.6 | 68.4 ± 7.5* |
| Height, mean ± SD, cm | 158.1 ± 8.5 | 159.1 ± 8.8 | 157.3 ± 8.3 |
| Weight, mean ± SD, kg | 58.4 ± 10.4 | 58.9 ± 11.7 | 57.9 ± 9.2 |
| BMI, mean ± SD, kg/m2 | 23.2 ± 3.1 | 23.1 ± 3.1 | 23.3 ± 3.1 |
| Educational history, n (%) | |||
| High school graduate | 193 (63.5) | 79 (59.8) | 114 (66.3) |
| Higher | 111 (36.5) | 53 (40.2) | 58 (33.7) |
| Household size, n (%) | |||
| Single | 33 (10.8) | 16 (12) | 17 (9.8) |
| Non-single | 273 (89.2) | 117 (88) | 156 (90.2) |
| Underlying disease in the medical history, n (%) | |||
| Yes | 77 (25.3) | 36 (27.5) | 41 (23.7) |
| No | 209 (68.8) | 85 (64.9) | 124 (71.7) |
| Unknown | 18 (5.9) | 10 (7.6) | 8 (4.6) |
| Missing | 5 | 2 | 3 |
| Smoking history, n (%) | |||
| Never smoker | 219 (71.6) | 97 (72.9) | 122 (70.5) |
| Former smoker | 82 (26.8) | 34 (25.6) | 48 (27.7) |
| Current smoker | 5 (1.6) | 2 (1.5) | 3 (1.7) |
| Missing | 3 | 0 | 3 |
| Working status, n (%) | |||
| Not working | 207 (67.9) | 78 (59.1) | 129 (74.6)** |
| Working | 98 (32.1) | 54 (40.9) | 44 (25.4) |
| Subjective health, n (%) | |||
| Poor | 21 (6.9) | 10 (7.6) | 11 (6.4) |
| Good | 282 (93.1) | 122 (92.4) | 160 (93.6) |
| Awareness of exercise and walking for health, n (%) | |||
| Yes | 289 (93.8) | 119 (90.2) | 170 (96.6)* |
| No | 19 (6.2) | 13 (9.8) | 6 (3.4) |
| Understanding how to exercise safely during the COVID-19 pandemic, n (%) | |||
| Yes | 248 (81.3) | 110 (84) | 138 (79.3) |
| No | 57 (18.7) | 21 (16) | 36 (20.7) |
| Fear of the virus that causes COVID-19 when exercising outside, n (%) | |||
| Yes | 66 (21.6) | 23 (17.6) | 43 (24.6) |
| No | 240 (78.4) | 108 (82.4) | 132 (75.4) |
| HLS-14 score ± SD | 54.9 ± 7.3 | 54.2 ± 7.9 | 55.4 ± 6.8 |
| BRS-J score ± SD | 18.8 ± 4.0 | 18.4 ± 4.2 | 19.1 ± 3.8 |
SD: standard deviation; BMI: body mass index; HLS-14: 14-item Health Literacy Scale; BRS-J: Brief Resilience Scale-Japanese version.
*p<0.05, **p<0.01, ***p<0.001.
p-value for comparing decreased step count and non-decreased step count groups using the χ2 test or the t-test.
Decreased and non-decreased step count groups were categorized as follows.
Decreased step count group: respondents whose average daily steps decreased during March–December 2020, which was defined as the COVID-19 pandemic period, compared with during March–December 2019, which was defined as the non–COVID-19 pandemic period.
Non-decreased step count group: respondents whose average daily steps did not decrease during March–December 2020 compared with March–December 2019.
Gender, height, weight, BMI, educational history, household size, medical history, and smoking history did not differ between the two groups. The mean age of the respondents was 66.5 ± 9.6 years in the decreased step count group and 68.4 ± 7.5 years in the non-decreased step count group, with the decreased step group being significantly younger (p<0.05). Regarding working status, the percentage of working individuals was 40.9% in the decreased step count group and 25.4% in the non-decreased step count group, with the decreased step count group being significantly more likely to be working (p<0.01).
HLS-14 scores, subjective health, and BRS-J scores were not significantly different between the two groups. Significantly more respondents in the decreased step count group reported that the COVID-19 pandemic had an effect on daily steps (p<0.05). Regarding awareness of exercise and walking for health, 9.8% of the decreased step count group and 3.4% of the non-decreased step count group answered “no”, which was significantly higher in the decreased step count group than in the non-decreased step count group (p<0.05).
We conducted binomial logistic regression analysis with forced entry of age, gender, HLS-14 score, and variables with p<0.1 in the univariate analysis: working status, awareness of exercise and walking for health, and BRS-J score. Working (odds ratio, 2.08; 95% confidence interval, 1.10–3.94) was significantly associated with decreased daily steps during the COVID-19 pandemic (Table 2).
Table 2. Factors associated with decreased daily steps taken based on logistic regression analysis.
| OR | (95% CI) | |
| Gender (Female=0, male=1) | 1.11 | (0.66–1.85) |
| Age | 1.00 | (0.97–1.04) |
| Working status (Not working=0, working=1) | 1.93 | (1.03–3.62)* |
| Awareness of exercise and walking for health (No=0, Yes=1) | 0.46 | (0.16–1.32) |
| HLS-14 score | 1.02 | (0.98–1.05) |
| BRS-J score | 1.04 | (0.98–1.11) |
OR: odds ratio; CI: confidence interval; HLS-14: 14-item Health Literacy Scale; BRS-J: Brief Resilience Scale-Japanese version.
Dependent variable: presence or absence of a decrease in the daily steps taken during the COVID-19 pandemic period.
*p<0.05.
DISCUSSION
This study investigated the decline in physical activity levels and associated factors over a long-term observation period during the COVID-19 pandemic among community residents. As a result, we found that daily steps decreased in approximately 43% of respondents and that working was significantly associated with a decrease in daily steps over the long term during the COVID-19 pandemic. The average number of steps taken per day during the COVID-19 pandemic period in the decreased step count group was approximately 6,900 steps, approximately 850 fewer steps than during the non-COVID-19 pandemic period. Regarding the association between disease incidence and physical activity, Aoyagi et al. found that the optimal activity threshold for prevention of lifestyle-related diseases such as metabolic syndrome, hypertension, and diabetes is >8,000–10,000 steps/day or physical activity reaching an intensity of >3 metabolic equivalents (METs) for >20–30 min/day31). In addition, a systematic review of the association between daily steps and risk of developing cardiovascular disease, reported a 6–36% reduction in all-cause mortality risk and a 5–21% reduction in cardiovascular disease risk for each additional 1,000 steps taken per day1). The decrease in daily steps observed in this study might have a negative effect on health.
Multivariate analysis showed that working was significantly associated with fewer steps taken per day during the COVID-19 pandemic period. In a previous study, teleworkers reported longer sedentary time and shorter physical activity time compared with those who did not telework32). Teleworking, which includes working at home and mobile work aimed at reducing human contact, has been recommended in Japan as a means of preventing COVID-1933). According to a survey by the Ministry of Internal Affairs and Communications of Japan, the rate of teleworking in private companies was 17% before the declaration of the state of emergency, 55% during the declaration of the state of emergency, and more than 30% after the declaration of the state of emergency34). It was possible that the rate of telework was higher among study participants during the COVID-19 pandemic period than during the non-COVID-19 pandemic period.
Physical activity can be divided into two domains35): “daily activities” such as working, housework, commuting to and from work, and “exercise” that is performed systematically and continuously for the purpose of maintaining and improving physical fitness. Among working individuals, “daily activities” may have decreased significantly due to changes in job characteristics such as teleworking during the COVID-19 pandemic period. Thus, overall daily steps might have decreased accordingly. On the other hand, among non-working individuals, it was possible that the impact of decreased daily steps as part of “daily activities” was small. Regarding “exercise”, participants who were required to maintain social distancing spent less time meeting with friends, and they may have walked or exercised outdoors instead. As a result, their daily steps might not have decreased.
In this study, there were no significant associations between health literacy and physical activity levels. Those with higher health literacy would have more skills in finding appropriate ways to maintain physical activity levels in the face of socially restrictive measures due to the COVID-19 pandemic. On the other hand, they might have more strictly maintained social distancing or stayed home, for example, by reducing the frequency of shopping or participation in hobbies, in order to reduce the risk of infection or severe illness for themselves or their family members. Therefore, it is possible that high health literacy does not necessarily contribute to more physical activity.
The strength of this study is that daily steps, used as an index of physical activity levels, was measured by a tri-axial accelerometer. Physical activity levels can be evaluated subjectively using a questionnaire or objectively using devices such as accelerometers. Most studies investigating physical activity levels and related factors during the COVID-19 pandemic have used questionnaires to measure physical activity levels36,37,38). Janovsky et al. reported that subjective assessments of physical activity levels might overestimate the decline in physical activity levels compared to objective assessments during the COVID-19 pandemic39). Therefore, it is highly likely that this study, which used an objective assessment method, provided an accurate assessment of physical activity levels.
This study had several limitations. First, the study was conducted in a single area of Japan with a lower rate of COVID-19 than other urban areas. The results might have been affected by factors such as local characteristics of the COVID-19 pandemic. However, the presence of an association between working and lower physical activity levels during the COVID-19 pandemic, even in a city with relatively few COVID-19 cases, might be generalizable to other regions. Second, study participants might not be representative of the general population in this area in that they own an accelerometer and have the motivation to check their steps records frequently, suggesting that they have a higher intention to walk than others. Third, a variety of external and internal factors might influence physical activity levels during the COVID-19 pandemic; this study might not have adjusted for all factors that may have affected outcomes. Fourth, this study did not examine the participants’ work characteristics. It is possible that physical activity levels during the COVID-19 pandemic period might have been significantly affected not only by working status, but also by differences in work characteristics, such as whether telework was possible or not. Therefore, future studies should take work characteristics into consideration in order to more effectively prevent decreases in physical activity levels.
Forty-three percent of the participants had a lower daily steps during the COVID-19 pandemic period than during the non-COVID-19 pandemic period. Working was significantly associated with a long-term decrease in daily steps during the COVID-19 pandemic. When restrictive measures such as teleworking are implemented, it might be necessary to take measures to prevent a decline in physical activity levels, such as providing home exercises and opportunities for walking.
Authors’ contributions
Shogo Kawada, Takami Maeno, Shoji Yokoya and Tetsuhiro Maeno contributed to the research design and collection of data. Shogo Kawada, Takami Maeno and Shoji Yokoya contributed to the analysis of the results. Shogo Kawada, Takami Maeno, Shoji Yokoya and Tetsuhiro Maeno contributed to the writing of the manuscript.
Funding
None.
Conflicts of interest
The authors report no declarations of interest.
Acknowledgments
We would like to express our sincere gratitude to the staff of the Elderly Welfare Division in the Kitaibaraki City who cooperated with the survey, and to the residents who responded to the survey.
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