Relaciones entre actividad física y calidad de vida relacionada con la salud en niños y adolescentes durante la distancia social COVID-19

Relationship between physical activity and health-related quality of life in children and adolescents during COVID-19 social distancing

Relações entre a atividade física e a qualidade de vida relacionada à saúde em crianças e adolescentes durante o distanciamento social COVID-19

The lifestyle changes on social distancing during pandemic coronavirus (COVID-19) could be related to decreasing health-related quality of life (HQOL), mainly in children and adolescents, that depends on other people and context to do the daily activities, like family, school, and friends (Rundle et al., 2020). Additionally, the probability of people presenting physical inactivity associated with lower levels of HQOL, and mental health problems are higher during this period (Jiménez-Pavón et al., 2020; Lippi et al., 2020; Nguyen et al., 2020). The Chinese population, for example, increased in 55% high-stress symptoms, 59% in anxiety, and 35% increments in depressive responses during social distancing time (Wang et al., 2020).

Besides, this period results in increased physical inactivity, which leads to the development of cardiometabolic risk factors in children and adolescents (Andersen et al., 2015; Di Cesare et al., 2016; Ortega et al., 2018). Also, the out-of-school time increases sedentary behavior, physical inactivity, and obesity (Rundle et al., 2020). A study developed in China, during the pandemic period estimate that people who reach high amounts of physical activity per week have a probability of 2.72 times more likely to present high quality of life compared to those who reach less physical activity levels per week (Nguyen et al., 2020). However, the association between physical activity and HQOL during the COVID-19 pandemic has not been explored in Brazilian children and adolescents. Studies carried out before this pandemic time suggest these associations, mainly between physical activity and well-being (Brown et al., 2004; Miller et al., 2019; Omorou et al., 2013; Standage et al., 2012).

The present study is of great relevance, once in some Brazilian states, as Santa Catarina, the physical education classes continued during the pandemic COVID-19 through the distance learning intervention. It was one of the first places to make official at public school an online education proposal during COVID-19 isolation time (CEE & Ramos, 2020b, 2020a; Lemes et al., 2022; Ribeiro & Lopes, 2019). This is justified since school is the main environment to social interaction and development of a healthy lifestyle, including physical activity practice, being closely related to the protection of health during COVID-19 time (Rundle et al., 2020).

In general, researches about physical activity and HQOL are well documented in some countries as well the negative impact of COVID-19 in HQOL (Guzmán-Muñoz et al., 2020; Hansel et al., 2022; Kharshiing et al., 2020; Lipskaya-Velikovsky, 2021; López-Ruiz et al., 2021; Ovdii et al., 2021; Ozturk & Duruturk, 2021; Riiser et al., 2020). Findings about this indicate that there are positive relations between the Physical activity and HQOL (López-Aymes et al., 2021). However, is still important to confirm these results in low and middle countries like Brazil and Latin America (Lemes et al., 2021a; Lemes et al., 2021), mainly due to social differences and vulnerability into these countries. From this, the confirmatory scientific reports can lead and reinforce new political procedures to improve the public health services, teaching methods, lifestyle, sports and physical activity for children and adolescents to reach a better level of mental and physical well-being and HQOL (Franco et al., 2021). Thus, understanding the associations between physical activity and HQOL could guide the development of strategies for health promotion in children and adolescents. Taking this aspect into consideration, the present study aimed to verify the relationship between physical activity with HQOL domains in children and adolescents during COVID-19 social distancing.

Table 1 presents the sample characteristics for girls and boys. Boys showed significative higher levels of MVPA per week, and physical well-being compared to girls. About 9.2% of girls and 22% of boys reached seven days for MVPA. Otherwise, girls have a higher quality of life in the school environment domain compared to boys. The categorical Kidscreen variables showed that boys have been practicing physical activities in a superior proportion (20%) than girls. Boys present 33% more chance to have been practicing physical activities compared to girls, while girls get along well with teachers in 1.11 times more probability than boys.

The internal consistency indexes (Cronbach’s alpha) for each HQOL scale domain and Physical activity are 0.740 for physical well-being, 0.598 for psychological well-being, 0.734 for autonomy and parents, 0.655 for social support and peers, and 0.641 for school environment. The goodness-of-fit for the structural equation model for validation of present instruments as acceptable for relationship tests are (SRMR=0.043); (CMIN/DF=2.520); (CFI/IFI=0.951/0.952); (TLI=0.919); (RMSEA=0.080), demonstrating adequate values of consistency, reliability and theoretical validation.

Table 1
Descriptive characteristics of the sample by sex.

Table 2 showed data concerning crude and standardized scores (adjusted by age, sexes, and school grade), for MVPA days per week associated with HQOL domains and HQOL total. These associations suggested that better models are those with adjustment for age, sexes, and school grade. In this sense, results indicated that MVPA days are positively and strongly associated with all domains of HQOL. Physical well-being presented the strongest association, followed by psychological well-being, school environment, autonomy and parents, HQOL total, social support, and peers. This finding indicates the relevance of MVPA practice during COVID-19 social distancing for a better general health perception in children and adolescents.

Figures 1 and 2 showed data distribution in scatter dot graph and linear correlation of MVPA and HQOL total z-scores, adjusted by age and school grade. It was found that these variables are positively associated, with stronger explanation in boys (46.9%) than girls (14.5%).

Figure 1
Boys Linear explanation (R²) of moderate to vigorous days a week of physical activity (Z-MVPA) correlated with health-related quality of life (Z-HQOL). The variables were transformed into z-scores values adjusted for age and school grade.

Figure 2
Girls Linear explanation (R²) of moderate to vigorous days a week of physical activity (Z-MVPA) correlated with health-related quality of life (Z-HQOL). The variables were transformed into z-scores values adjusted for age and school grade.

Considering the aforementioned results, we applied a moderation analysis (Table 3) between sex, age, and school grade weights in models of MVPA association with each HQOL domain. These results showed the reasons why the strength of the association was different according to sex. Thus, associations were similar in boys and girls only to the positive association of MVPA and physical well-being, MVPA and autonomy, and parents' HQOL domains.

MVPA days and psychological well-being were not associated with girls, because age was negatively correlated with psychological well-being, and school grade was positively related with more strength on this variable. Otherwise, for boys this association was significant, age and school grade were not associated with psychological well-being. A similar effect of relation was found for social support and peer’s domain. Therefore, only age was negatively associated with this HQOL domain in girls. In boys, MVPA was strongly and positively associated with social support and peers. MVPA was associated with the school environment domain only in boys, and age was correlated with less HQOL in this domain. In girls, no significant associations were found.

Finally, the relationship between MVPA and HQOL on girls was weaker compared to boys, since there was a considerable and stronger relationship between age and the school grade with HQOL. In girls, one year of age is associated with 5 negative points of HQOL, while one school grade is positively correlated with 4 points of HQOL. In another way, in boys only MVPA was associated with total HQOL, one day of MVPA represented an association with 2.36 points of HQOL, double the power relationship than girls (1.16), without the significant impact of age and school grade.

Table 2
General Relationship between moderate and vigorous physical activity and health-related quality of life, crude values and z-scores (n=240).

Table 3
Relationships between moderate and vigorous physical activity days and health-related quality of life domains for boys and girls with adjusted beta weights of age and school grade in generalized linear models.

The present study aimed to verify the relationship between physical activity with HQOL domains in children and adolescents during COVID-19 social distancing. The main findings indicate a small proportion of boys (22%) and girls (9.2%) that achieved MVPA seven days a week. Besides, it was found a strong relationship between more days per week of MVPA with all HQOL domains, except for the school environment. However, when the models were adjusted for age, sex, and school grade, all HQOL domains were associated with MVPA presenting the best parameters. When the analyzes were moderated by sex, it was found that the associations of MVPA with the HQOL domains were only observed in boys, except for autonomy, parents, and total HQOL, which remained in both sexes.

Due to social distancing, several daily activities had to be adapted, which also implied changes in lifestyle. Our results showed a small proportion of the sample that has been involved in MVPA seven days a week during the pandemic. This was also found in a study developed in the same period, developed with obese Italian children and adolescents (Pietrobelli et al., 2020). Likewise, a survey that looked at 15 countries showed that the time spent in places associated with physical activities, such as parks, beaches, and community gardens decreased 31% (Guan et al., 2020). Also, a study developed at the beginning of the pandemic reported the concern with the children´s health due to the reduction of physical activity in this period with an undetermined time of social distancing (Hemphill et al., 2020). Therefore, the literature shows a pattern of decreasing physical activity during the pandemic, which may be due to the closing of schools and the social distance.

One of the possible negative implications regarding decreased physical activity is quality of life, a relationship that has already been widely discussed in the literature (Marker et al., 2018; Salvini et al., 2018; Wu et al., 2017). A systematic review pointed out that higher levels of physical activity were associated with a better HQOL, and even suggested that the higher the frequency, the greater the gain (Marker et al., 2018). In agreement, the study indicated a small, but positive effect of physical activity on children's quality of life and indicated that intensity, frequency, and duration can act as moderators in this relationship (Marker et al., 2018). Specifically, during the beginning of pandemic period, only one study that considered the relationship between physical activity and quality of life was found, indicating that patients diagnosed with suspected COVID-19 symptoms had a higher quality of life when they practiced physical activity (Nguyen et al., 2020). These relationships can be explained by mediators and moderators speculated in the literature. Participation in sports and games can contribute for a better relationship with peers and thus, be accepted in the environment in which they live, being more active with their friends (Hilland et al., 2011; Lemes, Gaya, et al., 2020). Also, the physical activity practice can increase physical self-perception, social connections, mood, and emotions, consequentially impacting on HQOL (Lubans et al., 2016).

Our results also showed that the relationships vary according to sex. The motive for this can regarding self-perception about the body composition and the self-reported domains of HQOL for girls as the physical well-being evaluated in the present study. It appears that girls are affected in a higher proportion than boys by body changes in the transition from childhood to adolescence (Falconi et al., 2019; Piola et al., 2019). During the school period, the weekly hours spent on sports were associated with all subscales and the total quality of life for girls, and scores on the physical and social functioning subscales for boys. A study shows a similar view, indicating that the maturation moderates the relationship between social functioning and physical activity in boys and girls at these ages. Boys have more social support than girls to play sports and have better self-perception than girls (Falconi et al., 2019; Lemes et al., 2021a; Lemes et al., 2022; Piola et al., 2019).

Another study indicated the same pattern in Iranian adolescents (Jalali-Farahani et al., 2016). However, during the vacation period, which can be considered more similar to the current scenario, the only relationship found for girls was with social functioning and, for boys, physical functioning, emotional functioning, social functioning and total scores for quality of life, getting very close to our findings (Jalali-Farahani et al., 2016). Likewise, a study with Australian children and adolescents pointed out that the practice of sports was considered an important aspect for better scores of physical, mental well-being, and general quality of life in boys. For girls, in addition to the sport being associated with the general quality of life and physical well-being, it was also related to active commuting (Tsiros et al., 2017).

Our study brings new evidence regarding the relationship between physical activity and health of children and adolescents during the pandemic COVID-19. Furthermore, according to our knowledge, this is the first study that assesses the relationship between physical activity and the quality of life of Brazilian children and adolescents in the period of social distancing. Present findings are important in order to reinforce that the regular practice of physical activity may lead to beneficial consequences for health and quality of life in youth, even when facing a challenging reality. However, some limitations must be considered. The sample was selected by convenience, and the evaluation of physical activity was performed subjectively, which could intervene in the results. Furthermore, this is a cross-sectional study that does not allow a cause-effect relationship. Also, children were evaluated during the beginning of the pandemic period, which could intervene on the results, although we highlight that the first weeks of social distancing could be the ones that caused more impact, due to the change in daily routine, representing an appropriate period for developing present research. Thus, based on our data and research already carried out, we reinforce that it is time for health care and interventions to be developed remotely to minimize the family risk of inappropriate lifestyles, such as sedentary time, physical inactivity, stress, depression, and anxiety (Galea et al., 2020; Rundle et al., 2020; Wang et al., 2020). In this sense, physical activity by remote form in physical education classes can provide better physical, psychological, and general life well-being for children.

In conclusion, physical activity was positively associated with the quality of life of children and adolescents during social distance due to the COVID-19. These findings show the importance of this population to remain physically active so that health parameters are not affected during this period. Furthermore, it reinforces the need for remote interventions to be carried out with the help of technologies, aiming to maintain healthy habits.

The present study showed that children and adolescents who reach a high number of days by week practicing MVPA present most well-being and HQOL in several domains including psychological indicators. It is occurred even at social distancing at home during pandemic COVID-19 in the year 2020. Sports practice is one of the main kinds of interventions for this population to achieve MVPA, and improve HQOL mainly the in psychological, mental and emotional aspects (Jodra et al., 2019; Lemes, Gaya, et al., 2020; Suárez & Jiménez, 2021). In practical terms, there is a need to adapt remote physical education classes and sports promotion for difficult times likely social distancing at home. For example, the physical education lessons by electronic and digital means are forms to promote better moments of well-being and MVPA if they have help of best friends (Monteiro et al., 2021), in another words, adolescents need the social support to have more HQOL and physical activity. It is very pertinent for children and adolescents maintaining the social, physical, and psychological well-being and mental health.