key: cord-0696060-esie22c7 authors: Korkmaz Aslan, Gülbahar; Kılınç, Eda; Kartal, Asiye title: The effect of COVID‐19 pandemic on lifestyle‐related behaviours in Turkey: A web‐based cross‐sectional study date: 2022-03-30 journal: Int J Nurs Pract DOI: 10.1111/ijn.13053 sha: c2494f6ccedc7fe24a194c5c883bc7c07cf9f323 doc_id: 696060 cord_uid: esie22c7 BACKGROUND: The COVID‐19 pandemic and restrictions imposed to eradicate it have affected healthy lifestyle‐related behaviours. AIM: The aim of this study was to determine the effect of COVID‐19 on lifestyle‐related behaviours. METHODS: This cross‐sectional web‐based survey research was performed with a convenience sample of 1020 adults residing in Turkey. Data were collected with self‐report data collection tools on 8–28 April 2021: a sociodemographic characteristics form and the impact of COVID‐19 on lifestyle‐related behaviours questionnaire. RESULTS: Eating behaviours, physical activity and sleep patterns of the participants were negatively affected during COVID‐19 pandemic (p < 0.001). More than half of the participants experienced weight gain during the pandemic. Also, stress levels and smoking increased (p < 0.01). The participants reported having changes in their lifestyles most frequently due to the fear of COVID‐19 infection, stress, decreased motivation, closure of the facilities for social and sports activities and increased food prices. Predictors of lifestyle‐related behaviours were found to be education (β = .189), income (β = −.101), residing in a village (β = .113) and the presence of a chronic disease (β = .075) (p < 0.001). CONCLUSIONS: During the pandemic, COVID‐19‐related restrictions should be applied whilst taking account of both social distancing measures and maintenance of healthy lifestyle‐related behaviours. Nurses should offer counselling for maintenance of healthy lifestyle‐related behaviours. • The effect of COVID-19 on lifestyle-related behaviours has not been examined from a nursing perspective. What this paper adds? • In the present study, which was performed at a time when night curfews and weekend shutdowns were imposed in Turkey, lifestyles of the participants were found to be negatively affected. • More than half of the participants gained weight and had increased stress and smoking and a decreased sleep quality. • The negative effect on lifestyle-related behaviours was more severe in participants with low education and income levels, living in a village and suffering from a chronic disease. The implications of this paper: • Restrictions introduced during the pandemic should both take account of social distancing measures and allow healthy lifestyle-related behaviours. • Nurses playing a role in first line health care services should offer education and counselling for maintenance of healthy lifestyle-related behaviours by utilizing information and communication technology (e.g., video calls). The World Health Organization (WHO) declared COVID-19 outbreak to be a pandemic (WHO, 2020a) . Subsequently, several precautions were taken and some restrictions on the society were imposed to prevent the spread of COVID-19 (Bruinen de Bruin et al., 2020; Nussbaumer-Streit et al., 2020) . To bring the pandemic under control in Turkey, some restrictions such as working from home, closures of facilities for eating and drinking, recreations and social activities, night curfews and weekend shutdowns/stay at home orders were imposed (The Turkish Ministry of the Interior). Restrictions can be either strict or loosened depending on the number of COVID-19 cases. The virus has ongoing effects in the second year of the pandemic (Bakaloudi et al., 2021) . While these cautionary measures were necessary to lessen the burden of COVID-19 on the health system and decrease the number of fatalities associated with the disease, the same cautionary measures have also affected the daily life (Alothman et al., 2021) . Several studies performed in different countries at the early phase of the pandemic revealed that cautionary measures affected lifestyle-related behaviours like nutrition, physical activity, social relationships, sleep, stress and smoking (Arora & Grey, 2020; Cheikh Ismail et al., 2020; Chopra, Ranjan, Singh, et al., 2020; di Renzo et al., 2020; Husain & Ashkanani, 2020; Stockwell et al., 2021; Znazen et al., 2021) . Effects of the measures on dietary habits were found to vary from country to country. Some studies performed during COVID-19 pandemic showed that food consumption and eating pattern (food preferences, food avoidance, uncontrollable eating and number of snacks and meals) were unhealthier (Alfawaz et al., 2021; Ammar et al., 2020; Guzek et al., 2021) . Restricted outdoor activities, closures of gyms and parks and increased duration of working from home and in front of the screen led to a decrease in physical activity (Cheikh Ismail et al., 2020; Husain & Ashkanani, 2020) . In a systematic review conducted by Stockwell et al. (2021) , physical activity was found to decrease during COVID-19 shutdowns in most of the studies reviewed (Stockwell et al., 2021) . Long durations of shutdowns, fear of infection, lack of information and financial losses have had negative effects on psychological wellbeing (Bueno-Notivol et al., 2021) . These factors, which create stress and anxiety, lead to an impaired quality of sleep (Chopra, Ranjan, Singh, et al., 2020; Sher, 2020; Znazen et al., 2021) . Several studies have demonstrated that while sleep duration increased, sleep quality decreased (Alothman et al., 2021; Huancahuire-Vega et al., 2021; Kaur et al., 2021; Kolokotroni et al., 2021) . There has been a limited number of studies on the effect of shutdowns on lifestyle-related behaviours, and most of the studies have focused on nutrition and physical activity (Cheikh Ismail et al., 2020; Chopra, Ranjan, Singh, et al., 2020; di Renzo et al., 2020; Husain & Ashkanani, 2020; Sánchez-Sánchez et al., 2020; Stockwell et al., 2021) . To what extent lifestyle-related behaviours are affected can vary with strictness of the measures taken by countries (Ammar et al., 2020) . Therefore, further studies are needed to examine all aspects of lifestyle-related behaviours in populations that have different cultures and where different measures are taken (Alothman et al., 2021; Ammar et al., 2020) . There have not been any studies examining all aspects of the effect of COVID-19 on lifestyle-related behaviours in Turkey (Güney & Sangün, 2021; Önal et al., 2021; Özeno glu et al., 2021; Özlem & Mehmet, 2020) . This underlines the need for conduction of studies dealing with the effect of COVID-19 on lifestyle-related behaviours in Turkey. Besides, studies about the effect of COVID-19 on health were conducted in the early phase of the pandemic, and valid and reliable data collection tools were not used in those studies (Cheikh Ismail et al., 2020; di Renzo et al., 2020; Husain & Ashkanani, 2020; Sánchez-Sánchez et al., 2020) . Therefore, it can be important to determine the effect of the pandemic on lifestyle-related behaviours in the second year of the pandemic when restrictions are still being imposed in terms of the measures that will be taken. Eradication of a pandemic can take a long time. Therefore, effects of a pandemic on lifestylerelated behaviours can be of importance (Malay, 2020; Rahati et al., 2014) . Health professionals should also take initiatives to protect and improve the health of the community during the pandemic. Public health nurses have the most suitable position which allows performing effective interventions for individuals and the society to prevent unhealthy lifestyle-related behaviours causing chronic diseases (Edmonds et al., 2020; Sargent et al., 2012) . Conduction of research by nurses to examine the effect of the pandemic on lifestylerelated behaviours can guide the interventions they will plan. Further studies can help to improve not only health outcomes of behaviours during the pandemic but also public health interventions that will be carried out in case of another restriction on the population (encouragement of physical activity and healthy nutrition, regular and highquality sleep, etc.) (Sallis et al., 2020; Vessey & Betz, 2020) . To our knowledge, there has been no nursing research on the effect of COVID-19 on lifestyle-related behaviours. Therefore, the current study was directed towards examining the effect of COVID-19 on lifestyle-related behaviours concerning nutrition, physical activity and sleep and factors affecting these behaviours. This is a cross-sectional study. Convenience sampling was utilized in this study. Inclusion criteria were age over 18 years, living in Turkey, graduating at least from primary school and accepting to participate in the study. People diagnosed as COVID-19, being pregnant and being dependent on someone else for their daily life activities at the time of data collections were not included in the study. The sample size was calculated with reference to the mean score on balanced nutrition with its standard deviation in a study by Chopra, Ranjan, Singh, et al. (2020) . It was found to be 420 based on the effect size of 0.08, type 1 error of 5% and power of 95%. Since this was a web-based cross-sectional study, accessing more than 420 participants was planned and a total of 1032 people participated in the study. The reason for inclusion of more people in the study than the calculated sample size is that the research is based on the community. In population-based public health research, it is important to explain the relationship between variables and to examine the percentages in a large sample (Lumley et al., 2002) . Since four participants were younger than 18 and since eight participants did not fill in the data collection tools completely, they were excluded from the study. As a result, the study sample included 1020 people. The data were collected with a web-based questionnaire from individuals living in different regions of Turkey between 8 April and 28 April 2021. At the time of data collection, a stay at home order was imposed in Turkey due to the pandemic throughout weekends and between 7 p.m. and 5 a.m. on weekdays. Public places like restaurants, cafes and parks were shut down and educational institutions like universities, high schools and primary schools offered online education. The web-based questionnaire was created as a Google form and the link to the form was shared through social media platforms like Facebook, Instagram and WhatsApp and with personal contact lists of the researchers. The participants were also asked to share the questionnaire with other people to increase the sample size. The data collection tools shared by using a Google form included brief information about the study, the aim of the study and confidentiality of obtained data. Before the participants filled in the tools, their informed consent was obtained online. The impact of COVID-19 on lifestyle-related behaviours questionnaire was developed by to determine the effect of COVID-19 pandemic on lifestyle-related behaviours including eating behaviour, physical activity, sleep pattern and other behaviour. The questionnaire is composed of three sections: A, B and C. Section A includes sociodemographic and anthropometric parameters. Section B includes two parts: A and B. Each has 24 items. Part A (A1 to A24) is directed towards evaluation of eating habits, physical activity and sleeping pattern before COVID-19, and Part B (B1 to B24) is directed towards evaluating changes in lifestyle-related behaviours during COVID-19. The questionnaire is a 5-point Likert scale. Responses to each item in parts A and B are as follows: Not routinely, One to two times a week, Three to four times a week, Five to six times a week and Almost daily. The scores for the responses range from five to one. Five corresponds to Almost daily (the most acceptable behaviour), and one corresponds to Not routinely (the least acceptable behaviour). 9, [10] [11] [12] 16, [18] [19] [20] [21] [22] [23] [24] Translation and back-translation were used to achieve linguistic validity of the questionnaire (Esin, 2015) . Three nursing lecturers involved in this study, and a specialist in English language and literature translated the questionnaire into Turkish independently. After that, the Turkish version was translated back into English by one of the English language linguists who had not seen the original questionnaire and had a background in both English and Turkish language and culture. The Content Validity Index (CVI) (>0.80) was calculated to assess the content validity of the instrument (Esin, 2015; Field, 2018 ). The content validity of the questionnaire was verified by six nursing academicians. The experts were consulted for their opinions after the language adaptation for assessing the content validity of the questionnaire. The Davis technique was used to evaluate the opinions obtained with the CVI (Davis, 1992) . In accordance with the expert opinions, the CVI was found to be 0.91. Changes were made in the statements based on the recommendations, and the final version of the questionnaire was created. Instead of foods such as poori, bhujia, matri and fried foods, which are not widely consumed in Turkish cuisine, French fries, stir fry, fried chicken-fish, etc. were written. Ayran and yoghurt, which have a high consumption rate in Turkey, were added as the options of dairy products. A pilot study was carried out to test the clarity of content, ease of understanding, time required for responses and potential problems. The Turkish version of the translated questionnaire was piloted on 20 individuals meeting the inclusion and exclusion criteria. In determining the reliability levels of the instrument, Cronbach's alpha reliability coefficient (>0.60) was used (Everitt & Skrondal, 2010 ). Cronbach's alpha for the questionnaire was found to be 0.82 (α = 0.67 for Part A; α = 0.67 for Part B). The total questionnaire had a high internal consistency. Self-reported data on height and weight were used to calculate BMI Kolmogorov-Smirnov was utilized to determine whether data had a normal distribution (p > .05). Descriptive statistics (frequency and percentage) were employed to analyse data about sociodemographic characteristics and responses to the questions in the questionnaire. Paired sample t test was used to determine the difference between the mean scores on lifestyle-related behaviours before COVID-19 and the mean scores during COVID-19. Independent sample t test was utilized to determine whether changes in lifestyle-related behaviours differed in terms of sociodemographic characteristics between two groups, and Bonferroni corrected one-way ANOVA was utilized whether the changes were different between three or more groups. The variables found to be significant according to the results of independent sample t test and one-way ANOVA were included into multiple linear regression analysis to determine the factors affecting lifestyle-related behaviours. The statistical significance was set at p <0 .05. The study was conducted according to the Declaration of Helsinki. There was a significant decrease in 'regular consumption of meals pat- The causes of changes in eating habits were improved knowledge about nutrition (41.30%), less eating out (40.80%), stress and anxiety (39.80%) and higher cost of ingredients (31.80%). Although some participants had physical activity including going for a walk (43.80%), watching work out videos at home (29.10%) and doing aerobics at home (17.50%), their physical activity dropped due to social restrictions to parks and public places (52.40%), decreased motivation T A B L E 1 Demographic and health-related characteristics of the participants (n = 1,020) Age ( As presented in Table 4 , there was a significant difference in eating, Cheikh Ismail et al. (2020) found in their studies that the number of meals decreased during COVID-19 pandemic. An increase in the frequencies of eating snacks might have affected eating patterns. In the current study, a significant increase was found in consumption of fast food, fried food, junk food, sugary food and sugar sweetened beverages during COVID-19 pandemic compared to their consumption before the pandemic. Similarly, several studies performed in some countries during the lockdown at the beginning of the pandemic also revealed a rise in consumption of unhealthy food (Alfawaz et al., 2021; Ammar et al., 2020; Catucci et al., 2021; G ornicka et al., 2020; Sánchez-Sánchez et al., 2020; Scarmozzino & Visioli, 2020) . However, some studies have shown an increase in consumption of healthy food during the lockdown (Chopra, Ranjan, Singh, et al., 2020; Guzek et al., 2021; Huancahuire-Vega et al., 2021) . The reason for the conflicting evidence can be that measures taken during the lockdown change from country to country and that eating habits differ between cultures. In the current study, more than half of the participants experi- In the current study, the participants reported that the most significant cause of changes in their eating behaviours was stress and anxiety. In the previous studies conducted during COVID-19 pandemic, most of the negative eating behaviours were associated with psychological conditions like stress, anxiety and boredom (Catucci et al., 2021; Knell et al., 2020; Önal et al., 2021; Scarmozzino & Visioli, 2020 (Eyimaya & Irmak, 2021 ). In the current study, while the sleep duration significantly increased during COVID-19 pandemic, the sleep quality significantly decreased. The most important factor of the change in the sleeping pattern was can increase the tendency to smoke and take alcohol in addition to disrupting the sleeping pattern (Ammar et al., 2021; Fluharty et al., 2016; Sher, 2020; WHO, 2020b ). In the current study, there was a significant rise in smoking during COVID-19 pandemic. In this study, predictors of lifestyle changes in the COVID-19 pandemic were also examined. Having university education was found to be protective against negative eating and sleeping behaviours and other negative behaviours (smoking, alcohol intake, insufficient social support) during the pandemic. The participants with low education levels were found to have more unfavourable lifestyle-related behaviours, which is consistent with the results of previous research (Cheikh Ismail et al., 2020; Rodríguez-Pérez et al., 2020) . Another factor that had an impact on lifestyle-related behaviours was a low-income level. It was found to create a negative effect. Since a low income decreases access to healthy food (fresh fruit and vegetables, nuts, meat products, milk and dairy products), it might have caused the participants to consume carbohydrates more (Büyüksoy et al., 2021; Chopra, Ranjan, Singh, et al., 2020) . It has been noted in the literature that income and education are the primary social predictors of health behaviours (Braveman & Gottlieb, 2014; Büyüksoy et al., 2021; WHO, 2021b The finding that restrictions imposed during COVID-19 pandemic produced negative effects on lifestyle-related behaviours can provide guidance in measurements to be taken. It can be suggested that policy makers should take account of negative effects of night curfews, weekend shutdowns and restrictions on going to the parks. People should be allowed to do exercise outdoors by adopting physical distancing at times of night curfews and weekend shutdowns. They should be motivated to act on the suggestions offered by health professionals to maintain healthy lifestyle-related behaviours. Nurses providing first line healthcare services should give education and counselling for continuation of healthy lifestyle-related behaviours by using information and communications technology (e.g., video calls). WHO made some recommendations to support healthy nutrition and maintenance of an active lifestyle during the lockdown (WHO, 2021c). Nurses could follow these recommendations as a guide and play a role in adoption of these recommendations in the society (Edmonds et al., 2020) . They should take account of factors creating negative effects on lifestyle-related behaviours like education, income and residing in rural areas while designing interventions. Besides, they should cooperate with support groups and municipalities to help individuals with low incomes unable to access healthy food. This study showed that eating behaviours, physical activity and sleeping patterns of individuals were affected negatively during COVID-19 pandemic. Besides, stress, anxiety and smoking were found to increase. The most frequent causes of changes in lifestylerelated behaviours were stress, anxiety, inadequate motivation and closures of social recreation and sports areas. Lifestyle-related behaviours were more negatively affected in the individuals having low education and income levels, living in rural areas and experiencing chronic diseases. These factors should be taken into consideration in the interventions to be planned for individuals. It is recommended to implement interventional studies aiming at increasing the positive lifestyle behaviours of individuals. It can also be suggested that further studies with a cohort design should be performed to examine the effects of changes in lifestyle-related behaviours during COVID-19 pandemic on long term health outcomes. The author(s) received no financial support for the research, authorship and/or publication of this article. The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article. This study was designed and conceptualized by GKA and EK. Analysis of research data was done by EK. GKA, EK and AK contributed in data gathering and interpretation, agreeing on the design and scrutinizing the technical content and write ups of the full manuscript. EK, GKA and AK after final review of the revised version of the manuscript agreed and approved to be submitted for publication. The study was conducted according to the Declaration of Helsinki. Ethical approval was obtained from Pamukkale University Ethical Committee of Non-Interventional Clinical Research (Approval date: 30/03/2021; Approval number: E-60116787-020-40751). This study was presented as an oral presentation at the 5th International and 23rd National Public Health Congress between 13 and 18 December in Turkey. The data for this study are available from the corresponding author upon reasonable request. 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