key: cord-0885576-k8mv1ha2
authors: Katewongsa, Piyawat; Widyastaria, Dyah Anantalia; Saonuam, Pairoj; Haematulin, Narumol; Wongsingha, Narakorn
title: The effects of COVID-19 pandemic on physical activity of the Thai population: Evidence from Thailand's Surveillance on Physical Activity 2020
date: 2020-10-09
journal: J Sport Health Sci
DOI: 10.1016/j.jshs.2020.10.001
sha: 9974c5af56462e7465e7f28a538d37c0c19972d0
doc_id: 885576
cord_uid: k8mv1ha2

BACKGROUND: The coronavirus disease (COVID-19) pandemic has undoubtedly disrupted the physical activity (PA) of the Thai population. This study examined the effect of the COVID-19 pandemic on moderate-to-vigorous PA (MVPA) of Thai adults and assessed the effects of the national curfew policy and health promotion campaigns in influencing PA during the pandemic. METHODS: Thailand's Surveillance on Physical Activity (SPA) 2019 and 2020 datasets were employed to compare the PA level of Thai adults aged 18–64 years before and during the COVID-19 pandemic. Samples of 4460 respondents from SPA 2019 and 4482 respondents from SPA 2020 were included in the analysis. Global Physical Activity Questionnaires (GPAQ) Version 2.0 was used to measure PA in both periods. Sufficient MVPA for adults was defined based on the recommendation of 75 min of vigorous PA or a combination of 150 min of MVPA per week. RESULTS: The proportion of Thai adults who had sufficient MVPA declined from 74.6% before the pandemic to 54.7% during the pandemic, and that decline was accompanied by a reduction in the cumulative minutes of MVPA from 580 to 420. During the COVID-19 pandemic, male and middle-aged individuals were 1.3 and 1.1 times more likely to have sufficient MVPA, respectively. Those who were unemployed, resided in an urban area, and/or had chronic disease(s) were 27%, 13%, and 29% less likely to meet the recommended level of PA during the pandemic, respectively. Those who were exposed to the Fit from Home (FFH) campaign were 1.4 times more likely to have sufficient MVPA. CONCLUSION: The pandemic measures imposed by the government have reduced the cumulative minutes of work-related PA, transportation PA, and recreational PA and have slowed Thailand's progress toward its PA goals. Although the FFH campaign has probably contributed to a slight increase in MVPA, it will take some time for Thais to return to the pre-COVID-19 level of PA. Health promotion messages need to be continuously delivered to reduce irrational fear of infection and to boost the PA level of the Thai population as a health-promoting intervention.

Thailand reported the first domestic case of the coronavirus disease (COVID-19) on January 13, 2020, 1 after a lab-confirmed infection of a traveler from Wuhan, China. 2 The number of cases started to jump by mid-March 3 and increased continuously, which was partly attributed to night club and boxing stadium clusters. 4 Responding to the surge of cases, the Thai government followed the World Health Organization (WHO) recommendation for mitigating COVID-19 outbreaks by implementing aggressive measures to halt the infection. A curfew was imposed nationwide, starting on March 28, between the hours of 10 p.m. and 4 a.m. Nonessential businesses were shut-down to encourage people to remain in their home neighborhoods and limit social contact. Public facilities that normally also serve as venues for physical activity (PA), including schools, offices, malls, and public parks, were closed, and mass gatherings were prohibited.

In addition to adapting to these stringent measures imposed by the government, the emergence of COVID-19 in Thailand imposed a strain on the entire society. Academia and the business sector was strongly recommended to work from home, and advised to replace face-to-face interaction with online communication whenever possible. Ordinary community residents were also challenged to modify their leisure activities, such as dining-out, leisure travelling, and outdoor PA, with home cooking, home entertainment, and home-based PA. This rather extreme response by the government and by many individuals in Thai society was incited by dramatic super-spreader events and the growing awareness that COVID-19 could be spread by asymptomatic carriers through virtually airborne transmission when in close proximity to susceptible persons. [4] [5] [6] It is reasonable to posit that PA can play a significant role in boosting the immune system and relieving stress during the COVID-19 pandemic. [7] [8] [9] [10] [11] [12] Other things being equal, if a person is infected with COVID-19, the physically active person will have less severe symptoms, shorter recovery times, and may be less likely to infect others. 13 PA is also beneficial for those who are asymptomatic or experiencing only mild symptoms because it improves the natural immune response to both the influenza and pneumococcal vaccines. [13] [14] [15] Therefore, staying fit during the pandemic has become a major health promotion message. Indeed, the Thai government has encouraged the population to stay active during the pandemic by promoting Fit from Home (FFH): Technique and Guidelines, which was issued by the Thai Health Promotion Foundation and released right after the partial lockdown policy was imposed. The FFH campaign was distributed nationwide through various channels, including print and online media, and served as a guide for the Thai population in an effort to shift their outdoor PA into recommended home-based exercise, 13, 16, 17 such as brisk walking, stair climbing, yard and house work, and playing active games with the family. 13 FFH also provides sample videos of various training programs (i.e., strength, balance, endurance, body weight) and includes virtual activities such as running at home and biking at home.

Before the COVID-19 pandemic, the Thai government had been progressing toward a key milestone of its 5-Year National non-communicable diseases (NCDs) Prevention and Control Strategic and Action Plan (2017-2021): 80% of the population would be "active". 18 Thailand's Surveillance on Physical Activity (SPA) survey reported that 74.4% of the country's entire population and 78.4% of Thai adults were meeting the WHO 2018 recommendation of a cumulative 150 min of moderate or 75 min of vigorous PA per week, 19, 20 whereas 26.2% of Thailand's children and youth had a total of at least 60 min of moderate-to-vigorous physical activity (MVPA) daily. 21 However, the COVID-19 pandemic has undoubtedly slowed Thailand's progress toward the PA target and perhaps even reversed the improving trend. By essentially being confined to their domiciles and immediate neighbourhoods, individuals and families were faced with greatly restricted access to PA facilities. Furthermore, it can be expected that an increased percentage of society engaged more in sedentary activities due to the need to work from home (i.e., sitting in front of a computer screen) or due to watching more TV or video entertainment than usual.

Several studies have examined the effects of COVID-19 on the PA of other countries' populations. [22] [23] [24] However, there is no published data comparing the level and pattern of PA before and after the COVID-19 outbreak in Thailand. Thus, this study hopes to fill that void by comparing the PA level (prevalence of sufficient MVPA and average cumulative minutes of MVPA) prior to and during the pandemic in Thailand. Our study also documents the changes in the types and amount of PA among different groups of the Thai population based on their socio-demographic characteristics. Second, this study assesses whether people exposed to the national campaign, called Fit from Home (FFH): Techniques and Guidelines, had better PA outcomes during the pandemic. The results of our study provide the first evidence of the adverse effects of COVID-19 pandemic on PA as it pertains to Thailand, and this information should be beneficial for government officials and policymakers in formulating strategies for elevating the PA level of the population.

This study employed Thailand's SPA 2019 and 2020 datasets to compare the PA level of the Thai population before and during the COVID-19 pandemic. Conducted as an annual surveillance by the Institute for Population and Social Research-Mahidol University and the Thai Health Promotion Foundation, SPA datasets have been used as the source of reference by the Thai government in formulating Thailand's National Physical Activity Plans. The SPA 2019 employed a multistage, stratified random sampling to select a nationally representative sample by considering the place of residence (urban or rural), gender, and age. Face-to-face interviews were conducted in 5 regions, 13 provinces, and 36 villages and involved a total of 7333 cases age 5 years or older. However, to enable a comparison with SPA 2020, only 4460 adults age 18-64 years who could access the Internet were included in the analysis.

With the confinement and restriction of movement during the COVID-19 pandemic, SPA 2020 was conducted as an online survey, and the population of interest was defined as all Thai adults who had access to an online system. The online method was also chosen because 85% of the Thai population has Internet access. Using data provided by the National Statistical Office (NSO), the online population was calculated, classified by province, and represented as a proportion of the actual Thai population. Probability random sampling was applied to draw the samples from Facebook pages. The research team randomly selected Facebook pages by district and invited Facebook users to join the survey by using a systematic random technique. Using the inclusion criteria of having a clear gender specification on the Facebook profile page and being age 18-64 years, 4482 individuals from the SPA 2020 sample were included in the analysis.

To avoid different environmental effects (i.e., climate, season) in relation to PA, the data combination of vigorous and moderate intensity of PA for adults. 26 Gender, age, area of residence (urban/rural), education, occupation, having a chronic disease(s), and residence by type of epidemic zone (red, yellow, green) formed the independent variables for Objective 1 of the study: differentiating PA before and during the COVID-19 pandemic. Gender was dichotomized as (1) male or (2) female, and age was categorized into 2 groups: (1) young adult (18-39 years old) and (2) given and after their rights to join or withdraw from the research at their convenience was made clear.

Although the SPA 2019 was representative of all Thais age 5 years or older, in order to enable comparison with SPA 2020 only those who had Internet access and were age 18-64 years were selected for analysis. To validate different instruments and ensure their measurability, the test-retest method was conducted with 30 cases in order to compare responses from the SPA 2019 face-to-face interviews with the self-reports from the online questionnaires used for SPA 2020. The overall correlation showed a value of 0.882, attesting to the validity of the questions for all population characteristics. A paired t test was employed to evaluate individual items, and the results showed that there was no significant difference between the offline and online responses for all items of interest. Sampling bias was controlled by testing 2 samples that were included and excluded in the SPA 2019.

Descriptive statistics was presented to compare the sample characteristics from both surveys.

While a t test was employed to compare the cumulative minutes of MVPA between SPA 2019 and SPA 2020, an F test was used to compare MVPA across study periods. Since the data were not normally distributed, multivariate analysis with binary logistic regression was used to determine factors associated with sufficient MVPA of the Thai population during the COVID-19 pandemic. All variables were included in the model, with a significance level of 0.005 or lower used to determine whether a variable had an effect on PA.

The study sample comprised Thais age 18-64 years, with a slight tendency toward younger adults among SPA 2020 respondents. While the composition of the SPA 2019 sample was equal between genders, the proportion of males in the SPA 2020 sample was higher than females (53.4% and 46.6%, respectively). The socioeconomic characteristics of the sample (Table 1) .

The prevalence of sufficient MVPA among Thai adults decreased from 74.6% in SPA 2019 to 54.7% in SPA 2020 (Fig. 1A) . The decrease in the prevalence was also accompanied by a reduction in the average cumulative minutes of MVPA from 580 to 420 (Fig. 1A) . The prevalence of sufficient MVPA was at its lowest during the maximum curfew period (DC), when the Thai government imposed strict restrictions to contain the virus by closing public facilities, including public parks and gyms, and by prohibiting late-night travel. Although several measures were relaxed during the shorter curfew period and had limited facility openings, the prevalence of the sample with sufficient MVPA remained low, with only a slight increase during the AC period (Fig. 1B) . The restrictions were intended to contain the spread of the virus by limiting people's movement, but they also adversely affected all types of PA. The results of the t test analysis suggest that there was a significant difference in the cumulative minutes of MVPA of Thai adults before and during the COVID-19 pandemic (t = 11.864, p < 0.001). The F-test analysis also indicates that a significant difference in PA exists in two of 3 periods of the pandemic: BC vs. DC, and BC vs. AC (F = 70.610, p < 0.001) ( Fig.   1A and Fig. 1B) .

The cumulative minutes of work-related, transportation, and recreational PA also declined during the pandemic period (Fig. 2) . The detailed changes in the cumulative minutes of MVPA by sociodemographic characteristics, pandemic zones, and FFH intervention, classified by each type of PA (work-related, transportation, or recreational) are available in the Supplementary Table 1 .

The COVID-19 pandemic has affected the PA of the Thai population in both genders and all age groups. As was the case in the pre-pandemic period, Thai males accumulated a higher level of PA than their female counterparts during the pandemic (Table 2) . Likewise, the proportion of middle-age adults who had sufficient MVPA was consistently higher than for the younger adults in both the pre-pandemic and pandemic periods. The proportion of Thai adults who met the recommended level of MVPA was lowest among those who completed their secondary education and were unemployed, whereas the highest proportion was found among agricultural workers and those with a primary (SPA 2019) and post-secondary education (SPA 2020). Surprisingly, the proportion of respondents with sufficient MVPA was slightly higher among those with a chronic disease(s) in both years compared to those without a chronic disease(s) ( Table 2) .

Results of the multivariate analysis suggest that gender, age, occupation, the presence of chronic disease(s), area of residence, and exposure to the FFH campaign had statistically significant associations with MVPA sufficiency among Thai adults during the COVID-19

pandemic. When controlling for other factors, males were 1.3 times more likely to have sufficient MVPA during the pandemic compared to their female counterparts. Middle-aged adults were 1.1 times more likely to meet the recommended MVPA, whereas those residing in an urban area and with a chronic disease(s) were 13% and 29% less likely to meet the recommended MVPA during the pandemic, respectively. Compared to individuals employed in the agricultural sector, those who were unemployed were 27% less likely to have sufficient MVPA ( Table 3 ).

Given that behavior is partly influenced by knowledge, our study included the FFH campaign in the model as one of the interventions provided by Thai Health Promotion Foundation. As one of the key findings of the study, the effect of the FFH campaign is evidenced by the higher proportion and higher likelihood of having sufficient MVPA (Table 3) . Those who received the FFH techniques and guidelines were 1.4 times more likely to have sufficient MVPA compared to those who did not receive the information (Table 3 ). There was no significant effect on MVPA sufficiency by educational level and residence in or out of an epidemic zone. Also, living in an area with a lockdown policy had no significant effect on sufficient MVPA of Thai adults.

There is no doubt that the COVID-19 pandemic adversely affected the PA of the Thai population. PA was at its peak at the early stage of the COVID-19 pandemic and then began a decline as the government imposed several measures to contain the virus by restricting people's movement in society at large. Schools, offices, and public facilities were closed to encourage people to be fully at home from March 28 to May 2 and extended to limited movement up to July 1, 2020. The fear of infection also motivated Thais to self-isolate by working from home and replacing face-to-face interactions with online socializing or teleconferencing. As a consequence, the cumulative minutes of PA for work-related and transportation purposes declined since a majority of office work was performed at home. The closure of public parks, gyms, and other sports facilities also reduced the opportunity for Thais to engage in their regular recreational PA outside the home.

It is also worth noting that, in the earliest stage of the pandemic, the government focused on containing the spread of the virus, and health promotion was relegated to a lower priority.

Anticipating a prolonged period of restrictions, the Thai Health Promotion Foundation issued a series of guidelines (i.e., FFH) on how to stay fit during the pandemic to help Thais maintain or regain good health status. Although the amount of MVPA slightly increased after maximum curfew was relaxed (AC), it remained lower than the level of MVPA before the COVID-19 lockdown (BC).

Behavior theory suggests that a common emotional response to a pandemic is an exaggerated feeling of fear or anxiety. [27] [28] [29] Thus, persuading people that they need to engage in more PA may be difficult in the current environment. The boxing stadium cluster of COVID-19 infections (which was traced to a single super-spreader) has perhaps instilled a fear of mass gatherings to observe sports events or even engage in outdoor PA. Thus, it may take months or years for people to let their guard down and resume their pre-COVID-19 PA routine. On the other hand, while there has been a loosening of restrictions on movement and gradual reopening of public recreational facilities, the Thai government is being extremely cautious about the need to avoid a second outbreak. Although the Thai Ministry of Public Health (MOPH) has recommended social distancing of at least a 2-m radius, research suggests that running more than 2 m behind a (possibly infectious) person could still be dangerous since micro-droplets containing viable COVID-19 virus can remain airborne for minutes. 30 Our study found similar patterns of MVPA before and during the pandemic as well as an absolute decline in the amount of time spent in PA. Most MVPA was work-related, while the least PA was related to traveling from place to place. Reductions in cumulative minutes of work-related, transportation, and recreational MVPA imply that the COVID-19 pandemic has disrupted the pattern of PA of Thai adults in most aspects of their daily life. As more Thais attempt to work from home, the opportunity for MVPA is limited if they are confined to their domiciles or immediate neighborhoods. Also, working from home often means sitting for prolonged periods in a stationary position in front of the computer screen or other electronic device. In the pre-COVID-19 situation, it is assumed that people moved around more when working at the office, including commuting to and from the workplace. The partial lockdown policy also inhibited travel outside the home for dining, shopping, or leisure PA, all of which accumulates as more sedentary time.

In both pre-pandemic and pandemic periods, Thai males were more physically active than females. Both in terms of cumulative minutes and the proportion achieving sufficient MVPA, Thai males exceeded their female counterparts. Other things being equal, men are evolutionarily wired for more vigorous PA given their historical role as the "hunter", and have a predilection for competitive physical challenges. 31 The male body is also physiologically constructed for a larger skeletal frame and muscle mass, which can influence duration of exertion in performing PA. 32 Additionally, the cultural belief in the importance of fair skin for Thai females may have played a significant barrier to outdoor PA. 33 During the pandemic, while the restrictive measures applied to all Thais, males were still able to accumulate more minutes of MVPA than females. Furthermore, other studies have found that females are more likely to practice social distancing, 28, [34] [35] [36] whereas males are reported to be less compliant with self-isolation guidance. 34 Female psychological distress 37 and greater compliance with COVID-19 restrictive measures may have led many women to be more house-bound and, thus, they may have had fewer opportunities for PA.

Middle-aged adults (40-64 years) were more active than their younger counterparts, both before and during the pandemic. Since middle-aged adults include those in the peak earning years, most of their PA was work-related. Younger adults, on the other hand, are more likely to record more recreational PA since some of them are students. While a previous study reported that older adults participated in less PA during the pandemic due to their inability to find substitutes for their outdoor PA, 23 the reasons why the middle-aged Thai population in our study was more physically active than its younger counterparts in both pre-pandemic and pandemic period was unclear.

During the pandemic, urban residents were less likely to have sufficient MVPA compared to their rural counterparts. Urban dwellers also recorded fewer cumulative minutes of MVPA than the rural sample in all PA domains. This may be because during the pandemic many urban dwellers were occupied with screen-related activities and had fewer opportunities for PA due to working from home (WFH) policies, whereas rural residents were still able to work in the field. The containment policy was also more strict for urban residents because an urban setting is a better environment for the spread of aerosolized virus since there is more The limitations of our study should be acknowledged. The differing methods of data collection (face-to-face interviews vs. online self-reporting) could have affected our overall results, particularly because online surveys tend to overestimate certain data. PA levels among children and the elderly also could not be documented and compared to the previous surveys due to the limitations of these 2 populations in accessing the Internet.

The pandemic measures imposed by the government reduced the cumulative minutes of work-related, transportation, and recreational PA and slowed Thailand's progress toward its PA goals. Although the FFH campaign probably contributed to a slight increase in MVPA, it will take some time for Thais to return to pre-COVID-19 levels of PA. Health promotion messages need to be continuously delivered as a health-promoting intervention in order to reduce irrational fear of infection and boost the PA level of the Thai population.

It is important to note, however, that the COVID-19 pandemic is one of many public health threats with an unpredictable path. Although in Thailand the current trend is toward a continuous decline in new cases, there is always the possibility of subsequent waves of transmission, especially as the country enters the annual flu season in October. The pandemic has also placed the population at a double risk because physical inactivity and a sedentary lifestyle may worsen the impact of future epidemics or exacerbate non-communicable disease threats (e.g., obesity, hypertension, and diabetes), which are also risk factors for complications of COVID-19 infection). Thus, the decreasing prevalence of sufficient MVPA among Thai adults should be a matter of concern for the government and policy makers as they consider strategies for protecting the health of the population in the months and years ahead. (1) freelancers and (2) professional athletes. Red zone: more than 10 confirmed positive cases.

Orange zone: 1-10 confirmed positive cases. Green zone: no infection has been reported.

Sufficient MVPA: an accumulation of 75 min of vigorous-intensity PA per week or a 150min combination of vigorous-and moderate-intensity PA per week.

Abbreviations: MVPA = moderate-to-vigorous physical activity; SPA = Surveillance on Physical Activity. (1) 

Novel coronavirus (2019-nCoV) WHO Thailand situation report -6

Early transmission patterns of coronavirus disease 2019 (COVID-19) in travellers from Wuhan to Thailand

Novel coronavirus (2019-nCoV) WHO Thailand situation report -18

Actor Matthew Deane has coronavirus

Recent COVID-19 deaths linked to Lumpinee Boxing Stadium

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Associations of physical activity with positive mental health: a populationbased study

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Impact of physical activity on monocyte subset CCR2 expression and macrophage polarization following moderate intensity exercise

Physical activity and the prevention of depression: a cohort study

The relationship of physical activity to mental health: a 2015 behavioral risk factor surveillance system data analysis

The immunological case for staying active during the COVID-19 pandemic

Can physical activity ameliorate immunosenescence and thereby reduce age-related multi-morbidity?

Exercise and respiratory tract viral infections

Coronavirus disease (COVID-19): the need to maintain regular physical activity while taking precautions

Physical activity and coronavirus disease 2019 (COVID-19): specific recommendations for home-based physical training

Ministry of Public Health. 5-year national NCDs prevention and control strategic and action plan

Thailand physical activity surveillance

Thailand physical activity surveillance

Results from Thailand's 2018 report card on physical activity for children and youth

Effect of the COVID-19 epidemic on physical activity in community-dwelling older adults in Japan: a cross-sectional online survey

Sport and exercise in times of self-quarantine: how Germans changed their behaviour at the beginning of the COVID-19 pandemic

The impact of physical activity on psychological health during COVID-19 pandemic in Italy

World Health Organization. Global Physical Activity Questionnaire (GPAQ) analysis guide

World Health Organization. Global strategy on diet, physical activity and health

Using social and behavioural science to support COVID-19 pandemic response

Community Responses during early phase of COVID-19 epidemic

The fear of COVID-19 and its role in preventive behaviors

Towards aerodynamically equivalent COVID19 1.5 m social distancing for walking and running

Influence of age, sex, and race on college students' exercise motivation of physical activity

Skeletal muscle mass and distribution in 468 men and women aged 18-88 yr

Physical activity among medical students in Southern Thailand: a mixed methods study

Evaluating COVID-19 public health messaging in Italy: self-reported compliance and growing mental health concerns

Knowledge, attitudes, and practices towards COVID-19 among Chinese residents during the rapid rise period of the COVID-19 outbreak: a quick online cross-sectional survey

Perceptions and behavioural responses of the general public during the COVID-19 pandemic: a cross-sectional survey of UK Adults

The authors gratefully acknowledge funding support from the Thai Health Promotion Foundation with grant number 63-0030

PK conceived the study, performed the data compilation and formal data analysis, interpret the findings, and wrote the manuscript; DAW conceptualized and drafted the manuscript, interpreting the findings and wrote the manuscript; NW conceived the study; NH performed the data analysis; PS conceptualized the manuscript. All authors reviewed and contributed to the final manuscript. All authors have read and approved the final version of the manuscript, and agree with the order of presentation of the authors.

The authors declare that they have no competing interests.