key: cord-0906960-e64c3lpb authors: Pombo, André; Luz, Carlos; Rodrigues, Luis Paulo; Ferreira, Carlos; Cordovil, Rita title: Correlates of Children’s Physical Activity During the Covid-19 Confinement in Portugal date: 2020-09-22 journal: Public Health DOI: 10.1016/j.puhe.2020.09.009 sha: d7c4cb828ce97fcd60cb362ec2563d2020d45ae6 doc_id: 906960 cord_uid: e64c3lpb Objectives To understand the role of household variables on the percentage of physical activity (%PA) during the COVID-19 confinement in Portugal. Study Design A Cross-sectional study design using an anonymous online survey was launched to assess how Portuguese families with children under 13 years of age adjusted their daily routines to the confinement. Methods Separate ANOVAs were performed to investigate how factors, such as the number of children, age, sex, the housing characteristics, and the adults’ job situation, can affect the percentage of time for physical activity (%PA). Results Findings, based on data from 2159 children, indicate that: I) Boys and girls did not differ in the %PA on any of the age groups; II) Children with an outdoor space and who had other children in the household were significantly more active (p<.001); III) Children from families with all adults working from home showed lower levels of %PA; IV) Being younger, having a big outdoor space, having other children in the household, and having at least one adult free from working from home, were significant positive predictors of children’s %PA, explaining 21% of the overall variance. Conclusion Time allocated for PA during this period is reduced compared to what is usually reported on normal days. It is necessary to find strategies to increase children's PA, especially in families where both parents are working and have no outdoor space. Late December 2019, a series of unexplained cases of pneumonia were reported in the city of Wuhan, China 1 . On the 30 th of January of 2020, WHO classified this epidemic as a public health emergency of international interest 2,3 and on February 11 th classified the disease as Corona Virus Disease 2019 (COVID-19). On that same day, the Coronavirus Study Group (CSG) of the International Committee on Virus Taxonomy, named it Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) 4 . As it continued to spread, on May 27, 2020, it had reached 188 countries, with 5.604.461 cases confirmed, of which 350.752 resulted in death. In Portugal, on this same date, 31.007 cases were registered, 1342 of which resulted in death 5 . In the absence of effective treatments for this pandemic situation, the best way to control the sources of infection was enforcing social isolation and confinement 4 . Therefore, in almost all countries, governments declared the state of emergency, tightening the effort to keep people at home. Schools´ systems were shut down, non-essential government and private services were closed, and employees were moved to work from home. Portugal followed this same pattern, as schools, companies and nonessential public services across the country were closed on March 16 th and the state of emergency was declared two days later, on March 18 th . Also, the Portuguese government decided that children would stay at home-schooling until the end of school year, starting what it seemed to be a long period of movement restriction, without any organized physical activity or free play time outdoors. Knowing that during long periods without school, children are more susceptible to unhealthy behaviors, J o u r n a l P r e -p r o o f such as excessive sedentary behaviors 6,7 with a negative impact on children's motor competence 8 , as well on their body composition and cardiovascular fitness 9 , we aimed to understand how the children's daily routines were established during confinement times. For that, and at the exact same week when the Portuguese state of emergency was instated, we started an online survey for home confined families with children up to 13 years of age, in order to understand not only the routines that were being established during confinement times, but specifically what, and how much, physical activity were children having at home. Following the international physical activity and public health research agenda to inform COVID-19 policies and practices 10 Knowing which variables are more related with physical activity is fundamental to better understand this phenomenon and can be helpful to create strategies, as well to prevent future unhealthy behaviors in similar situations of prolonged confinement. We hypothesized that older and only children, who live in houses with no outdoor space, and who have parents working from home, are being specially affected by the confinement situation, presenting lower levels of physical activity time than their peers. To assess how children under 13 years of age are dealing with the COVID19 confinement situation, we created a survey on LimeSurvey, hosted on the Faculty of 2.Housing characteristics: Type and characteristics of the house (e.g., apartment or detached house; number of rooms), existence or not of indoor space for physical activity (gym or exercise room) and of outdoor space (no outdoor space, small outdoor space -up to 12 m 2 ; large outdoor space -more than 12 m 2 ). 3. Household routines: Questions about the level of concern regarding the situation of Covid-19 and the way routines are being adjusted (i.e., comparison between time spent in different activities before and after confinement). 4. Children's routines: Questions related to the characterization of each child (age, sex, PA before confinement, health status) and the time (reported in minutes) spent in different activities during the previous day. The first three categories (Intellectual activity, playful screen time and play without physical activity) were added to calculate overall sedentary time, and the last two categories (play with physical activity and physical activity) were added to calculate overall physical activity time. This value was then converted into a percentage of the total time reported for all categories of the children, from now on called Percentage of Physical Activity (%PA). Factors associated with the child (i.e., sex and number of children in the household), the housing characteristics (i.e., existence and dimension of outdoor space) and of the adults' job situation (i.e., all adults having to work from home or not) were used to analyze which would influence the %PA. The initial data of this survey included 3075 responses given by parents regarding their Descriptive statistics and frequency analysis were used for the initial characterization of the 2159 children divided by age groups, their household conditions and housing characteristics. An a priori power analysis was conducted using G*Power3 (Faul, Erdfelder, Lang, & Buchner,2007) to test the difference between four independent group means using a two-tailed test, a medium effect size (d= .50), and an alpha of .05. Result showed that a sample of 74 participants was required to achieve a power of .80. Separate ANOVAs were performed to investigate how different factors associated with the child (i.e., sex and number of children in the household), the housing characteristics (i.e., existence and dimension of outdoor space) and of the adults' job situation (i.e., all adults having to work from home or not) affected the %PA by age group. Age groups were considered as follows: group 1 = 0-2 years; n=462, group 2 = 3-5 years, n=765; group 3 = 6-9 years, n=606 and group 4 = 10-12 years, n=326. Finally, a forward stepwise regression (p to enter <0.05, p to remove >0.10) was performed to investigate the best predictors for the %PA done by children. Age of the child and the variables previously investigated in the ANOVAs were entered into the model. was used for analyses. Descriptive data regarding the factors associated with the children (age group, gender, health status and number of children at home), the housing characteristics (type of house and availability of outdoor space) and the adults' job situation (working status of the adults) is presented in Table 1 . When analyzing the %PA by age group (Table 2) , we found that the youngest age group (0-2 years) presented the highest values of %PA, followed by the 3-5, 6-9 and 10-12 age groups, respectively. Additionally, four ANOVA'S testing for differences on daily PA according to sex, space, number of children in the house, whether or not parents are working from home revealed significant main effects for all tested factors (all p's<.002), except for sex (p=.068) and no interaction effects (see Table 2 and Figure 1 ). Boys and girls did not differ in the %PA on any of the age groups. Furthermore, the PA average time for both sexes was about two hours (2.2h and 2.3h respectively for girls and boys; data not shown). Considering the typology of house space, we found that having a big outdoor space plays an important role, positively influencing PA mainly between 3-to-9 years of age (compared to all other typologies, p<.001). This influence can also be seen in the younger age group, since having a big outdoor space is significantly different than having no outdoor space (p<.001). No differences were found between the three typologies of outdoor space for the older age groups. When analyzing the number on children in the household, we can see that being an only child is a disadvantage regarding the %PA. Higher values of %PA were found when more children were present in the household, and that it was true for all group ages (p's<.001 in the first 3 age groups) except in the older age groups where no significant differences were found. Additionally, children from families who had all the adults working from home showed lower levels of %PA. Our aim was to understand the role of household variables on the %PA in this confinement situation. The results showed that being younger was the strongest predictor for %PA, followed by having a big outdoor space, having more children in the household, and not having all adults working from home. The effect of the different variables on children's %PA is discussed in the next topics. Normal activities like walking to school, engaging in physical education classes, playing in recess, going to sport clubs, etc., were totally forbidden in this confinement situation. Due to this, and although it was expected that %PA would decrease along the growing age groups, given the knowledge we have on PA behavior of children 23 , the findings that boys and girls present no differences on this decreasing trend is somehow new and not fully anticipated [15] [16] [17] . We know that boys use more play areas and equipment, they tend to display higher levels of moderate-to-vigorous PA while using them 24 and seem to be more physically intense on the exploration of the playground features, while girls experience a higher enjoyment for activities like playing tag games, walking, creative tasks, climbing, sliding, hiding, sitting, and relaxing 25 . The same tendency occurs in organized sport participation during childhood, with boys engaging more often organized and high physically intense sports than girls 22 . In our results, girls and boys showed equal participation on organized physical activities before confinement (66% and 67% reported respectively for girls and boys) additionally , the fact that they're all "in the same boat", without access to the kind of space, equipment, or social organization that usually afford sex-biased movement differences in the normal day time, can help to explain why both sexes showed similar PA behavior along age groups. Furthermore, the non-existence of sex differences in PA might be related to the fact that the majority of activities reported during confinement are probably of light intensity, which is usually not significantly different between boys and girls 26, 27 . Although the government decision was the same for all people, it is wrong to think that this decision affects all equally. Most of the children in our study live in apartments (60,2%) and we found that having an outdoor space influences positively the %PA. The home environment is an important influence on the PA and sedentary behavior of children, being especially relevant for those who have limited independent mobility and spend much of their time at home and indoors 14, 15 . Although, our results indicate that having a small outdoor space at home (up to 12 m 2 ) did not make a J o u r n a l P r e -p r o o f difference, having a larger space positively impacted the %PA. These results are in line with other studies, that mention that the amount or lack of outdoor space can have a great impact on the children PA 7,18-20 . Some studies showed that as the amount of home space increased, so did children's PA 18,28 , and the lack of a yard space at home was identified as a barrier to PA and active play of children 7,19 . Yard features were positively associated with the minutes per day preschoolers spent in home-based outdoor play 29 . We believe that the results are in accordance with the knowledge that both boys and girls of lower socioeconomic status areas have decreased odds of spending more than 2h outdoors on weekends 30 and lower levels of fitness and activity compared to their peers from higher socioeconomic status areas [31] [32] [33] . Having siblings in the house can also affect the %PA. Only children have significantly lower levels of moderate-to-vigorous PA 16 and are more prone to have higher sedentary time 17 than children with siblings. It seems that PA of younger siblings benefits from the presence of their older siblings during summer (non-school) time 34 35 . In fact, a recent systematic review and meta-analysis 36 found a significantly higher likelihood of being overweight and obese in only children . This lack of peer modeling and company in the confined house certainly helps to understand that only children had a negative effect on the time spent on PA, independently of gender and age. Parents have an important role in supporting or restricting children's sedentary behaviors. If they perceive PA as important for their children, they will probably create J o u r n a l P r e -p r o o f more opportunities for children's PA at home 29 and will organize more active family activities 37 . Having all adults in the household working from home can surely be a stressful situation for a home confined family and this has been related with an increase in the depressive symptoms among working women with young children 38 . The number of tasks that parents have to undertake at this time is immense, they have work tasks, house tasks, children school tasks, meal related tasks, etc., and all this while trying to give emotional support to their kids and family. This can be a challenge for promoting PA, as fatigue is reported as an health barrier to be active with their children 39 . Furthermore, with no parent free to engage in interaction with the children, and the need for a quiet work environment at home, surely that children's movement and noise inside the house are heavily censured. Even though this study provides important information regarding the role of several variables on the %PA during this confinement situation, it is important to highlight that it has some limitations. First, it is a cross-sectional study design and thus susceptible to biases. Second, it is a parental report online and not a direct or quantifiable observation of the children's time. Quantitative information about the intensity levels of PA were not gathered in the present study. Although apparatus like Fitbit and similar can be used for addressing PA in the adult population 21 , it is unusual to have these types of gadgets used by children, and in the wake of the sudden situation it was not possible to distribute such apparatus to families. Regardless, in our results, the J o u r n a l P r e -p r o o f value found in the PA average time for both sexes is less than half of the total time of PA reported by accelerometry for Portuguese children (5.0h for boys and 4.5h for girls) 22 . We believe that these methodological options (i.e., cross-sectional study based on parental reports) were necessary considering the confinement situation. Finally, despite the good response rate, we cannot consider this survey to be representative of Portugal, since it is not possible to assure that the coverage area was the entire country. This study was the first to reveal the differential effect of the COVID-19 confinement in These results are of outmost importance for parents and policy makers. Nobody can change their house size or add an outdoor area instantaneously, but governments can regulate about both parents working from home when there are children confined with them. Parents must be aware of the need to prioritize PA time for their children, since they are not getting the usual stimulation during this period. This effort should be even greater for parents of older children with no outdoor space available, especially because this can constitute a double burden situation when the family already presents a socioeconomic profile at risk. Furthermore, in the post-confinement stage, additional efforts will be required to offer PA and outdoor play opportunities for children who were most affected by the COVID-19 pandemic response. All the authors participated in the conceptualization of the study, the design, coordination and completion of data collections and drafting of the manuscript. All authors have read and approved the final version of the manuscript and agree with the order of presentation of the authors. Two of the Authors were partly supported by the Portuguese Foundation for Science and Technology, under Grant UIDB/00447/2020 to CIPER -Centro Interdisciplinar para o Estudo da Performance Humana (unit 447) and under project UID04045/2020. The authors declare that they have no competing interests. J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f • Although confined to their house, boys and girls still allocate some time to PA tasks. • For children of both sexes and of all ages, the %PA showed to be positively affected by the existence of a big outdoor space, and by the presence of other children in the house. A negative effect was found when all adults were working from home. • Parents must be aware of the need to prioritize PA time for their children, and governments can regulate about both parents working from home when there are children confined with them. 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