key: cord-0920884-odnif497
authors: AlDukhail, Shaikha; Bahdila, Dania
title: Self-perception of health and physical activity among adults before and amidst the COVID-19 pandemic: United States, 2019–2020
date: 2022-03-25
journal: Prev Med
DOI: 10.1016/j.ypmed.2022.107037
sha: 685669a231bdf4dd6653c7ff7263af1ac0cebda4
doc_id: 920884
cord_uid: odnif497

The compounded impact of the COVID-19 lockdowns on self-perception of health (SPoH) and physical activity (PA) levels among U.S. adults remains to be explored. We sought to: (1) describe the SPoH and PA levels among U.S. adults; (2) explore the relationship between SPoH and PA before and amidst the COVID-19 pandemic. We analyzed data from the 2019 and 2020 Health Information National Trends Survey (HINTS). COVID-19 was declared a pandemic by the World Health Organization on March 11th, 2020. This date was chosen to demarcate the responses as before and amidst the COVID-19 pandemic. Weighted prevalence estimates were presented alongside adjusted odds ratios from multivariable logistic regression of general SPoH and PA levels for U.S. adults before and amidst COVID-19 pandemic. We analyzed data for 9328 participants. Over half of the U.S. adult population reported performing no muscle strengthening exercise in 2019. The number of inactive people has slightly increased in 2020 (27.8%), compared to 2019 (26.5%). Overall, levels of PA for active people were comparable in 2020 pre and post the WHO pandemic declaration date (36.4% and 39.8%; respectively). Higher odds of negative SPoH were observed among black individuals, current cigarettes smokers, with annual income less than $35,000, physically inactive individuals, people who do not perform muscle-strengthening exercise, and who were very obese. Negative SPoH were associated with lack of moderate exercise, and lack of muscle-strengthening training among U.S. adults before and amidst the pandemic. Pandemic policies and recommendations should include and facilitate PA, specifically among vulnerable populations.

On March 11 th , 2020, the World Health Organization (WHO) COVID-19 a global pandemic. 1 Cueing public health authorities to implement a series of preemptive measures such as social distancing, self-quarantine practices, travel restrictions, in addition to cancellation of recreational events. 2 These isolation measures are likely to have resulted in a number of unintended consequences including decreased physical activity (PA) and increased negative self-perception of health (SPoH) in the population. 3, 4 SPoH refers to the subjective perception of one"s health in general. 5, 6 It captures the impact of health conditions on various aspects of an individual's health, including but not limited to, physical and mental well-being. 5,6 SPoH is a reliable, low-cost method to measure individual"s well-being and found to be consistent with objective health status. 5, 6, 7 It has also been used as a predictor for mortality and quality of life. 5, 6, 8 SPoH is also sensitive to income inequality, socioeconomic status, gender and PA levels. 9, 10, 11 In light of COVID-19 pandemic, decreased PA could negatively impact SPoH through two pathways. Firstly, a sudden reduction in PA might have exacerbated pre-existing physical and mental health conditions. 12 Secondly, evidence suggests that sufficient PA is linked to improved quality of life and lower mental health burden. 13, 14 During the early Hispanic Other. Residence was defined using the U.S. Department of Agriculture"s 2013 Rural-Urban Continuum Codes. 25 Codes 1 to 3 were designated as urban, while codes 4 to 9 were categorized as rural. Household annual income was categorized into 4 categories: less than $35 000, $35 000 to $49 999, $50 000 to $74 999, and $75 000 or more.

Pandemic return variable: Data collection for HINTS 5 Cycle 4 started before COVID-19 was declared a pandemic and continued after the declaration by WHO March 11th, 2020. There is an assumption that people who returned the survey earlier may have responded in different ways to some of the survey questions than people who responded later. This variable was chosen to demarcate responses as responses before and amidst the COVID-19 pandemic.

Existing health conditions: Diabetes, high blood pressure, heart condition (heart attack, angina, or congestive heart failure), chronic lung disease (asthma, emphysema, or chronic bronchitis), mental health issues (depression or anxiety disorder). These were assessed by asking "if a doctor or other health professional ever told you that you had any of them".

Smoking status: Derived from two questions, "Have you smoked at least 100 cigarettes in your entire life?" Those who answered no were categorized as never smokers. Among those who answered yes, a follow-up question was asked: "Do you now smoke cigarettes every day, some days, or not at all?" Those who answered not at all were categorized former smokers, while others were considered current smokers. 

We performed secondary data analysis of cross-sectional data. Descriptive statistics were used for categorical variables including participants' SPoH and sociodemographic characteristics. Weighted percentages were used to report nationally representative results and to account for the complex survey design. We performed unadjusted and adjusted logistic regression models to evaluate the association between negative perception of health and: (Model 1) Weekly moderate exercise, and (Model 2) Muscle J o u r n a l P r e -p r o o f Journal Pre-proof strengthening exercise as main predictors. In both models we adjusted for the demographic (age, sex, race-ethnicity, rural-urban residence, household annual income, and highest education achieved) and lifestyle characteristics (smoking status, PA, and BMI), and existing health conditions (diabetes, heart diseases, high blood pressure, chronic lung conditions, depression, and anxiety disorders) of respondents. We calculated odds ratios (OR), adjusted odds ratios (AOR) and 95% confidence intervals (95%CI). Statistical significance was defined as a P value less than 0.05, and all statistical analyses were performed using STATA version 14 (StataCorp). Table 1 presents the demographic characteristics and the prevalence of PA levels and SPoH among U.S. adults in 2019 and 2020. In 2019 and 2020, over half of the samples were women (51.2% in 2019 and 51.4% in 2020), and predominantly of non-Hispanic white ethnicity (63.5%). In both years, most of the respondents had an income above $75K (39.6%, 42.5% respectively), and were living in urban areas (86.7% and 87.8% respectively). In 2020, 13.8% reported being a current smoker compared to 12.5% in 2019. In both years, 36.0% of the sample reported having high blood pressure and 8.1% reported having a heart condition ( Table 1) . Table 1 ). There were higher perceptions of being unhealthy among adults with less than high-school education (32.0% in 2019 and 20.4% in 2020; Table   1 ). In 2020, after the pandemic declaration date, 21.0% of current smokers had negative SPoH, compared to 26.6% post declaration date (Supplementary Table 1 ). In 2019 and 2020, adults who were physically inactive, and adults who do not perform any muscle-strengthening exercise, and those who were very obese have consistently higher negative health perceptions (Table 1) . Overall, poor SPoH was higher among people with chronic medical conditions both before and amidst the pandemic (Table 1) .

In 2019, 26.5% of adults reported being inactive, and over half of the U.S. population (53.1%) reported no muscle-strengthening exercise. The prevalence of inactive people has slightly increased in 2020 (Table 1 ). Figure 2 summarizes PA levels among different age categories before and amidst the COVID-19 pandemic. In 2020, 27.6% of adults who reported being inactive were 65+ years, compared to 28.2% in 2019. In 2019, adults aged 50-64 years were the most active age group (29.5%), and 28.9% of them performed adequate muscle-strengthening exercise. In 2020, 27.1% of young adults below the age of 35 reported performing adequate muscle training exercises compared to 29.1% in 2019.

The relationships between self-perception of health and physical activity among US adults before and amidst the COVID-19 pandemic:

The unadjusted odds of negative health perceptions were higher among adults who were inactive (OR 4.50, 95%CI 3.06 -6.61, P≤0.0001) and (OR 3.04, 95%CI 1.95-4.74, P≤0.0001) compared to active adults in 2019 and 2020, respectively. The odds of negative SPoH were higher among adults who did not perform any musclestrengthening exercise (OR 2.35, 95%CI 1.71-3.23, P≤0.001) and (OR 2.68, 95%CI 2.05-3.50, P≤0.0001) compared to active adults in both 2019, 2020 respectively. Table 2 and 3 present the adjusted results of the multivariable logistic regression models of the association between negative SPoH and both, weekly moderate exercise, and muscle-strengthening activities in 2019 and 2020. After adjusting for potential confounding factors, the association between the lack of moderate exercise and negative SPoH were significant. People who were inactive had three folds the odds of perceiving themselves as unhealthy compared to those who were sufficiently active in 2019 (AOR 2.97, 95%CI 1.94-4.55; P≤0.0001), and similarly in 2020 (AOR 1.92, 95%CI

1.92-3.44; P=0.029; Table 2 ). Furthermore, adults who did not perform any musclestrengthening exercise had over twice the odds of perceiving their health as poor or fair in 2019 (AOR 1.94, 95%CI 1.35-2.78; P=0.001), similarly in 2020 (AOR 2.43, 95%CI 1.70-3.48; P≤0.0001), compared to adults who were sufficiently active that respective year (Table 3) . Those with medical conditions, such as diabetes, had over twice the odds of perceiving their health to be negative, compared to non-diabetics (AOR 2. 

This is the first national study to explore SPoH, PA levels, and their associations among U.S. adults, before and amidst the COVID-19 pandemic. We identified that over half of U.S. adults did not perform any muscle-strengthening exercise in 2019. The number of inactive people has slightly increased in 2020. In general, levels of PA for active people were comparable in 2020 pre and post pandemic declaration dates. We also identified high levels of negative SPoH among non-Hispanic black individuals, current smokers, people with heart conditions, those with annual income less than $35 000, physically inactive individuals, people who do not perform muscle-strengthening exercise, and who were very obese.

Albeit high, we found that the overall proportion of individuals reporting negative SPoH was relatively lower in 2020 compared to 2019. A possible explanation could be that early media messages consistently emphasized that people who are at risk of COVID-19 infection are older adults and individuals with multiple morbidities. These messages might have created a sense of "optimism bias", that is the belief that bad outcomes are less likely to occur to oneself than others. 28,29 Therefore, optimism bias could have caused younger and healthier individuals to underestimate their likelihood of contracting diseases and elevated their self-awareness of health. 28, 29 Additionally, there is a conceptual contrast between "internal" views of health (one"s self perceptions) and J o u r n a l P r e -p r o o f "external" views (based on the observations of experts). 30 Evaluating general health status is complicated by the fact that a person's own understanding of their health may not accord with the appraisal of medical experts. 30 Levels of PA for active people were comparable in 2020 pre and post declaration dates.

In response to stress, some active individuals tend to increase PA engagement, meanwhile, stress negatively impacts PA levels among inactive individuals. 31 Active people usually exhibit autonomous motivation to physical exercise compared to inactive individuals; maintaining their activity levels during the panemic. 32 We also found that physical inactivity was associated with increased odds of negative health perception among adults in both 2019 and 2020. The association was stronger between lack of muscle-strengthening exercise and negative self-perception in 2020 compared to 2019.

These findings are aligned with the evidence suggesting that PA, specifically resistance training, has a clear impact on a range of health and morbidity related risk factors 33, 34 and quality of life. 13 Physical inactivity coupled with the heightened anxiety during the early months of the pandemic might have exacerbated negative SPoH among inactive people.

Furthermore, the associations between PA and general SPoH in 2020 highlighted some inequities among vulnerable populations. Similar to other studies, we found that Hispanics, Asians, people who are 65+ of age, those with lower income, and people with high school education had higher odds of negative self-perceptions of health compared to their reference groups. 9,10,11 Minorities and vulnerable populations have been disproportionately affected by the negative consequences of the COVID-19 pandemic such as unemployment, non-essential businesses closure, and significant J o u r n a l P r e -p r o o f reduction in access to healthcare. 35, 36, 37 The spillover effect of the upstream social determinants of health for various inequalities has been associated with psychosocial stress and negative health outcomes. 35, 36, 37 Thus, in addition to the major consequences of COVID-19 to the economy, communities, and existing inequalities, COVID-19 may have disproportionately exacerbated negative self-perceptions of health.

The strengths of this study include the nationally representative sample from 2019 and 2020. Furthermore, we were able to explore the data before and after WHO pandemic declaration date for various demographics and health conditions. This study was also subjected to some limitations. Respondents who returned the surveys in 2020 after the declaration date could have completed them before March. Additionally, major changes in behaviors and SPoH might have not come on effect in the early weeks after declaration date. A follow up study using longitudinal data would be of interest. The study was also susceptible to response bias because it relied on self-reported information (e.g., medical conditions and level of PA). Causal links between the outcome and predictors cannot be assumed because of the observational nature of the study. Furthermore, some confounders were not included such as pre-existing eating disorders and employment status, which might have been greatly disturbed during COVID-19 lockdown. 38,39 Finally, HINTS data collection periods were slightly different for 2019 (January to April) and 2020 (February to June). This difference in seasons could have relatively impacted our PA levels findings.

Daily lives disruption during national emergencies are inevitable. However, in the case of an extended disruption period, maintaining PA becomes more vital to preserve one's well-being and in achieving the goal of "Active People, Healthy Nation", which is a J o u r n a l P r e -p r o o f national initiative led by the CDC to help Americans become more physically active by 2027. 40 The bidirectional relationship between PA and health has also been demonstrated in a study where meeting PA guidelines was strongly associated with a reduced risk for severe COVID-19 outcomes among infected adults. 41 Our study highlights physical inactivity as a modifiable risk indicator for negative SPoH. These findings are contrasted by the limited efforts of public health authorities to promote the benefits of PA during the pandemic. The potential for habitual PA to lower negative SPoH should be promoted by the medical community and public health agencies.

Additionally, pandemic policies and recommendations should include and facilitate regular PA, specifically among vulnerable populations.

Negative SPoH was associated with lack of moderate exercise and lack of musclestrengthening exercise among adults in the U.S. before and amidst the COVID-19 pandemic. Higher odds of reporting negative SPoH were found among non-Hispanic black individuals, current cigarettes smokers, people with heart conditions, those with annual income less than $35 000, and who were very obese. Our study highlights physical inactivity as a modifiable risk indicator for negative SPoH. Pandemic policies and recommendations should include and facilitate regular PA, specifically among vulnerable populations.

S.A. analyzed the data. S.A. and D.B., were involved in article"s conception and design, interpreted the data, drafted the manuscript, provided final approval of the version and J o u r n a l P r e -p r o o f agreed to be accountable for all aspects of this work. No financial disclosures were reported by the authors of this paper. J o u r n a l P r e -p r o o f Table 2 for Logistic regression analysis of the association between Self-Perception of Health and Physical Activity among before and after WHO pandemic declaration date March 11th, 2020. Table 3 . Logistic regression analysis of the association between negative self-perception of health and Muscle-strengthening exercise among U.S. adults -Health Information National Trends Survey (HINTS) 2019 -2020. Table 2 for Logistic regression analysis of the association between Self-Perception of Health and Physical Activity among before and after WHO pandemic declaration date March 11th, 2020.

J o u r n a l P r e -p r o o f

Guidance for COVID-19

Logistic regression analysis of the association between Self-Perception of Health and Physical Activity among before and after WHO pandemic declaration date March 12 th

Pre-Declaration AOR (95% CI)

Post-Declaration AOR (95% CI)

AOR: adjusted odds ratio; CI: confidence interval; Reference: reference group. The bold values are significant, p <0.05. Model (1) adjusted for Weekly moderate exercise, Sex, Age, Race, Education Level, Annual household Income, Residence, Smoking status, Body Mass Index and Existing medical conditions. Model (2) adjusted for Muscle-strengthening exercise, Sex, Age, Race, Education Level, Annual household Income, Residence, Smoking status