Changes in physical activity and sleep among adults in Russian Federation during COVID-19: a cross-sectional study.

Abstract


Background
Physical activity is one of the major risk factors [1], and it increases risk of all-cause mortality [2], nonfatal CVD and diabetes [3].The WHO has developed guidelines describing physical activity levels allowing to maintain adequate health and tness.It includes in at least 150 min of moderate-intensity physical activity or 75 min of vigorous-intensity physical activity per week or its combination for adults [4].A meta-analysis of prospective studies reported that meeting the WHO recommendations for physical activity was associated with 17% lower risk of cardiovascular events, 23% lower risk of cardiovascular mortality and 26% lower incidence of type 2 diabetes [5].Around 30% of adults in Russian Federation meet the WHO PA recommendations [4], a gure consistent with global rates [6].
The outbreak of novel coronavirus (COVID-19) in late December 2019 in China, and subsequent declaration by the World Health Organization (WHO) as a global pandemic in March 2020 [7] has forced countries to implement strict hygiene regimes and social distancing measures.Extensive social distancing policies were put into place restricting people's daily activities.While these restrictions helped slow the rate of infection, there may also be concomitant negative effects as a result of limiting participation in normal daily activities such as walking and cycling for transport and leisure and access to many types of recreational activities such as team sports, gyms, tness centres, and dancing classes.
Several studies have shown the detrimental effect of COVID-19 on the physical activity.An Australian survey of around 1500 participants found that nearly half reported a decrease in PA levels in April 2020 compared with before COVID-19 [8].Reduction in physical activity levels were associated with increasing levels of depression and anxiety.An international survey of physical activity changes with Europe, Africa, Asia and both Americas participants found that pandemy had detrimental effect on all types of PA (vigorous, moderate, walking and overall) [9].Sedentary time increased by 28.6% during restrictions, the number of days of vigorous intensity PA decreased by 22.7%, the number of days of walking decreased by 35% [9].In contrast, an online survey of 3533 participants conducted across Italy in April 2020 reported a slight increase in physical activity [10].In an early global study, 19.1 million daily step count measurements were provided by 455 404 unique users from 187 countries, within 10 days of the pandemic declaration.There was a 5.5% decrease in mean steps (287 steps), and within 30 days, there was a 27.3% decrease in mean steps (1432 steps) [7].
Social distancing, travel bans, the cancellation of sporting and other mass participation events, and changes to work practices have dramatically affected daily life throughout the country.Major restrictions were introduced on the 28th March 2020 with the level of restrictions varied depending on the epidemiology of the virus from region to region.
Cities with a large number of cases had the most strict restrictions such as limitations on any outdoor activities.
Further, citizens were requird to possess an electronic pass to leave the house and this was only permitted for workers during work hours, and to access essential services such as medical or health care, to shop for groceries, or to visit parks and green zones (excluding outdoor activities entirely).In cities with a smaller number of cases limitations were less strict, especially with outdoor activities.Indoor sport activities were limited across the country and outdoor sports were restricted -depending on the situation in the region.Social distancing measures such as keeping a minimum 1.5 meters between people were introduced, as well as a ban on any public gatherings of more than 50 people.On-line learning for schools and universities and recommendation for remote working for employees were introduced.
In the Russian Federation, population levels of physical activity are sub-optimal [12,13] This low prevalence of adequate physical activity is a main contributing factor to the high prevalence of overweight and obesity [14].In addition, the prevalence of adequate sleep (de ned by the US CDC and National Sleep Foundation as 7-9 hours per night for adults) was only 37% [15].However, the effect of COVID-19 on levels of physical activity and sleep is not known.
The aim of this study was to evaluate the impact of COVID-19 on the levels of physical activity and sleep and to

Study design and population
The National Medical Research Center for Therapy and Preventive Medicine (Russia) organized online-survey "Study of the impact of restrictions on physical activity of the population in self-isolation due to COVID-19."Google platform was used for anonymous survey.A link to the survey was distributed using social media (Facebook, Vkontakte and Odnoklassniki), through web-sites and emails.To increase the regional participation a link to the electronic survey was send to the chief specialist in public health and preventive medicine in regional Ministries of Health who then distributed it at regional levels in Russia via a range of methods: shared link on the o cial web-pages and social media of regional Centers for public health and Medical Prevention and regional Ministries of Health o cial pages.The starting page of the survey informed participants about the goals and details of the survey at the landing page of the distributed link.This method of data collection cannot provide fully representative sample.However, it was effective considering the research goals, because it provided the dissemination of the survey throught all the bif country during a period where, due to COVID-19, there were many restrictions.
Eligible participants included all Russian adults aged 18 years and over.Data collection occurred between 26 April 2020 and 6 June 2020.This was the period of tightest restriction through the country, as from the 9 th June 2020 there was a gradual releasing of restrictions depending on the regional context.

Survey development
The online survey was designed by a steering group at the National Medical Research Center for Therapy and Preventive Medicine of the Ministry of Health of Russia.Existing COVID-19 surveys from Canada, China, and the United Kingdom were used to inform development of the survey.
A 7-day self-report recall measure was selected as a method for physical activity assessment.Since the study was conducted during the challenging time of the pandemic-related lockdown, PA assessment was simpli ed to avoid the negative effect of the length of the questionnaire and its complexity on the response rate [16,17].
The questionnaire contained 30 items and included mostly close-ended questions.Section 1 consisted of 10 general and context-related questions regarding demographic data and following self-isolation recommendations.Section 2 was designed to assess physical activity and sleep before Covid-19 and in the last 7 days during the pandemic.Section 3 evaluated how participants followed the Covid-19 preventive measures recommended by the Ministry of Health.Questions in Section 2 were presented in a differential format, to be answered directly in sequence regarding "before" and "during" con nement conditions.The full version of the questionnaire is available in the Supplementary le.
Physical activity was assessed using eight items assessing frequency and duration of walking, moderate and vigorous physical activity, and muscle strength activities before Covid-19 and during the past seven days.Total physical activity was calculated according to the WHO guidelines [4]: ≥150mins/week MPA or ≥75mins/week VPA or combination of MVPA, muscle strength activities ≥2 days/week.To calculate the proportion who meet the rst guideline, we rst worked out the number of minutes per week spent in vigorous-intensity activity, moderate-intensity physical activity and walking by multiplying the number of days spent in each of these activities by the time usually spent doing them.For the muscle strengthening, we added together the number of days strength training and the number of days basic calisthenic exercises (such as stretching, Zumba, yoga, pilates, Tai Chi) were undertaken.

Data Privacy and Consent of Participation
During the informed consent process, survey participants were assured all data would be used only for research purposes.Participants' answers were anonymous and con dential according to Google's privacy policy (https://policies.google.com/privacy?hl=en).Participants were not permitted to provide their names or contact information.Additionally, participants were able to stop participation and leave the questionnaire at any stage before the submission process; if they chose to do so their responses were not saved.Responses were saved only by clicking on the "submit" button at the end of the survey.By completing the survey, participants acknowledged their voluntary consent to participate in this anonymous study.This study was approved by the Ethics Committee of the National Medical Research Center for Therapy and Prevention of the Ministry of health of Russian Federation.

Descriptive statistics
Descriptive statistics, including frequencies and percentages, were generated for categorical variables; means and standard deviations (SD) were generated for continuous variables.Data were analysed in SPSS 20 (SPSS Inc., Chicago, IL, USA).Normality of the data distribution was con rmed using non-parametric analysis of Wilcoxon ranksum.

Linear and logistic regressions
Linear regression was used to test the associations between changes in physical activity and selected COVID-19 factors.Crude estimates and estimates adjusted for gender were reported with 95% Con dence Intervals (CI).
Finally, logistic regression was used to test which factors had impact on meeting the physical activity recommendations (both muscle strengthening activities and minutes per week of MPA/VPA).Binary logistic regression analyses were conducted to investigate the association between categorical variables (dependent) and continuous or categorical ones (independent).For these analysis 'meeting PA Recommendation (150mins/week MPA or 75mins/week VPA)' and 'meeting muscle-strengthening activities recommendation (≥2 days/week)' were speci ed as the dependent variables, and followed self-isolation recommendations, had access to outside/green zone, had an increase in the number of days per week with sleep problems, used digital or online PA resources, followed at least two relevant preventive measures from Ministry of Health, and geographic location were speci ed as independent variables.All data Statistical signi cance was set a priori at p< 0.05.

Results
The characteristics of the study sample are presented in Table 1.A total of 2540 participants from 62 regions commenced the survey with 18 participants (0.7%) failing to complete and their data not being used in the analyses.Of the 2432 participants who completed the survey, 83% were females.Compared with males, females tended to be older, married, have children under 18 living with them, and in full-time employment, less likely to have completed higher education, and more likely to follow self-isolation recommendations.In terms of employment status, 1714 (70.5%) participants had a full-time job, 399 (16.4%) were students, 65 (2.7%) were unemployed, and 47 (1.9%) were retired.
During the COVID-19 period, most participants completely or partially followed the self-isolation recommendations (n=2160, 88.8%).The preventive measures followed most frequently were "wash hands more often" (90.3%) and "maintain social distancing" (79.7%).Over 90% of participants still had access to outdoor areas and 70% had access to a green space during the restriction period.Two-thirds of participants reported that COVID-19 affected their physical activity, mostly as a result of their tness centre closing, of not being able to leave the house and of being able to undertake only simple calesthenic exercises at home.One-third of participants reported using online physical activity resources to help them be active, during this period.
Changes in sleep and physical activity from pre-COVID to during COVID are reported in Table 2.There was a signi cant decline in the number of days per week participants reported not getting enough sleep (3.21±2.44 to 2.86±2.57;p<0.001) and participants also reported an increase in the number of days per week they had trouble falling asleep (1.70±2.24 to 2.13±2.48;P<0.001).All physical activity outcomes declined signi cantly from pre-to during COVID.The average time spent in MPA and VPA each declined by around 12 minutes per day (42.43±37.57to 30.44±35.35 and 37.79±37.80 to 26.56±34.69,respectively [all P<0.001]).The number of minutes per day spent walking decreased by around 20 minutes from 60.5±38.66 to 40.83±38.6(P<0.001).
The proportion of participants who met the WHO Guidelines for any type of physical activity declined from 68% to 49% (P<0.001).The proportion who participated in muscle strengthening activities for 2 or more days per week declined from 53% to 45% (P<0.001).
Following self-isolation recommendations (β=-0.6,95%CI -0.8 to -0.3) and having assess to a home gym (β=-0.1,95%CI -0.4 to 0.2) were associated with a greater reduction in the number of days per week participants reported not getting enough sleep.In contrast, having children under 18 years of age in the residence (β=0.4,95%CI 0.2 to 0.6) and not being able to leave the house for PA (β=0.2, 95%CI 0.02 to 0.4) were associated with a smaller reduction in the number of days per week participants reported not getting enough sleep.
Associations between meeting WHO Global PA and muscle-strengthening recommendations and selected COVID-19 factors are reported in Table 4. Compared with those who did not use online PA resources, those who did were 1.4 (95%CI 1.3, 1.5) and 1.9 (95%CI 1.8, 2.1) times more likely to meet the recommendations for PA and for musclestrengthening activities, respectively.Compared with those who did not have access to a green space, those who did were more more likely to meet the PA (OR=1.2,95%CI 1.1, 1.2) and muscle strengthening (OR=1.1,95%CI 1.1, 1.2) recommendations.Those who owned a pet dog (OR=1.2,95%CI 1.1, 1.3) and those who followed the self-isolation rules (OR=1.3,95%CI 1.2, 1.4) were more likely to meet the PA and muscle strengthening recommendations, respectively, than those who did not.Conversely, compared with their urban counterparts, rural adults were less likely to meet the PA recommendation (OR=0.9,95%CI 0.8, 0.9).

Discussion
We found that as a result of COVID-19 restrictions in Russia, there were signi cant declines in participation in physical activity and sleep duration compared with pre-COVID levels.Not being allowed to leave the house for physical activity and the closure of tness centres were policies associated with greater declines in physical activity and sleep.
Conversely, those individuals who could access a green space or who participated in activities at home -using online resources or with the necessary equipment -showed much smaller declines in physical activity and sleep.In addition, we found that those who lived in apartments and in rural areas were more likely to be adversely affected in terms of their participation in physical activity.
In our study the number of days per week that participants got enough sleep decreased while the number of days per week that participants had trouble falling asleep increased.These results are consistent with studies in China [18], and Italy [20,21] showing the negative impact of COVID-19 home con nement on sleep.In Russia, COVID-19 upended daily routines in a number of ways: more people were working from home, meals times were altered, sedentary behaviorespecially screen time -increased.These factors in addition to the social distancing requirements likely resulted in a disruption to circadian rhythms [22].Home con nement is associated with reduced levels of physical activity which, in addition to the social isolation, may increase stress levels and disrupt night-time sleep.Physiological factors such as reduced sunlight exposure and weaker light-dark cycles as a result of less time spent outdoors may also have affected sleep and circadian rhythms [23].
We found that the restrictions during COVID resulted in a reduction in number of days per week and number of hours per day spent in PA and a reduction in all types of activities.Despite an increased offering of digital or online resources that could be accessed at home, participants were not able to maintain their normal pre-COVID PA levels.Those who did take up the offering and use such resources were more likely to meet PA recommendations.More support needs to be provided to those who were not able to access these resources, which may have been exacerbated by the higher increased levels of stress and uncertainty.Providing opportunities for PA is important in strengthening peoples immune systems and making them less susceptiable to infection.However, the extent to which PA participation is impacted by the COVID-19 pandemic is dependent upon the con nement policies of individual governments.For example, in China different policies at regional levels was associated with differences in PA participation [24].
We found that an increase in sleep problems was associated with a a greater decline in PA and less likelihood to meet the PA guidelines.This re-inforces how PA and sleep are interrelated, which is consistent with evidence from systematic reviews demonstrating the association between sleep and exercise.Exercise promotes increased sleep e ciency and duration regardless of the mode and intensity of activity, especially in populations suffering from disease [19].
We identi ed several factors that were associated with healthier levels of physical activity and sleep during COVID-19.
These suggest that the impact of the pandemic has not been uniform among Russian adults.People living in urban area were less likely to achive the PA recommendations, which is consistent with ndings from before the pandemic and demonstrates that those living in urban areas are more active that their rural counterparts [12].Living in a detached house, owning a dog, having a home gym were all favourably associated with healthy movement behaviours.In addition, having access to a green space was positively associated with physical activity.This information informs policymakers of population sub-groups who are at highest risk of being inactive during COVID and what should be considered when planning a response to provide opportunities to be active while at the same time adhering to social distancing requirements.Participants living in a house versus an apartment may have easier access to front or back yards for outdoor play and physical activity [25].Families who had a dog had higher physical activity and outdoor time.A recent systematic review also showed that dog-related interventions increased physical activity [26].
To the best of our knowledge, this is the rst published study to report on physical activity and sleep among Russian adults during the COVID-19 pandemic.Another international online survey on physical activity had similar ndings but did not include participants from the Russian Federation.[9].Other studies from Australia [8] and Poland [27] reported similar reductions in physical activity and increases in sedentary behaviors during lockdown in adults.This is in contrast to a study from Italy reporting a slight increase in physical activity [10], especially in muscle strengthening activities.
There is a need to address the impact of COVID-19 on healthy levels of movement behaviours and subsequent NCD risk, including using modern technologies (on-line) as part of a suite of strategies [28].To prevent the unintended consequences of COVID-19 restrictions and 'stay home' advice on physical activity and sleep -and as a corollary mental and social health, a balance is needed between preventing the spread of infection and providing opportunities for people to participate in healthy levels of movement behaviours.
Our results can be used to further research and development in public health promotion in Russia during the COVID-19 pandemic.Health promotion campaigns aimed at informing the population about the risks of physical inactivity are recommended.Evidence also suggests that web-[28] and app-based [29] interventions that people can access in their home might be especially bene cial if participants are motivated to adhere to the requirements.Some technology and social media have used gami cation to overcome challenges in adherence.Further enhancements such as providing opportunities for social interaction should also be considered.

Limitations
While there are a number of strengths of the present study, such as the large sample size, and the timing of data collection relative to lockdown restrictions in Russia, there are a number of limitations.First, our study was crosssectional meaning participants perceived the changes in their PA and sleep from before to during COVID-19.As such, participants may have been more likely to overstate the changes in PA and sleep in the absence of any true baseline data.Second, all data were self-reported and subject to recall bias such as overestimation of time spent in physical activity and in sleep.Third, our sample included an under-representation of males, which although unfortunate is consistent with other COVID-19 survey research among adults [8, 10,27].As such, these data should not be seen as a re ection of males living in Russia.In our opinion this survey can be generalized to some groups in the Russian population, predominantly women of young and middle age from ve regions (Tver, Tatarstan, Irkutsk, Sakhalin, and Bashkortastan) who actively use Internet.This group would be a target for any or web-or app-based interventions to promote healthy levels of physical activity and sleep considering that it will likely impact not only on them but potentially also members of their families, children and male partners.Finally, during the COVID-19 outbreak, the main instruments of the investigating the changes of physical activities were on-line surveys [9,10,30].This method has limitations but was the only method available during this period and much easier to collect data compared with a telephone survey.Online research is therefore a recommended approach if one wants to reach a large group of participants in a short period of time, ensuring their safety under pandemic conditions [31].

Conclusion
Surveys results will provide data, useful for developing measures aimed to improve the negative impacts of COVID-19 pandemics on the lifestyle.Clear demonstration of the detrimental effects of pandemic on the levels of the physical activity requires health promotion strategies directed to improve health-related behaviors such as targeted social media messaging.Continuing evaluation of the impact of restrictions is necessary to develop targeted health promotion strategies.Healthy levels of physical activity and sleep also affect the immune system through promoting healthy circadian rhythms and as such might serve as a protective strategy against infectious diseases.This study have implications for policymakers in Russia.It demonstrates the need for efforts to stimulate wider use of on-line resources for physical activity, and to consider the possibility of re-opening gyms and tness centres with all possible safety measures in the period of restrictions.Local councils should consider the importance of providing access to green spaces as part of their COVID-19 policies, especially if accompanied by infection control measures such as social distancing and wearing face masks.Special considerations should also be made for high risk groups such as adult people and people with chronic diseases.
Future studies should evaluate the longer-term consequences of the COVID-19 virus outbreak and recovery on physical activity, sedentary and sleep behaviours.To develop targeted health promotion strategies in Russia, it would be useful to identify province-speci c or geographic differences in uencing health behaviours.
examine speci c COVID-19 factors that may be associated with changes in physical activity and sleep among adults in Russia.The research questions were: 1.To what extent has physical activity and sleep changed as a result of the COVID-19 restrictions?2. What COVID-19 factors were associated with these changes in physical activity and sleep?

Table 2 .
Changes in sleep and physical activity from pre-to during COVID-19

Table 3 .
Associations between changes in time spent in physical activity and sleep and selected COVID-19 factors Change (In the last 7 days minus Before COVID-19)

Table 4 .
Associations between meeting WHO Global PA Recommendations and selected COVID-19 factors