Comparing the mental health and quality of life of athlete and non-athlete adolescents during the COVID-19 pandemic

This study was designed to compare the mental health and quality of life of athlete and non-athlete adolescents during the COVID-19 pandemic. The study statistical population included all adolescents aged 14–18 years living in Mazandaran province, out of which, 2897 adolescents were randomly selected. We performed an online survey among adolescents in Mazandaran province using GAD-7, PHQ-9, PFABS, and PEDSQL questionnaires. According to the results, athlete adolescents showed lower levels of anxiety and depression and higher quality of life compared to non-athlete adolescents. Moreover, the findings indicated that as the number of practice sessions increases throughout the week, the scores of physical activity and quality of life of athlete adolescents increase and their overall depression and anxiety scores decrease; however, the scores of generalized anxiety, depression, and quality of life among adolescent athletes with different training sessions in a week seem to be equal with no significant difference between them. The present results confirm the positive effect of physical activity on the mental health and quality of life related to the health of student adolescents. The COVID-19 pandemic has posed numerous challenges to public health, Physical activity is known as an effective strategy for improving mental health and quality of life. Providing more opportunities and facilities for physical activity for inactive and sedentary teenagers, whether online or in parks and open spaces, the potential of physical activity can be used to improve physical health and mental well-being during the epidemic.


Introduction
Since late December 2019, a new phenomenon of pneumonia diseases known as Coronavirus (COVID 19) was reported in Wuhan, China, which quickly spread internationally and turned into a pandemic [1].In January 2020, the World Health Organization (WHO) addressed and announced the COVID-19 disease in an emergency meeting as a global crisis and public health emergency [2].The coronavirus pandemic has practically imposed a significant impact on the way of life of people around the world [3].During the winter of 2019, when the Coronavirus epidemic began in Iran, schools and many sports clubs in the country were closed in an attempt to slow down the spread of the coronavirus.As suggested by researchers, these restrictions may be associated with profound social, economic, and psychological consequences for adolescents [4].As the pandemic still continues along with its related constraints worldwide, growing concerns should come into consideration about its impact on mental health.Studies around the world have demonstrated that most people have experienced increased mental distress and worsening mental health.Given the specific sensitivities of adolescence, social distancing measures associated with closing schools are more likely to impose greater negative impacts on adolescents [5].
The COVID-19 pandemic led to the rapid dissemination of research to evaluate its impact on physical activities, social communication, and mental health.There is a current growing tendency to do research on the mental health of children and adolescents during the COVID-19 pandemic [6].The first studies conducted in China, where the COVID-19 epidemic spread earlier and initially affected more people, reported a rise in stress, anxiety, and depression rates.Jiao et al. [7] reported that one-third of children and adolescents aged 3 to 18 years were dependent, inattentive, irritable, and anxious.Zhou et al. [8] also reported that 44% of people aged 12 to 18 years showed signs of depression, 37% had anxiety, and 31% revealed both types of symptoms.According to Puccinelli et al. [9] results, 30% of Brazilian adolescents had moderate/severe depressive symptoms and 23% showed moderate/severe anxiety symptoms.Research done on German children and adolescents indicated that they experienced more mental health problems and higher levels of anxiety than before the disease during the epidemic [6].Li et al. [5] demonstrated in their study that three quarters of Australian adolescents have faced a worsening of their mental health.In total, the research results indicated that the prevalence of mental illnesses (the most common: depression and anxiety) has got higher than pre-epidemic estimates.
Health-Related Quality of Life (HRQoL) is one of the important concepts related to adolescents' health that can play an effective role in their lives [10].Health-Related Quality of Life (HRQoL) is generally related to the perceived health of individuals, which encompasses physiological, psychological, and functional aspects of health and wellness.The HRQoL in children and adolescents contains dimensions of physical and mental well-being, experiences, and relationships in different environments such as family, school, and peers [11].The impact of the COVID-19 pandemic on the HRQoL is not well understood yet.Children and adolescents face huge changes in their daily lives, including school closures, being stuck at home, and social distancing regulations that can put severe pressure on them [12].Ravens-Sieberer et al. [6] showed in their study that German adolescents are significantly under the pressure caused by quarantine, social distancing, and educational activities at home and their HRQoL is significantly low.In their research, De Matos et al. [13] pointed to the decrease in all scores of quality of life of Brazilian adolescents affected by the epidemic.Also, Abawi et al. [14] reported a significant reduction in the mean scores of quality of life during the pandemic in the studied population.Moreover, in a review study, Nobari et al. [12] confirmed the impact of this pandemic on the quality of life of children and adolescents.
Organized participation in sports profoundly affects adolescent students' health and well-being.Higher academic achievement, more physical activity, lower levels of anxiety and depression, and a higher quality of life have been often reported in athletic students compared to students who do not participate in organized physical activities [4].Based on the research, the level of physical activity during social distancing is significantly lower than pre-pandemic levels [9].Maugeri et al. [14] showed that quarantine in Italy has significantly reduced the total weekly energy related to physical activities in all age groups.Di Stefano et al. [15] reported that restrictions negatively affect physical activities and this impact is higher on men and those with overweight.Okuyama (2021) found in his review research that two studies from China and a study from Spain reported a decrease in physical activity during the quarantine period [16].Also, the research literature suggests that the reduced level of physical activity may cause have negative consequences on mental health, and is probably associated with increased symptoms of anxiety and depression [17].
Physical activity is one of the most effective ways to promote mental and physical health, prevent diseases and, most importantly, strengthen the immune system during the COVID-19 pandemic.Physical activity can play a special role in reducing the unfair consequences of the COVID-19 pandemic [18].Physical activity can protect mental health [19].The study results have found a positive relationship between physical activity and mental well-being during the COVID-19 pandemic [20].Schinke et al. [21] reported that exercise can improve individuals' mental conditions and help reduce their psychological problems during the outbreak of coronavirus.Hammami et al. [22] also revealed in their research that participation in physical activity can significantly reduce the negative effects caused by quarantine during the coronavirus outbreak period.Senışık et al. [23] demonstrated in their study that the symptoms of depression, stress, and anxiety were higher in non-athletes than in athletes and there was also a significant positive correlation between the level of physical activity and mental health of individuals.In another study, Kürşat et al. [24] evaluated the anxiety status caused by COVID-19 disease in athletic students.According to their results, female students had higher levels of COVID-19 anxiety compared to male students.On the other hand, the findings implied that students who exercised at home reported less anxiety.Sokić et al. [25] showed in their study that elite athletes, as well as those with high levels of physical activity, experienced the lowest level of distress.Also, no difference was found in well-being between elite and recreational athletes who had higher welfare compared to non-athletes.
Grocke-Dewey et al. [19] described the relationship between physical activity and mental health as a two-way and rotational one.Researchers showed that increased mental distress can lead to decreased levels of physical activity during the COVID-19 pandemic (phase 1).This decrease in physical activity leads to a further rise in mental distress (phase 2), and then, this further rise in mental distress will cause a further reduction in physical activity (phase 3).
This research tried to answer the following questions: 1. What effect has the COVID-19 pandemic had on the mental health and quality of life of athlete and non-athlete adolescents?2. Is there any difference in mental health and quality of life between the athlete and non-athlete adolescents according to the time of activity or not?

Research methodology
The present study was applied research in terms of objective and descriptive one concerning methodology.The study's statistical population included all adolescents aged 14-18 years in Mazandaran province, out of which, 2897 adolescents were randomly selected.
A stratified cluster sampling method was used to collect samples.The sampling process was such that, at first, in a stratified form, three education departments of the city were selected from among the cities of the province in the west, center and east of Mazandaran province.Then, the schools of each region were selected randomly.
Athlete adolescent refers to an individual who participates in at least two sessions per week in a team or individual sport and exercises more than 1.5 h of moderate to high-intensity physical activity at each session.
The data required for the research were collected using online questionnaires in the social media platforms of Shad and WhatsApp from 2021.02.02 to 2021.03.08 in the Red Status of the COVID-19 pandemic in Mazandaran province.
Before conducting the research, the nature and purpose of the research were explained to the participants in the online questionnaire.
The criteria for entering the study were male and female students in the age range of 14-18 years and their satisfaction and willingness to participate in the research.
The questionnaires used were as follows: Demographic Profile Questionnaire, Generalized Anxiety Disorder (GAD-7) Scale, Patient Health Questionnaire (PHQ-9), Pediatric Quality of Life (PEDsQL) Inventory, and Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS).Descriptive and inferential statistics were used for data analysis.The data distribution was examined in the inferential section using the Kolmogorov-Smirnov test.Then, the Mann-Whitney U test and Kruskal-Wallis test were used to compare the differences between the groups due to the nonnormality of the data distribution.All statistical analyses of the mentioned tests were done using SPSS 26 statistical software.

Mental health
The short generalized anxiety disorder (GAD-7) scale and patient health questionnaire (PHQ-9) were used to evaluate the symptoms of anxiety and depression.Both questionnaires ask participants to assess and estimate the extent of anxiety and depression symptoms they have experienced in the past 2 weeks.The short GAD-7 scale is developed by Spitzer et al. to diagnose generalized anxiety disorder and assess the severity of clinical symptoms.The Cronbach's alpha coefficient of this scale and its retest coefficient at a 2-week interval were reported to be 0.92 and 0.83, respectively, indicating the scale's high internal consistency and good reliability [26].The results of Nainian et al.'s study showed that the short GAD-7 scale has a suitable Cronbach's alpha and the reliability coefficient of the scale has been evaluated to be appropriate based on running the test twice [27].The questions are scored from 0 to 3 based on a Likert scale.The total score of anxiety is calculated by summing the scores of the seven main questions, ranging from 0 to 21.A higher score indicates a higher level of anxiety.Besides the total score, the classified scores of 0-4, 5-9, 10-14, and 15-21 are associated with without, mild, moderate, and severe anxiety symptoms, respectively [5].
The patient health questionnaire (PHQ-9) is a 9-item self-reporting tool, which has been designed to screen, diagnose, monitor and measure the severity of depression.Nandakumar et al. (2019) suggested that the questionnaire benefits from appropriate validity and reliability to assess the depression of adolescents in the age range of 13 to 18 years and reported the internal consistency (Cronbach's alpha coefficient) of the tool ranging from 0.85 to 0.87 [28].The questionnaire needs to be answered based on a 4-point scale (0-3) and the subjects are asked to answer questions based on their condition within the last two weeks.The scores range from 0 to 27.In addition to the total score, the classified scores of 0-4, 5-9, 10-14, 15-20, and more than 20 are associated with minimum to none, mild, moderate, relatively severe, and severe depressive symptoms, respectively [5].

Pediatric Quality of Life (PEDsQL) Inventory
The Pediatric Quality of Life (PEDsQL) Inventory is a 23-item instrument that measures the children's quality of life on 2 scales physical health (8 items) and psychological health (15 items).The scale is a tool with appropriate psychometrics to assess the quality of life in various populations.The respondents rated the frequency of each of the 23 items of the quality of life based on a five-point Likert scale (never, rarely, sometimes, often, always).In their research, Hadianfard et al. [29] examined the psychometrics of this questionnaire in Iranian adolescents.The internal consistency and reliability of testing the retest for this instrument in this study were reported as 0.92 and 0.87, respectively.

Physical activity
The levels of physical activity were assessed by the Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS).This 8-item inventory is a valid instrument designed to measure the activity of children aged 10-18 over the past month.The range of scores is from 0 to 30 where a higher score represents more physical activity (Fabricant et al. 2014(Fabricant et al. , 2018)).In their research, Fabricant et al. reported high reliability with internal correlation coefficient of 0.91 and an internal compatibility with Cronbach's alpha of 0.914 for this scale [30,31].Based on the results obtained by Bel et al. [32], the HSS Pedi-FAB scale has convergent validity (rs = 0.991), internal consistency (α = 0.868), and reliability (SEM = 0.334).Also, the overall scores of the questionnaire and each of the questionnaires show high internal consistency and reliability, and thereby, it can be used to evaluate the level of physical activity in the adolescent population.Also, according to the results obtained by Dietvorst et al. [33], Cronbach's alpha coefficient (0.82) and the retest score (0.76) indicate the high internal consistency and reliability of the retest of the questionnaire.

Research results
The results of the analyzing 2897 questionnaires revealed that the mean age of participants was 15.80 years (the age range of 14-18 years).Of these, 1567 were non-athlete adolescents (54%) and 1330 (46%) were athlete adolescents.
Based on the results, the physical activity scores of athlete adolescents (14.98) are more than twice the scores of non-athlete adolescents (7.17).In this section, male adolescents in both athlete and non-athlete groups had a higher physical activity score than female adolescents.In the anxiety section, the lowest scores belonged respectively to male athletes, female athletes, male non-athletes, and female nonathletes.About 20% of non-athlete adolescents had moderate to severe anxiety, while this number was about 105 in athlete adolescents.
The results in the depression scores showed that nonathlete adolescents, both males, and females, had a higher average score in depression than adolescent athletes, while 14% of non-athlete adolescents had relatively severe and severe depression.This value was half among athlete adolescents.In addition, more than 60% of non-athlete adolescents reported depression symptoms, while this rate was reported to be less than 47% in athlete adolescents (Tables 1, 2).
The adolescents' quality of life scores indicated that athlete adolescents gained higher mean scores in all aspects of the quality of life than non-athlete adolescents.Also, male athlete adolescents reported higher mean scores than others in all aspects of the quality of life (mental and physical).
The Kolmogorov-Smirnov test was used to determine the normality of the research data.According to the results of this test in the table below, the significance level concerning all variables is lower than 5%.As a result, the distribution of data for all variables is non-normal.Therefore, the nonparametric Mann-Whitney U test had to be used to compare the differences between the two independent groups.
According to the results of Table 3, the Mann-Whitney U test statistic regarding the variables of generalized anxiety disorder, depression, physical activity, and the quality of life between two groups of athlete and non-athlete adolescents reveals that its significance level is less than 0.05.Thus, the levels of generalized anxiety, depression, physical activity, and quality of life are not equal between athlete and nonathlete adolescents and have significant differences from each other.
The scores of athlete adolescents according to the level of physical activity during the week are given in Table 4 to answer the second question of the research.The findings show that as the number of training sessions increases during the week, the scores of physical activity and quality of life increase, and the total scores of depression and anxiety decrease.No difference is seen between the groups in terms of the number of people with moderate to severe anxiety in the section on anxiety, and each group has reported this level as about 13%.In the depression scores section, the difference between the scores of the groups is more evident so that the score in all categories of depression decreases with increasing the duration and number of sessions.The quality of life scores of athlete adolescents according to the number of physical activity sessions indicates that athlete adolescents with four training sessions per week benefit from a better physical and mental fit than other athlete adolescents.
The results of the Kolmogorov-Smirnov test concerning the normality of athlete adolescents' data in the table below show that the level of significance regarding all variables is less than 0.05; thus, the distribution of data for all variables is non-normal.As a result, the non-parametric Mann-Whitney U test needs to be used to compare the differences between the three groups of athletes (groups with two training sessions, 3 training sessions, and 4 or more training sessions per week) (Table 5).
Based on the results of Table 6, the statistic of the Kruskal-Wallis test regarding the variables of generalized anxiety disorder, depression, and quality of life among three groups of athlete adolescents (groups with two training sessions, 3 training sessions, and 4 or more training sessions per week) shows that its significance level is calculated to be greater than 0.05.Therefore, the levels of generalized anxiety, depression, and quality of life among athlete adolescents with different training sessions per week are equal with no significant differences.

Discussion and conclusion
The rapid spread of the coronavirus has caused physical health concerns around the world followed by the emergence of a number of psychological illnesses.Thus, the mental health of different people in society may be endangered in the current high-risk situation.Therefore, identifying the dimensions of psychological disorders in different people and utilizing appropriate and timely treatment methods can protect people's mental health.
This study aimed to evaluate the mental health status and quality of life of athlete and non-athlete adolescents during the COVID-19 pandemic as well as the differences between the mental health and quality of life of athlete adolescents according to their time and level of activity.The study results demonstrated that athlete adolescents had lower levels of anxiety and depression and a higher quality of life compared to non-athlete adolescents.These findings are consistent with the studies conducted by Sheykhangafshe et al., Shahbazi et [21-25, 34, 35].
Several mechanisms have been suggested to explain the relationship between PA and mental health, including improvements in physical self-perception, self-confidence, and perceived competence that lead to enhanced self-esteem.In addition, organized sports may influence mental health and well-being through psychosocial mechanisms such as the restoration of athletic identity, social connections and support, and role models [37].
The majority of studies showed that those who performed PA on a regular basis with higher volume and frequency and kept the PA routines stable showed fewer symptoms of depression and anxiety [36].Some theories were suggested to define the positive effect of exercise on mental distress, such as depression and anxiety disorders.Among them, there are psychological theories such as mental distraction, self-efficacy, and social interaction, and biochemical theories such as serotonin and endorphin responses [25].
There was consistent evidence that those who could not keep their PA routine stable during the pandemic showed more depression and anxiety symptoms.Those reporting higher total time spent in moderate to vigorous PA had 12% to 32% lower chances of presenting depressive symptoms and 15-34% of presenting anxiety [36].
It is well known that the adequate presence of any appropriate type of PA (e.g., walking, jogging, cycling, swimming) has a positive physiological effect and reduces the risk of non-communicable diseases, such as cardiorespiratory disorders, type 2 diabetes, hypertension, as well as other  chronic diseases and comorbidities that can result in death.Appropriate physical exercise ensures the preservation of the immune system and the general improvement of health status, mental health, and quality of life.Strengthening the immune system through appropriate physical exercise can potentially reduce the spread of communicable viral infectious diseases.Increased physical activity level reduces neuroendocrine stress hormones, cortisol, and epinephrine.Such a deficit of stress hormones caused by appropriate PA is a possible factor in improving the unfavorable and disturbed psycho-physical condition [38].Another possible explanation is that exercise plays a role as an important buffer against stressful events and reduces emotional strain.
The psychosocial aspects of physical activity are also significant for disorders such as anxiety and depression and encompass experiencing feelings of self-efficacy and selfefficiency and getting rid of daily stressors.Accordingly, physically active people show fewer symptoms of anxiety and depression compared to their inactive counterparts [39].Consequently, one can say that active people have higher self-efficacy, which will lead to more success in facing the hardships and difficulties of life.Exercise helps people not to feel helpless and inability in the face of problems.People with high self-efficacy do not feel frustrated or anxious in difficult situations and they do not feel defeated in encountering problems and believe that they can successfully overcome the obstacles of life [35].
The results of the present study suggested that athlete adolescents have gained higher mean scores in all aspects of the quality of life of adolescents than compared to nonathlete adolescents.Male athlete adolescents also reported higher mean scores than others in all aspects of quality of life (mental and physical).
Overall, HRQoL seems to improve as students are included in higher PA levels [40].These results were in line with previous studies [40][41][42].Statistically significant differences in HRQoL are reported between students who do not engage in any kind of exercise/physical activity or do it irregularly and those who do it several times a week [40].Wu et al. [41].suggested that elevated levels of physical activity are associated with higher PedsQL, whereas a low level of PA and higher time spent in sedentary behavior are inversely related to health-related quality of life among children and adolescents.Masini et al. [42] showed that Children who spent more time partaking in moderate PA were associated with a higher total PedsQL score.
Since PA influences children's physical characteristics/ properties and has positive effects on well-being, their HRQoL increases too.In addition, PA benefits not only young people's fitness but also their cognition and mental processes n contrast, sedentary behaviors impair not only fitness and body composition but also lead to reduced selfesteem and depression.Increased screen-based activities promote sedentariness and are related to poorer mental health, which is directly linked to HRQoL [40].Physical activity stimulates the production of endorphins to enhance mood and act as natural pain relievers and reduces the level of stress hormones such as adrenaline and cortisol.Regular physical activity participation can also cause physiological adaptations in areas such as stroke volume, resting heart rate, blood pressure, and cardiac output, leading to improvements in cardiorespiratory and musculoskeletal performance that will promote individuals' HRQoL.Prolonged homestays could increase behaviors that lead to physical inactivity and contribute to stress.This, in turn, could lead to a sedentary lifestyle that may increase the risk of a range of chronic health conditions that adversely affect HRQoL.For example, the limitation of daily activity has been found to significantly impair HRQoL among SARs patients in Hong Kong [43].
The results also showed that as the number of training sessions increases during the week, the scores of physical activity and quality of life of athlete adolescents increase and their overall depression and anxiety scores decrease.
PA implemented with a low, moderate, and/or vigorous intensity is essential to encourage health promotion.Highintensity PA is related to greater physical fitness, bone health, and motor skills [40].Our findings are consistent with previous studies during the pandemic, suggesting that higher MVPA levels are associated with reduced depressive, and anxiety symptoms [44][45][46][47].In a study carried out in Italy, it was observed, subjects classified as highly active and moderately active showed a significant correlation between the change in total activity and the Psychological General Well-Being Index, which included life domains like anxiety and depression [14].Taken together the present findings suggest that participating in higher levels of physical activity during COVID-19 self-isolation is associated with better total mental health status.Several plausible mechanisms may explain the observed association between higher levels of physical activity and better reported mental health during the COVID-19 pandemic including increases in neurogenesis and reductions in inflammatory and oxidant markers, as well as improvements in self-esteem [46].
The results of the research showed that the quality of life score related to health is higher in athletic teenagers than inactive teenagers.
In connection with the amount of physical activity and quality of life, a previous study showed that physical activity levels can predict HRQoL in children, as well as that physial activity, is the main behavior in the prediction of the quality of life for a population of school adolescents.In this regard, previous studies showed that adolescents who had longer exposure and lower physical activity levels reported lower HRQoL.Moreover, previous studies have been focused on the impact of physical activity volume and intensity on the improvements in HRQoL.Regarding physical activity volume, previous studies found that the higher the physical activity level, the higher the HRQoL [48].This shows the importance of physical activity in improving the quality of life, especially during epidemics.
Although the athlete adolescents' scores change concerning the studied variables with the increased number of sessions and training duration, however, the levels of generalized anxiety, depression, and quality of life seem to be equal among athlete adolescents with different training sessions per week and have no significant differences.
However, the findings regarding the protective effect of PA against depression in terms of duration and intensity fluctuate and are inconsistent.Kim et al. [49] concluded that according to the risk-benefit ratio of PA, performing high PA levels has no positive effect on depressive symptoms.Larun et al. [50] concluded that exercise intensity had little impact on depression and anxiety scores in the general population of children and adolescents.
This finding is in accordance with previous studies showing that daily physical activity was associated with a lower risk of psychiatric distress, regardless of form and intensity [51].Zhang et al. [51] reported maintaining regular exercise was helpful to alleviate negative emotions, and 2500 METs of PA every week was the optimal load.A suitable amount to minimize negative emotions occurred when weekly physical activity was about 2500 METs, corresponding to 108 min of light, 80 min of moderate, or 45 min of vigorous physical activity every day.60 min of moderate-to-vigorous PA every day is recommended to maintain physical and psychological health [52].At least 4 h of MVPA reduces by 49% odds of depressive symptoms.
For more explanation of these results, numerous reviews have demonstrated the positive impact of PA on adolescent mental health, with some hypothesized mechanisms related to neurobiological, psychosocial, or behavioral factors [53].
As a result, under the COVID-19 pandemic conditions, athlete adolescents may have achieved the amount of physical activity needed for proper mental health with at least two moderate to severe training sessions, and thus, significant changes in the mental health and quality of life of athlete adolescents may not happen by increasing the number of training sessions.
The COVID-19 pandemic generated numerous challenges for public health, particularly the significant burden of mental health in the population.In addition, PA has been recognized as an effective mitigation strategy for improving mental health [54].Physical activity (PA) is a health resource.For instance, they have the potential to buffer the effect of stress and it has been shown that they are related to mental health and quality of life [55].Exercising regularly can improve physical health, life satisfaction, and psychological well-being.
In the event of an epidemic, opportunities should be provided for inactive and less active adolescents to participate in physical activity programs.Also, given that the majority of adolescents attend school, responsible organizations need to pay attention to online physical activity training.In addition, the grounds for further activities for adolescents should be provided in parks, sports clubs, and outdoors, while considering the conditions of this epidemic.

Table 5
One-Sample Kolmogorov-Smirnov Test