Changes in Health-Related Quality of Life and Physical Activity Among Older Adults in the First-Wave COVID-19 Outbreak: A Longitudinal Analysis
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Journal of Aging and Physical Activity, (Ahead of Print)
https://doi.org/10.1123/japa.2021-0104
© 2021 Human Kinetics, Inc. ORIGINAL RESEARCH
Changes in Health-Related Quality of Life and Physical Activity
Among Older Adults in the First-Wave COVID-19 Outbreak:
A Longitudinal Analysis
Rosiane Jesus do Nascimento, Valter Cordeiro Barbosa Filho, Cassiano Ricardo Rech,
Rafaela Batista Brasil, Renato Campos Junior, Inês Amanda Streit,
and Ewertton de Souza Bezerra
The current study aimed to follow the effects of social/physical distancing strategies on health-related daily physical activity and
quality of life among older adults during the COVID-19 pandemic. Seventy-two older adults who were enrolled in a University–
Community program in March 2020 (age = 66.8 ± 4.82 years, ♀59) answered five phone-based surveys up to 120 days after the
COVID-19 outbreak (from April to August 2020). The Short Form 6D and international physical activity (short version)
questionnaires were applied. A significant reduction was observed in daily physical activity levels, metabolic equivalent of task,
and health-related quality of life scores as well as an increase in sitting time during the week and on weekend days (all p < .01).
The authors noted differences in lifestyle conditions at the beginning of the social/physical distancing in the community assessed
(p < .01). Health vulnerabilities among older adults have been emphasized during the COVID-19 outbreak, impacting daily
physical activity and health-related quality of life.
Keywords: aging health, coronavirus disease, public policies
When the World Health Organization recognized the COVID- These rates are directly related to comorbidities such as heart
19 pandemic on March 11, 2020, one of the first actions to combat disease, diabetes, and obesity (SUSAM, 2020), and the relation
it was to involuntarily provoke the separation of people as the main seems to be a constant in other affected countries, as observed in a
agents of transmission (Guan et al., 2020). Some countries adopted recent meta-analysis (Borges do Nascimento et al., 2020).
a radical lockdown, whereas others, including Brazil, opted for Although these restrictions help to decrease the rate of infec-
social/physical distancing with restrictions on circulation, reduced tion, they can result in negative effects, limiting participation in
hours of trade, and increased care with personal hygiene and daily activities, especially for those who live in the community and
foodstuffs (Ministério da Saúde-Brasil, 2020). who are independent. Many individuals stopped attending (or
Notoriously, the virus presents idiopathic behavior with no should have attended) medical appointments, going to the phar-
pattern of magnitude of occurrence (van Doremalen et al., 2020). macy, bank, or market, and visiting public leisure spaces (Estima,
However, there are groups with a higher incidence (e.g., those with 2020) in addition to reducing their physical activity (PA) and
hypertension [Strabelli & Uip, 2020], diabetes [Hussain, Bhowmik, regular exercise (e.g., gyms, community programs that promote
& do Vale Moreira, 2020], pneumopathologies [Alonso et al., PA, and social groups, etc.) (Hossain, Sultana, & Purohit, 2020).
2020]) in addition to people over 60 years of age, who seem to A consequence that was not initially considered is that staying at
suffer the symptoms with greater intensity, increasing the relevance home for a long period may reduce the level of daily PA, especially
of compliance with these measures by groups at a higher risk from among individuals considered active (Schrempft, Jackowska, Hamer,
COVID-19. According to data from the Health Surveillance Foun- & Steptoe, 2019). In addition, this behavior appears to be different
between PA classifications; for example, during the COVID-19 first
dation of Amazonas (Amazonas, 2020), this group represented
wave, one Canadian study demonstrated that 40.5% of inactive
48.8% of hospitalizations and 73.8% of deaths compared with
individuals became less active, whereas only 22.4% of active in-
40.6% of hospitalizations and 25% of deaths in younger adults.
dividuals became less active (Lesser & Nienhuis, 2020). Regular PA,
mainly leisure activities and of moderate to vigorous intensity, is
Nascimento and Bezerra are with the Post-Graduate Program in Health Sciences, associated with a 1–40% lower risk of hip and all fractures (Cauley &
Faculdade de Medicina, Universidade Federal do Amazonas, Manaus, Brazil. Giangregorio, 2020), Furthermore, declining mobility and physical
Barbosa Filho is with the Federal Institute of Education, Science and Technology performance is associated with lower quality of life in sedentary older
of Ceara, Aracati, Brazil; and the Research Group for Physical Activity, Health and adults (Groessl et al., 2019). However, to our knowledge, no studies
School, Post-Graduate Program of Collective Health, Ceara State University, have evidenced the consequence of the sudden stop in regular PA on
Fortaleza, Brazil. Rech is with the Post-Graduate Program in Physical Education, older adults with different functional performance levels.
Centro de Desportos, Universidade Federal de Santa Catarina, Florianopolis, Brazil.
Therefore, the postpandemic consequences on public practices
Brasil and Bezerra are with the Human Performance Laboratory, Faculdade de
Educação Física e Fisioterapia, Universidade Federal do Amazonas, Manaus, Brazil.
and policies are based on the behaviors observed during the
Freire Junior and Streit are with the Post-Graduate Program in Human Movement pandemic, especially with regard to a reduced level of PA
Sciences, Faculdade de Educação Física e Fisioterapia, Universidade Federal do (Sallis, Adlakha, Oyeyemi, & Salvo, 2020). Thus, the objectives
Amazonas, Manaus, Brazil. Bezerra (ewertton_bezerra@ufam.edu.br) is corre- of the present study were: (a) to evaluate the impact of social/
sponding author. physical distancing on indicators of daily PA and quality of life in
12 Nascimento et al.
older adults and (b) to analyze whether the level of functional
performance at the beginning of the distancing directly influenced
the level of PA and quality of life of older adults during the social/
physical distancing. Thus, our hypothesis was that social/physical
distancing would negatively influence the level of PA and quality
of life of older adults. Furthermore, for the second objective, our
hypothesis was that older adults classified as having a higher
functional performance level could be more impacted by social/
physical distancing than those with a lower classification.
Materials and Methods
Participants
This study was performed in Manaus, Amazonas, Brazil, in 2020. At
the moment of the study, the city had a population of 2,219,580 and
was the seventh most populous city in Brazil. Manaus was one of the
cities most affected at the beginning of the pandemic in Brazil,
increasing from 175 to 5,081 cases in the first 30 days
(Amazonas, 2020). Two hundred and fifty-eight participants of an
institutional community program at the Federal University of Ama-
zonas were eligible to participate in this study. After the initial analysis
of exclusion criteria, only 133 older adults were contacted by
telephone of which 81 responded to the call and answered a version
of the Short Form 6D (SF-6D) questionnaire and International PA
Questionnaire (IPAQ). These questionnaires were repeated 30, 60,
and 120 days after the baseline (Figure 1). All participants signed the
consent form, and the study was approved by the Ethics and Research
Committee of the Federal University of Amazonas (CAAE:
30542020.2.0000.0008, number of the ethical report 3.985.520)
and was performed in accordance with the 1964 Helsinki Declaration
(2013: seventh revision, 64th meeting, Fortaleza, Brazil).
Study Design
A cohort study design was used to analyze behavior of quality of life
and PA level among older adults during the first wave of the COVID-
19 outbreak in Manaus. The study included a total of six steps, as
explained in Figure 2. In the first step, all participants of older adult
community programs at the Federal University of Amazonas were
assessed (functional physical performance and anthropometric mea- Figure 1 — Flowchart of participants in the cohort study.
surements), as usually performed at the start of each year. At this
moment, no provision for social distancing had been taken; however,
on April 15, a local decree (No. 42.193) instituted the state of public METs), and low PA (3.3 METs). The respondents were classified
calamity and social distancing for 180 days. We applied the baseline as meeting PA guidelines (i.e., reporting ≥150 min weekly of
telephone interview at the end of April, and subsequently, each 30 moderate to vigorous PA, ≥75 min weekly of vigorous PA, ≥600
days during May and June, we telephoned to perform a new interview. MET·min weekly) in three dose categories, low (0 toChanges in Health-Related During COVID-19 Outbreak 3
Figure 2 — Timeline of cohort study design and COVID-19 case notification (absolute numbers) during the first wave of the COVID-19 outbreak in
Manaus, Amazonas, Brazil. All decrees were issued by the state government of Amazonas. Note. IPAQ = International Physical Activity Questionnaire;
HRQoL = health-related quality of life index; AI = anthropometric index; DQ = social distancing questionnaire.
mental health, and vitality). Based on the selection of one item from the social distancing that is being guided by health authorities, that
each of the six dimensions or domains that make up the instrument, a is, staying at home and avoiding contact with other people, how
unique SF-6D score is given, ranging from 0 to 1, which represents an much do you think you are complying or have you managed to
individual’s preference for a given quality of life status on a scale comply?” options: “Very little,” “Little,” “More or less,” “Quite,”
where 0 equals the worst health status and 1 means the best health and “Practically isolated from everyone”; Question 3: “How was or
status. In this study, the Brazilian Portuguese version was applied has your activity routine been?” options: “Stay at home all the time,”
(Campolina, Bortoluzzo, Ferraz, & Ciconelli, 2011), and the analyses “Go out only for essentials, like buying food,” “Go out from time to
were carried out using the algorithm developed by (Cruz et al., 2011). time to shop and stretch your legs,” “Go out every day for some
activity,” and “Go out every day, all day, to work or another regular
activity”; Question 4: “Thinking about the home routine, who has
Social Distancing Questionnaire
access to your house?” options: “Only family members who live
To evaluate social distancing, some questions were added during the together, if any, and no one else,” “Some close relatives visit once or
final telephone interview (August). These referred to two specific twice a week,” “Some close relatives visit almost every day,”
moments of the cohort study (March and July). Question 1: “How “Friends, relatives, or others visit once or twice a week,” and
many people live with you?” option: free; Question 2: “Regarding “Friends, relatives, or others visit almost every day”; Question 5:
(Ahead of Print)4 Nascimento et al.
“During the isolation period, what do you think about your health?” Stats. Open. Now, Sydney, Australia; The Jamovi Project, 2020),
options: “Worsened,” “Neither improved nor worsened,” and and the graphs were constructed with Graph Pad Prism (version
“Improved”; Question 6: “Regarding your quality of life, would 6.0; San Diego, CA). Normality distribution testing was performed
you say that” options: “It is much worse than before the pandemic,” for all continuous variables using the Shapiro–Wilk test. Consid-
“It is worse than before the pandemic,” “It is the same as before the ering that the normality of the data was violated (except the waist-
pandemic,” “It is better than before the pandemic,” and “It is much to-hip ratio and body mass index), the nonparametric test for
better than before the pandemic”; Question 7: “Did you experience repeated measures (Friedman’s test) was used to verify the time
any of these symptoms during the quarantine period?” options: “No effect (April [baseline], May [30 days after baseline], June [60 days
symptoms,” “Fever,” “Chills,” “Headache,” “Muscle aches,” “Diz- after baseline], and August [120 days after baseline]) on the PA
ziness,” “Rhinitis (runny nose),” “Sore throat,” “Lack of taste and/or level (IPAQ-short version) and quality of life index (SF-6D) with
smell,” and “Shortness of breath”; Question 8: “Indicate whether pairwise comparisons (Durbin-Conover test; Pohlert, 2014). The
you performed any of these actions,” options: “None of them,” Mann–Whitney U test compared groups (HIGH vs. LOW) at each
“Have you been to the health center in the last 14 days,” “Have you time moment as well as the baseline comparison for sex. The social
been hospitalized for the past 14 days,” “Were you tested for distancing questionnaire was assessed using the chi-square test of
COVID-19,” and “Has someone who resides with you been diag- independence (χ2) with degree of association observed by the
nosed with COVID-19.” During the interview, the questions were Cramer’s V test. In addition, the absolute and expected frequency
given to each participant in randomized order. The first, seventh, and was analyzed following the adjusted standardized residue.
eighth questions were applied only for sample description. To calculate the sample size, a pilot study was performed
(sample = 80), and the results were input in the statistical software
G*Power (University of Düsseldorf, Dusseldorf, Germany). Given
Physical Functional Performance and
the study design (repeated measures), an a priori power analysis
Anthropometric Variables Before the COVID-19 was conducted with the following criteria: effect size 0.30, an alpha
Outbreak errorChanges in Health-Related During COVID-19 Outbreak 5
Table 1 Participant Characteristics of the Total Sample and by Sex at Baseline (Manaus, April 2020)
Variables Overall (n = 72) Women (n = 59) Men (n = 13)
Age (years) 67.2 (4.89) 66.51 (4.84) 68.31 (4.83)
Height (m) 1.56 (0.08) 1.53 (0.06) 1.67 (0.06)
Weight (kg) 70.20 (15.1) 67.7 (12.7) 81.70 (20.2)
Body mass index (kg/m2) 28.9 (4.99) 28.90 (4.8) 28.90 (6.00)
Waist-to-hip ratio 0.9 (0.07) 0.88 (0.06) 0.99 (0.06)
Physical functional performance
Handgrip strength (kgf)
Right 21.55 (7.38) 19.42 (4.97) 32.71 (8.03)
Left 19.79 (6.98) 18.01 (4.99) 29.1 (8.55)
Chair stand test (repetitions/30 s) 13.19 (2.67) 12.97 (2.76) 14.38 (1.75)
Arm curl test (repetitions/30 s) 16.46 (4.08) 16.05 (3.98) 18.61 (4.11)
Chair sit and reach test (cm) 2.5 (9.66) 2.94 (9.51) 0.76 (10.65)
Back scratch test (cm)
Right −7.7 (10.42) −6.54 (10.08) −13.76 (10.45)
Left −13 (10.70) −12.48 (10.55) −19.11 (10.08)
Timed up and go (s) 6.47 (1.47) 6.60 (1.53) 5.80 (0.83)
6-min walk test (m) 511.9 (70.18) 496.6 (61.32) 594.60 (57.54)
Note. Values are expressed as mean (SD).
Table 2 Timeline Changes: PA Indicators and Quality of Life Index (a) and IPAQ Level Activity Classification (b),
Manaus, n = 72, 2020; Friedman Test
Baseline After 30 days After 60 days After 120 days
Variables (April) (May) (June) (August) χ2 p
(a) PA indicators and quality of life index
Metabolic equivalent 798 (480–1,386) 480 (240–960)* 540 (248–930)* 797 (245–1,533)**,*** 18.26 Nascimento et al.
showed a decrease in total PA and quality of life and an increase in
sitting time during the week and on the weekend in older adults. In
addition, we noted an association between social behavior and local
government decrees in many lifestyle conditions of the assessed
population. Our second aim was to verify whether the level of initial
functional performance directly influenced the level of PA and quality
of life of the older adults during social distancing. The results did not
show any influence of physical functional performance index on daily
PA and quality of life in the older adults investigated.
Although there are no other studies with similar data, we believe
that reduced (hypokinetic) movement in older adults could lead to an
increase in osteodegenerative diseases (Peffers, Balaskas, &
Smagul, 2018), risk of stroke (Correia Nogueira et al., 2010),
and cardiac events (Batty, 2002). For some time, the IPAQ has
been a widely used tool to assess the level of daily PA in adolescents
(Mannocci et al., 2018), adults (Madeira et al., 2013), and older
adults (Dumith et al., 2019) and has been shown to have a high
relationship with regard to lifestyle and changes in lifestyle (Vernaza
Pinzón, Villaquiran-Hurtado, Paz-Peña, & Ledezma, 2017). In
particular, our results point to an 18.5% transition from active to
irregularly active in the initial 30 days of social distancing. This
condition only stabilized 120 days after the baseline. It is important
to highlight that this change in activity has a direct impact on the
reduction in energy expenditure (METs), which, in turn, can be an
indicator of positive energy balance, which has been shown to be a
potential marker of body fat gain (Dunton, Berrigan, Ballard-
Barbash, Graubard, & Atienza, 2009; Holliday et al., 2018;
Vatier et al., 2012). Increased body fat, especially abdominal fat,
Figure 3 — Behavior of the older people during the four initial months
of the first-wave outbreak of COVID-19 in Manaus, Amazonas, Brazil, triggers metabolic problems, such as dyslipidemia (Moreno &
2020. (a) IPAQ qualitative classification and (b) MET. Note. Low, Casanueva, 2007) and diabetes (Dewan & Wilding, 2003), in the
medium, and high number of METs expended in 1 week (for more medium and long term in this population.
details read IPAQ section). IPAQ = International Physical Activity Another important point to be considered is the increase in
Questionnaire; METs = metabolic equivalents of task; PA = physical sitting time either during the week (51%) or on the weekend (43%).
activity. Values observed in the initial 30 days persisted until June and
returned to initial levels only in August. It is worth mentioning that
long periods of sitting are associated with increased overload in the
open to receiving close relatives to visit once or twice a week
lower back (Beach et al. 2005) and, subsequently, with the
(44.4%) or almost every day in March (25.9%) compared with
appearance of low back pain (Kastelic, Voglar, & Šarabon,
28.4% and 7.4% for the same condition, respectively, χ2(2) =
2018). All the aforementioned elements may have a direct connec-
65.30; p < .001, Question 4. When asked about their health condi-
tion with the drop in the SF-6D score, an important indicator of
tion (Question 5), 35.8% declared “worsened” in March (beginning
quality of life (Ferreira, Ferreira, Pereira, Rowen, & Brazier, 2013),
of social distancing) compared with 8.6% in July (flexibility in
which in many countries, is also used as an indicator of change in
social distancing), χ2(2) = 36.84; p < .001. On the other hand,
economic profile (Busija et al., 2011; García-Gordillo et al., 2015;
quality of life did not show an association between social behavior
and local government decrees, χ2(2) = 4.61; p = .202, Question 5. Zhao et al., 2019). The reduction in the SF-6D in our study
Questions 1, 7, and 8 present only descriptive data. occurred during the longest period of social distancing imposed
by local authorities, April to June.
Self-perception of the relationship between the official mea-
Physical Functional Performance Index sures for social distancing and their consequences on lifestyle was
Comparison indicated through a recall questionnaire estimating the months of
March and July. The results pointed out that initially people stayed
Our secondary analysis did not demonstrate an influence of
at home more without receiving visits (only from close relatives,
physical functional performance index (for more details, see
maximum twice a week), that their perceived health was worse,
subject section) between HIGH and LOW groups for metabolic
although this did not reflect in worsening quality of life, and that all
equivalent, quality of life (SF-6D), and sitting time in the week and
these points improved in July (month with greater flexibility). In
on the weekend (in minutes) with p > .05; Supplementary Figure
Brazil, a study conducted in the state of Rio Grande do Sul (Estima,
S1a-S1d, respectively (available online).
2020) pointed out that 19% of respondents were older adults, and of
these, 40% and 42% were totally or almost totally isolated,
Discussion respectively. The majority of these made only essential outings
(48%), although many also reported staying at home isolated
To our knowledge, this is the first prospective study carried out in a (34.7%). A large number had greater contact with family living
developing country to assess the impact of the COVID-19 pandemic in the same place (49.5%), and far fewer had visits from people
on changes in PA and quality of life in older adults. Our main findings outside the home (33.5%). These results corroborate with our
(Ahead of Print)Changes in Health-Related During COVID-19 Outbreak 7
findings. It can be further highlighted that only 2.5% of the sample Beach, T.A.C., Parkinson, R.J., Stothart, J.P., & Ciconelli, R.M. (2005).
in our study had a diagnosis of COVID-19. Effects of prolonged sitting on the passive flexion stiffness of the in vivo
Some limiting points and strengths should be considered. The lumbar spine. Spine J, 5, 145–154.
study sample cannot be considered to generalize behavior in the city Borges do Nascimento, I.J., Cacic, N., Abdulazeem, H.M., von Groote,
of Manaus. In addition, there were losses in the collection process, T.C., Jayarajah, U., Weerasekara, I., : : : Marcolino, M.S. (2020).
from the predicted respondents to those who participated in the final Novel coronavirus infection (COVID-19) in humans: A scoping
phase, and the application of telephone surveys can generate points of review and meta-analysis. Journal of Clinical Medicine, 9, 941.
confusion for the respondent, which can generate bias in the response; doi:10.3390/jcm9040941
furthermore, another limitation of our study is the subjective nature of Busija, L., Pausenberger, E., Haines, T.P., Haymes, S., Buchbinder, R., &
the questionnaires used. On the other hand, our study has some strong Osborne, R.H. (2011). Adult measures of general health and health-
points that deserve to be highlighted. We applied repeated measures related quality of life: Medical Outcomes Study Short Form 36-Item
analysis and provided data on behavior during the first wave of the (SF-36) and Short Form 12-Item (SF-12) Health Surveys, Notting-
COVID-19 outbreak. Another positive point was that the sample ham Health Profile (NHP), Sickness Impact Profile (SIP), Medical
consisted of older people who practiced PA, and currently, Manaus Outcomes Study Short Form 6D (SF-6D), Health Utilities Index Mark
has many community projects for older adults with similar profiles. 3 (HUI3), Quality of Well-Being Scale (QWB), and Assessment of
Quality of Life (AQOL). Arthritis Care Research, 63(1), S383–S412.
doi:10.1002/acr.20541
Conclusion Campolina, A.G., Bortoluzzo, A.B., Ferraz, M.B., & Ciconelli, R.M. (2011).
The results of this study suggest that the adoption of social Validação da versão brasileira do questionário genérico de qualidade de
distancing measures to control the COVID-19 pandemic had an vida short-form 6 dimensions (SF-6D Brasil). Ciência e Saúde Coletiva,
impact on the quality of life and level of PA of the participants. This 16, 3103–3110. doi:10.1590/s1413-81232011000800010
could indicate that although in the short term, such a measure may Cauley, J.A., & Giangregorio, L. (2020). Physical activity and skeletal
be effective, in the medium and long term, the reduction in these health in adults. Lancet Diabetes and Endocrinology, 8(2), 150–162.
two indicators can trigger more lasting systemic problems. In view doi:10.1016/S2213-8587(19)30351-1
of this, a broader action plan may be important, which, when social Correia Nogueira, I., Maria De Sousa, Z., Santos, A., Gardano, D., Mont´
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Acknowledgments M.P., : : : Polanczyk, C.A. (2011). Estimating the SF-6D value set for
a population-based sample of Brazilians. Value in Health, 14(5),
This work was supported in part by the Conselho Nacional de Desenvol-
S108–S114. doi:10.1016/j.jval.2011.05.012
vimento Científico e Tecnológico (grant number 001) and Coordenação de
Dewan, S., & Wilding, J.P.H. (2003). Obesity and type-2 diabetes in the
Aperfeiçoamento de Pessoal de Nível Superior. This work was carried out
elderly. Gerontology, 49(3), 137–145. PubMed ID: 12679603 doi:10.
under the research program Ciências da Saúde of Universidade Federal do
1159/000069176
Amazonas. All procedures performed involving human participants were
Dumith, S.C., Maciel, F.V., Borchardt, J.L., Alam, V.S., Silveira, F.C., &
in accordance with the ethical standards of the institutional and/or national
Paulitsch, R.G. (2019). Preditores e condições de saúde associados à
research committee and with the 1964 Helsinki Declaration (2013: Seventh
prática de atividade física moderada e vigorosa em adultos e idosos no
revision, 64th Meeting, Fortaleza, Brazil) and its later amendments or
sul do Brasil. Review of Brasileiros Epidemiology, 22, e190023.
comparable ethical standards, Research Committee of the Universidade
doi:10.1590/1980-549720190023
Federal do Amazonas (CAAE: 30542020.2.0000.0008, number of the
Dunton, G.F., Berrigan, D., Ballard-Barbash, R., Graubard, B., & Atienza,
ethical report 3.985.520). Informed consent was obtained from all indi-
A.A. (2009). Joint associations of physical activity and sedentary
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