Reviews

Effects of the COVID-19 Pandemic on Physical Activity in Children: A Systematic Review

Alex Ramirez¹, Ashley B. Rapp², Sara Santarossa³

doi: http://dx.doi.org/ijms.2024.1716

Volume 12, Number 3: 311-333
Received 22 09 2022; Rev-request 08 02 2023; Rev-recd 09 02 2023; Accepted 11 06 2023

ABSTRACT

Background:

Extended lockdowns established to minimize the spread of COVID-19, may have affected physical activity (PA). The objective of this systematic review is to report how PA of children was impacted by the COVID-19 pandemic.

Methods:

A database search of CINAHOL, Embase, MEDLINE, PsycInfo, and Web of Science was conducted on 03/29/2021 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Studies were included if they reported a measure of PA for children ≤18 years and were published in English in a peer-reviewed journal. The search generated 673 unique citations. After applying the criteria above, 69 articles were included. The quality of the included articles was assessed using the NIH NHLBI Study Quality Assessment Toolbox.

Results:

Unstructured play, walking, and virtual PA (e.g., YouTube, online classes) were the most frequently reported modes of PA during the COVID-19 pandemic. The PA of children decreased among 89% of articles that reported changes in PA (e.g., frequency, intensity, duration, or the percentage of children who met PA recommendations) of children during the COVID-19 pandemic. Increased PA was reported more often among younger children, boys, children who lived with other children, and children with more outdoor space.

Conclusion:

Globally, PA of children decreased during the COVID-19 pandemic. Further work is needed to develop policies to support global PA increases. Limitations of this review include the use of online surveys which are limited by participants ability to recall PA behaviors and access to online resources.

Introduction

The COVID-19 pandemic (the pandemic) and its effects rapidly permeated the globe with over 100 million cases by February 1^st, 2020.¹ By March 2020, many governments issued stay-at home orders, shelter-in-place orders, lockdowns, and various social-distancing guidelines to mitigate the spread of COVID-19.² These restrictions, including the closure of schools, parks, and organized sports, may have altered movement behaviors, including physical activity (PA).^3,4 PA in children encompasses a variety of modes (e.g., exercise, sports, and active play).⁵ It has been defined as any body movement that increases energy expenditure and can be characterized by the components of the FITT principle: frequency, intensity, time (e.g., duration), and type.⁶ The WHO recommends children (ages 5–17) engage in ≥60 min/day of moderate-to-vigorous (MVPA) intensity PA⁷ where 3 days/week include vigorous-intensity aerobic activities, muscle-strengthening and bone-strengthening activities.⁸ As a critical component of child development, PA has substantial long-term health benefits including the prevention of chronic health conditions.^9,10 Conversely, insufficient PA in children can increase the risk of developing cancer, heart disease, obesity, and type 2 diabetes.¹¹ Despite the known benefits of PA on health, global levels of PA were insufficient in 4 out of 5 children prior to the pandemic.¹² Thus, the prolonged stay-at-home orders brought on by the pandemic may have exacerbated the proportion of children with insufficient PA, as previous studies have shown that children have less PA when they are outside of school (e.g., holidays, summer, weekends).^13,14 Although children seem to have a lower risk of contracting COVID-19,^15,16 the physical health burden of the pandemic and the resulting restrictions are of increasing interest.^1,17,18

Previous studies have demonstrated that childhood health behaviors, including PA, are likely to persist through adulthood and can impact lifetime health.^19,20 It is important to monitor PA changes in children to reduce the risk of developing long-term health consequences associated with inadequate PA (e.g., cardiovascular disease, type 2 diabetes, obesity).^21,22 Not only can PA prevent many chronic diseases,²³ but it can also have acute health benefits such as boosting the immune system.^24,25 A recent study in adults infected with COVID-19 found reduced risk of critical outcomes in individuals who routinely adhered to PA recommendations.²⁶ Although this relationship has not yet been established in children, several studies have found obesity to be the most prevalent characteristic in children infected with COVID-19.^27,28 The disruption of PA in children may increase the prevalence of childhood obesity and other comorbidities which could, in turn, increase the risk of infection and subsequent severity in outcomes from COVID-19.^15,29

As childhood is a critical period of development, understanding the implications of the pandemic on health behaviors is important and there is a need to highlight potential adverse effects that may need to be actively monitored and remediated as COVID-19 restrictions lift and vaccines are distributed. Identifying changes in PA (FITT principle) of children is important for understanding the extent to which the pandemic impacted the already low levels of global PA among children. In addition, recognizing the biological, social, and environmental factors that affected changes in PA is critical for the development of effective programs to prevent short- and long-term health consequences. To the authors' knowledge, this is the first review to synthesize the literature at the time of the data search regarding the global impact of the pandemic on the duration and types of PA children participated in and what biological, social, and environmental factors contributed to those changes. The goal of this review was to synthesize the global impact of the pandemic on PA of children by addressing the following questions:

• What types of PA did children participate?
• To what extent did PA (e.g., duration of PA, percentage of children meeting PA recommendations) of children change?
• What biological, social, and environmental factors affected changes in PA of children?

Methods

This review was conducted using the PRISMA guidelines.³⁰ The selection process for the included articles is summarized in Figure 1.

Figure 1.

Article Selection Diagram Using PRISMA.

Search Strategy

Two research librarians independently searched MEDLINE, Embase, PsycInfo, CINAHOL, and Web of Science on 03/29/2021. The searches were limited to the English language, COVID-19, and 2020-current (03/29/2021). The key words used in the search strategy included various combinations of terms such as: “physical activity,” “exercise,” “activity level,” or “sports” AND “child,” “adolescent,” “girl,” “boy,” or “youth” AND “covid-19,” “severe acute respiratory syndrome coronavirus 2” or “'sars-cov-2”. Following their independent searches, the librarians compared results and removed duplicates.

Article Inclusion and Exclusion Criteria

Included studies were those that were published in English in a peer-reviewed journal, measured PA during the pandemic, and encompassed PA data for children ≤18 years. Articles were excluded if they did not present original empirical findings, if they described the development of a tool or measure, or if they were inaccessible to the authors (e.g., no free full-text download was available).

Article Selection

After the librarians eliminated duplicate articles, 673 articles remained. The following article selection process was conducted in 4 steps. First, 2 authors conducted an independent abstract review to determine whether each article should be included or not based on the inclusion and exclusion criteria. Second, the 2 authors discussed any articles they disagreed on until consensus. Following this discussion, 572 articles were excluded because they had a study population outside the context of the current review, meaning that PA data presented in the findings were not specified for participants ≤18 years old. Third, the full text of the remaining 101 articles was reviewed to ensure the articles were within the scope. The data extracted included authors, year of publication, sample source (e.g., the country the sample was gathered from), sample size, sample age range, PA measure, main findings, and factors (e.g., biological, social, and environment) related to PA and are outlined in Table 1. Ultimately, 32 of these articles were excluded because they met ≥1 exclusion criteria. In the fourth step, all authors met to confirm the final 69 articles should be included. The data from the 69 articles was synthesized into a table adapted from a review paper of a similar topic Table 1. ³¹

Quality Assessment

The quality of the included articles was assessed using the NIH NHLBI Study Quality Assessment Toolbox.³² This quality assessment tool describes a “good” study as one with a low risk of bias and a “fair” study as one with some bias.³²

Results

General Characteristics

General characteristics of the included articles are shown in Table 2. Most articles included participants in Europe (n=34),^33–66 North America (n=13), ^67–79 or South America (n=6).^49,58,80-83 The distribution of countries represented by the articles in this review are depicted in a heat map in Figure 2.

Figure 2.

Sample Source (Countries) of Included Articles.

The sample sizes ranged from 9 children⁷⁶-16177 parents.⁸⁴ Most articles (n=32) ^{33–35,38–41,43,47,48,50,51,76,60,62,63,67,70,71,74,75,81,82,85–93} had a sample size between 100–1000, but 2 articles had a sample size >10000.^77,84 As the present study is focused on children, most of the articles are inclusive of age groups between 0–18 years. However, 5 articles included participants d19 years because the articles specified their sample as either adolescents (n=4)^58,76,77,89 or school-aged youth (n=1).⁷⁴ Because adolescents are defined by the WHO as individuals 10–19 years old,⁹⁴ these articles were included despite the exclusion criteria of ≤18 years. One article did not specify the age of participants,⁷⁸ however, specified participants were in grades 3–12, and was ultimately included.

Most participants were children without chronic health conditions, but some articles focused on characterizing PA during the pandemic for children with various health conditions (e.g., autism spectrum disorder, congenital heart disease, chronic respiratory disorders, obesity, type 1 diabetes, attention-deficit/hyperactivity disorder; n=11).^{52,54,56,63,66,70,76,85,88,92,95} Some articles examined PA during the pandemic only (n=13), ^{35,45,55,57,61,68,69,77,82,86,91,93,96} while others compared PA from before to during the pandemic (n=56).^{33,34,36–44,46–54,56,58–60,62–67,70–76,78–81,83–85,87–90,92,95,97–102}

PA data was reported by either the child (n=28),^{38–41,43,48,52,56,58–62,64,68,74,76,77,80,86,89,91,96,97,99–102} the parent or guardian (n=32),^{34,35,37,42,44,47,49–51,53–55,63,66,67,69,71–73,75,79,81–85,87,88,90,92,95,98} a different secondary subjective individual such as a school administrator (n=1),⁷⁸ or a combination of these groups (n=5).^{36,45,57,65,93} Based on the NIH NHLBI Study Quality Assessment Toolbox,³² 50 articles received a rating of “good,” while 19 articles received a rating of “fair” Table 1.

PA Measures

PA measures used in the included articles are depicted in Table 2. Online surveys were predominantly used to collect PA data. Common PA questionnaires included the International Physical Activity Questionnaire (IPAQ, short or long form; n=8)^{58,63,64,67,80,96,100,102} and the Physical Activity Questionnaire for Adolescents (PAQ-A; n=5)^38–41,101 or for children (PAQ-C; n=2).^44,45 The PAQ-A designates a physical activity level (PAL) based off a scale of 1–5: 1 designating no activity or a low activity level and 5 designating a high activity level. A PAL score below 2.73 suggests an insufficient PAL and a score above 2.73 suggests a sufficient PAL. A few surveys took place in-person (n=2)^43,66 or over the phone (n=4).^37,54,56,95 Seven studies used objective measures to collect PA data, including the use of a Fitbit,⁷⁰ accelerometer,^33,37,48,62 smartphone sensors (e.g., pedometer),⁸⁹ or a 20-meter shuttle run test to measure VO2 max.⁴⁶ The most prevalent FITT principle collected to determine PA was time (e.g., duration of PA; n=46),^{33,36,42,45,47,48,50,52–68,71–73,75,76,80–84,86,87,89–93,96–100} followed by frequency (n=30),^{38,39,43–45,49,51,52,59,60,63–65,68,69,71,73,74,76,77,79–81,84,90–92,96,102} type of exercise (n=30),^{36,38,39,43–45,51,59,60,62,63,68,71–73,75,77–79,84,89–92,95–98,100,102} and intensity (n=25).^{33,36,45,48,52,53,59,62–64,67,68,71–74,79,80,84,91,96,97,99,100,102}

Types of PA

Among the articles included, there were conflicting results concerning the effects of the pandemic on the types of PA in which children participated. Five articles reported that outdoor PA declined during the pandemic,^{71–73,95,98} while 3 studies reported that outdoor PA increased.^37,51,90 The types of outdoor PA included activities such as walking, biking, outdoor play, playing at parks or other public spaces, and sports. Eight studies reported that many children (e.g., 82%)⁸⁴ were active at home.^{60,61,63,71,75,84,90,95} Some studies reported the use of online platforms such as streaming services (e.g., YouTube), virtual classes (e.g., yoga),^45,75 or other virtual PA forms⁷⁹ to accumulate PA during the pandemic.^78,91 In a US study, the most common forms of PA during the pandemic were unstructured play (90%) and walking (55%).⁷⁵ In contrast, a Chinese study reported the most common form of PA changed from outdoor activities (e.g., cycling) to indoor activities (e.g., rope skipping).⁹⁵

Extent to Which PA Changed During the Pandemic

Several studies (n=10) reported most children obtained <30 min/day or <3 hrs/week of PA,^{33,35,42,47,56,61,66,68,96,99} with 2 reporting most children participated in PA 0 days/week.^35,68.⁹⁹ Of the 12 articles ^{37,45,49,50,53,57,62,64,69,73,91,99} that reported the percentage of children meeting PA guidelines (i.e., 60 MVPA min/day), 1 article reported <10%,⁹¹ 9 articles reported 10–30%,^{45,49,53,57,62,64,69,73,99} and 2 articles reported >50% ^37,50 of children met PA recommendations during the pandemic. All articles that utilized the PAQ-A to assess PA (n=5),^38–41,101 reported a significant decrease in PAL.

Of the articles that compared PA before the pandemic to during the pandemic (n=56),^{33,34,36–44,46–54,56,58–60,62–67,70–76,78–81,83–85,87–90,92,95,97–102} 89% reported a decrease in PA (i.e., frequency, intensity, type/duration, type) of children. Among these articles, the proportion of participants that reported a decrease in PA behaviors during the pandemic ranged from 42%⁴³–95%.⁴⁸ One study reported that although the total minutes of PA/week did not significantly change, the duration and frequency of organized PA decreased, while unstructured PA and outdoor play increased.⁹⁰

Similarly, another study found 80.4% of high school students reported their MVPA stayed the same at 1.5 hrs/week.¹⁰⁰ Two studies ^37,59 reported an increase in PA (e.g., duration, frequency of meeting PA recommendations/week) of children (n=4), 1 of which reported a specific increase in outdoor time compared to before the pandemic.³⁷ One study reported 90.3% of preschoolers (3–5 years old) met PA guidelines of ≤180 minutes of PA/day, with 60 minutes of MVPA/day.³⁷ The articles that reported PA (e.g., duration, frequency of meeting PA recommendations per week) increased during the pandemic had samples from Sweden,³⁷ Canada,⁷¹ and Germany.^59,65

Conversely, four studies from Canada,^67,70,72,73 four studies from Australia,^84,88,89,92 and one study from Germany⁴³ reported PA (e.g., frequency, intensity, daily steps, meeting PA recommendations) decreased. For studies that included children with pre-existing health conditions (n=11),^{52,54,56,63,66,70,76,85,88,92,95} PA (e.g., daily steps, duration, frequency) decreased compared to before the pandemic. For example, among children with obesity in Italy, sports participation decreased by 2.30±4.60 hrs/week (p=0.003).⁵⁴

Biological, Environmental, and Social Factors Affecting PA

Common trends were evident among the studies of this review that related factors such as gender, age, and the environment outside as well as inside the home to the PA of children during the pandemic. In general, boys had higher levels of PA (e.g., more minutes of PA/day or more likely to meet PA recommendations) than girls. A study in Tunisia found that total PA (score from the Ricci and Gagnon sedentary behavior questionnaire based on duration and intensity of PA) decreased by 17% and 7% among girls and boys, respectively. ⁹⁷ Older children tended to have greater reductions in time/duration of PA compared to younger children. For example, in 2 Spanish studies, PA decreased an average of 43.3 min/day among preschoolers aged 4–6 years old,³³ while PA decreased an average of 91±55 min/day among older children aged 8–16 years old.⁴⁸

There were mixed results for PA of children and parents' socioeconomic status (e.g., lower levels of PA were reported almost equally for both high and low parental income and education). Children who lived in a rural areas ⁸³ or had more outdoor space to play ^36,48,55,82 had lower reductions in PA (e.g., duration, less likely to report decreased PA, greater percentage of day spent participating in PA). For example, children with access to an outdoor area at home had a 1.4±0.1 hrs/day reduction in PA compared to a 1.7±0.1 hrs/day reduction in children without access (p<.01).⁴⁸ In contrast, children who lived in a high-density neighborhood ⁷² or urban area^36,41 had greater reductions in PA (e.g., more likely to report decreased PA, less likely to meet PA recommendations, greater reduction in PAL). Children who lived in an apartment had lower levels of PA (e.g., decrease in duration of PA or less likely to meet PA recommendations) compared to children who lived in a house.^72,83

The environment inside the home also seemed to affect PA of children during the pandemic. One study reported that children who lived in a home with more people had greater reductions in duration of PA,⁸³ while 3 studies reported children who lived in multi-child households (e.g., with siblings) participated in more PA (e.g., greater duration or greater percentage of day spent participating in PA)^55,83 or more frequent outdoor play.^51,72 Children who had less family conflict, more parental support, and more family engagement in PA had greater durations of PA.^53,73,76 However, children who had more conflict with their parents or who had parents with higher stress levels had less PA (e.g., shorter duration of PA or less likely to achieve a sufficient PAL).^38,53

Discussion

The present study aimed to address the types of PA children participated in, the extent to which PA (e.g., frequency, intensity, duration, and type) changed, and factors affecting PA during the pandemic. Schools, active transportation (e.g., walking to and from school), afterschool programs, and sport programs were predominant sources of MVPA prior to the pandemic.^103,104 The stay-at-home orders and social distancing policies put in place to mitigate the spread of COVID-19 restricted the ability of children to obtain PA through these previously popular sources. While the studies in this review revealed walking, outdoor activity, and activity at home were types of PA children engaged in during the pandemic, a study before the pandemic found that children were less likely to participate in routine PA (e.g., going to the gym, walking) compared to unstructured play.⁵ Social distancing restrictions could have contributed to shorter durations of PA and overall decreased participation, despite walking becoming a common source of PA during the pandemic.⁷⁵ In addition, some studies reported many children were active at home (e.g., indoors or not at a park/public space).^{60,61,63,71,75,84,90,95} Studies conducted prior to the pandemic found that indoor PA (e.g., at home, at school) tends to be a greater source of lighter intensity PA,¹⁰³ which could help to explain the reduction in children able to meet MVPA recommendations during the pandemic.

The results of this review suggested that while there was heterogeneity in the extent to which the pandemic affected PA (e.g., frequency, intensity, duration, and type) in children, overall, there was a decrease in PA of children globally. Although the impact of the pandemic on PA of children is still evolving, trends before the pandemic have shown that children tend to have lower levels of PA when they are not in school.^13,14 Studies that investigated changes in MVPA during time out of school (e.g., weekends or a 3-week school break) found that MVPA decreased by 10–14 minutes compared to week days during the school year.^13,105 In contrast, the reductions in PA presented by the studies in this review ranged from 32–91 min/day.^{33,48,54,83,99} These results revealed that the decreases in time/duration of PA during the pandemic may have been greater than those typically observed during days when children are not in school. Prior to the pandemic, global PA levels of children were already low, with 81% of children insufficiently physically active.¹² Of the studies that reported a decrease in PA during the pandemic, the percentage of children who did not meet PA recommendations ranged from 80%–99.7%.^{45,49,62,69,73,91} This suggests that global levels of PA in children may have worsened during the pandemic.

The results of the current study indicate that during the pandemic, boys, and younger children tended to have higher levels of PA (e.g., more likely to meet PA recommendations), which is consistent with PA trends that existed prior to the pandemic.^{104,106–109} Previous studies have found that self-efficacy is an important predictor of PA.^108,110 Not only are girls less likely to participate in PA,¹¹¹ but they also tend to have a lower perceived ability to overcome PA barriers.¹¹² The social cognitive theory suggests that self-efficacy moderates the relationship between the social and physical environment and changes in PA, such that individuals with a high self-efficacy for overcoming PA barriers should be more likely to participate PA despite changes in the environment.¹¹³ With the changes in the social and physical environment surrounding children during the pandemic, self-efficacy for overcoming PA barriers may have played a role in the observed changes in PA. Similarly, lower levels of self-efficacy in girls may also be due to lower levels of social support to participate in PA compared to boys.¹¹¹

The relationship between self-efficacy, social support, and PA may also apply to age-related changes in PA. Several studies prior to the pandemic reported that children and adolescents with higher levels of peer and family support had higher levels of PA (e.g., frequency, more likely to meet PA recommendations).^5,114–116 For example, one study found that adolescents with higher parental support were 40% more likely to achieve sufficient PA (60 minutes of MVPA/day).¹¹⁵ While it has been established that PA (e.g., proportion of children meeting PA recommendations) decreases with age,^117–120 1 such study reported that adolescents with greater self-efficacy had lower age-related reductions in PA.¹¹⁸ The benefits of social support on child PA behaviors could have been especially critical in providing additional support to children navigating barriers to PA during the pandemic. In addition, a past study also found that older girls prefer to do PA at school or in a community setting than at home and participate in team sports.¹²¹

The changes in PA behaviors during the pandemic were likely due to the intersectionality of many social factors that resulted in decreased PA (e.g., frequency, intensity, duration), especially among girls and older children. Greater participation in PA among children with greater social support could also explain why children living in multi-child home had higher levels of PA (e.g., frequency, duration) during the pandemic. Studies before the pandemic have shown that children with siblings or other children to play with participated in more spontaneous and unstructured play.^122–124 More children inside the home may have been a protective factor for PA in children during the pandemic, as it could have offered greater opportunities and incitement to participate in PA.

The studies in this review suggested that during the pandemic, children in rural areas had lower reductions in PA (e.g., duration) compared to children in urban areas. While some studies before the pandemic have shown MVPA of children was higher in environments with less urbanization,^125,126 one study suggested that children in suburban or rural areas have less PA.¹¹⁰ The inconclusive relationship between rurality and PA in children could be due to the lack of a global definition of rurality and different distributions of built environments that are conducive to PA in different countries. A study of low- and medium-income countries in Africa found that urban development led to changes in the environment that were less favorable for outdoor PA.¹²⁷ While outdoor time has been shown to be positively related to PA,^128–130 rural environments do not guarantee higher levels of outdoor time. Instead, rural environments may also create barriers to PA such as limited quantity of and access to resources that promote PA, such as playgrounds, parks, trails, and other recreational areas. Another study found that differences in MVPA between children in rural and non-rural areas of the U.S. were mediated by differences in neighborhood resources.¹³¹ Rather than comparing PA levels by rurality, more general characteristics of the PA environment such as quantity of and accessibility to community recreational areas, neighborhood safety, traffic levels, and walkability may be more helpful in identifying global factors that affected PA in children during the pandemic.

In conclusion, the purpose of the present review was to synthesize the global impact of the pandemic on PA of children. This review adds to the current body of literature on the effects of the pandemic on PA by specifying changes in the frequency, intensity, duration, and type of PA performed by children, as well as the proportion of children who met PA recommendations. The greatest strength of this systematic review is the range of PA data presented for a wide geographic distribution. Information about different changes in PA (e.g., frequency, intensity, duration, type), as well as characterizations of PA during the pandemic may help to create a succinct picture of the impact of the pandemic on PA in children. A limitation of the systematic review process is some relevant studies may have been missed in the database search due to database selection and exclusion of studies not published in English. In addition, the use of online surveys, the most frequent data-collecting method used in the included studies, is an important limitation of this review, as surveys can only report subjective measures of PA. Furthermore, studies that asked participants to recall PA behaviors prior to the pandemic could be inaccurate. Moreover, online surveys may not have been accessible to individuals of low socioeconomic status who may not have access to the internet. Limited representation of individuals of low socioeconomic status could, therefore, affect the generalizability of the results of this review.

While many PA trends that existed prior to the pandemic persisted, the further reductions in already low global PA levels among children is worrisome. As the world reopens and vaccines are distributed, it is important to determine whether these PA trends will persist and for how long. Following a natural disaster in East Japan in 2011, significantly decreased child PA levels persisted more than 3 years later.¹³² Consistently insufficient levels of PA in children around the world may have detrimental effects on overall population health. The results of this review may be helpful in identifying barriers and facilitators to PA in children during the pandemic to determine what policies and programs would be most effective at increasing PA of children after the pandemic and beyond.

Summary – Accelerating Translation

The goal of “Effects of the COVID-19 Pandemic on Physical Activity in Children: A Systematic Review” was to synthesize the global impact of the COVID-19 pandemic on physical activity of children. Identifying changes in physical activity of children is important for understanding the extent to which the pandemic has affected already low levels of global physical activity among children. In addition, recognizing the biological, social, and environmental factors that affected changes in physical activity is critical for the development of effective programs to prevent short- and long-term health consequences. To the authors' knowledge, this is the first review to summarize the literature at the time of the data search regarding the global impact of the pandemic on the duration and types of physical activity children participated in and what biological, social, and environmental factors contributed to those changes. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were used to conduct a database search on 03/29/2021. Included studies were peer-reviewed, in English language, and included both a measure of physical activity during the COVID-19 pandemic and physical activity data for children aged 18 and younger. The search yielded 673 unique citations and, ultimately, 69 articles were included in the review. The results of the study found that during the COVID-19 pandemic, frequently reported physical activity included walking, unstructured play, and virtual physical activity through online platforms. Of the articles that reported changes in physical activity of children during the COVID-19 pandemic, 89% reported physical activity (e.g., frequency, intensity, duration, or the percentage of children who met physical activity recommendations) of children decreased. Boys, younger children, children who lived with other children, and children with more outdoor play space had higher levels of physical activity. From these results, it was concluded that the COVID-19 pandemic resulted in decreased physical activity among children around the world. The results of this review may be helpful in identifying barriers and facilitators to physical activity in children during the COVID-19 pandemic. Future work in policy and program development is needed to target physical activity of children beyond the COVID-19 pandemic.

Acknowledgments

The authors acknowledge Brianna Andre and Steven Moore from the Sladen Library at Henry Ford Hospital for their assistance with the literature search. The authors acknowledge Abigail C. Radomsky, a 4^th year medical student from Wayne State University School of Medicine, for her assistance with abstract review and article selection.

Conflict of Interest Statement & Funding

The Authors have no funding, financial relationships or conflicts of interest to disclose.

Author Contributions

Conceptualization, A.R.; Investigation, A.R., A.C.R.; Writing – Original Draft, A.R.; Writing – Review and Editing, A.B.R., S.S.; Visualization, A.R.; Supervision, A.B.R., S.S.

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Alex Ramirez, 1 B.S., Third-year Medical Student, Wayne State University School of Medicine/Henry Ford Health System, Detroit, USA.

Ashley B. Rapp, 2 MPH. Henry Ford Health System, Detroit, USA.

Sara Santarossa, 3 PhD. Henry Ford Health System, Detroit, USA.

About the Author: Alex Ramirez is currently a third-year medical student at Wayne State University School of Medicine in Detroit, MI, USA of a 4 year program. She has been conducting research in the Public Health Sciences Department at Henry Ford Health since 2020.

Correspondence: Alex Ramirez. Address: 540 E. Canfield Ave. Detroit, MI 48201, USA. Email: alex.ramirez@med.wayne.edu

Editor: Francisco J. Bonilla-Escobar; Student Editors: Shuo-Yan Gau, Diego Carrion Alvarez Copyeditor: L V Simhachalam Kutikuppala; Proofreader: Laeeqa Manji; Layout Editor: Julian A. Zapata-Rios; Process: Peer-reviewed

Searches ran on March 29, 2021

Ovid MEDLINE(R) and Epub Ahead of Print, In-Process, In-Data-Review & Other Non-Indexed Citations, Daily and Versions(R) <1946 to March 26, 2021>

• (exp Exercise/or exp Sedentary Behavior/or Dancing/or exp “play and playthings”/or exp Sports/or Screen Time/or (exercise or exercises or sedentary or screen-time or screen-use or fitness or (physical adj2 (activit* or inactivity or education))).ti,ab,kf.) and (exp adolescent/or exp child/or (adolescen* or boy? or boyfriend or boyhood or girlfriend or girlhood or child* or girl? or juvenil* or kid? or minors or minors* or paediatric* or peadiatric* or pediatric* or preschool* or puber* or pubescen* or school* or teen* or underage? or under-age? or youth*).ti,ab,kf. or (pediatric* or paediatric* or child* or adolescen* or young).jn,jw.) 135600
• limit 1 to (english language and yr=“2020-Current” and covid-19) 402

((‘exercise’/exp/mj OR ‘sedentary lifestyle’/de OR ‘physical activity’/exp OR ‘play’/exp OR ‘sport’/exp/mj OR ‘screen time’/de OR ‘physical inactivity’/exp OR ‘sitting’/de OR ‘sedentary time’/de OR ‘youth sport’/de) OR (‘fitness’:ti,ab OR ‘sedentary’:ti,ab OR ‘screen time’:ti,ab OR ‘screen use’:ti,ab) OR (physical NEAR/2 (activit* OR inactivity)):ti,ab) AND (‘juvenile’/mj OR ‘boy’/mj OR ‘girl’/mj OR ‘child’/mj OR ‘preschool child’/mj OR ‘school child’/mj OR ‘adolescent’/exp/mj OR ‘minor (person)’/exp/mj OR ‘adolescence’/exp/mj OR ‘childhood’/exp/mj OR boy:ti,ab OR boys:ti,ab OR boyfriend:ti,ab OR boyhood:ti,ab OR girl*:ti,ab OR kid:ti,ab OR kids:ti,ab OR child:ti,ab OR child*:ti,ab OR children*:ti,ab OR schoolchild*:ti,ab OR schoolchild:ti,ab OR ‘school child’:ti,ab OR ‘school child*’:ti,ab OR adolescen*:ti,ab OR juvenil*:ti,ab OR youth*:ti,ab OR teen*:ti,ab OR under*age*:ti,ab OR pubescen*:ti,ab) AND (‘coronavirus disease 2019’/exp OR ‘severe acute respiratory syndrome coronavirus 2’/exp OR ‘severe acute respiratory syndrome coronavirus 2’ OR ‘2019 ncov’ OR 2019ncov OR ‘covid-19’ OR ‘2019-ncov’ OR ‘sars-cov-2’ OR ‘2019ncov’ OR ‘novel coronavirus’) AND [english]/lim AND [2020–2021]/py 263

APA PsycInfo <2002 to March Week 4 2021>

(exp “Summer Camps (Recreation)”/or exp Leisure Time/or exp Exercise/or exp Physical Activity/or Activity Level/or Physical Fitness/or exp Sports/or Athletic Participation/or Dance/or Childhood Play Behavior/or Childrens Recreational Games/or (exercise or exercises or sedentary or screen-time or screen-use or fitness or (physical adj2 (activit* or inactivity))).ti,ab.) and (minors or minors* or boy or boys or boyfriend or boyhood or girl* or kid or kids or child or child* or children* or schoolchild* or schoolchild or school child or school child* or adolescen* or juvenil* or youth* or teen* or under*age* or pubescen* or pediatric* or paediatric* or peadiatric* or school or school*).mp. and (coronavirus/or (‘severe acute respiratory syndrome coronavirus 2’ or ‘2019 ncov’ or 2019ncov or ‘covid-19’ or ‘2019-ncov’ or ‘sars-cov-2’ or ‘2019ncov’ or ‘novel coronavirus’).mp.) 62

limit 9 to (english language and yr=“2020-Current”) 39

S9 S4 AND S5 AND S6 Limiters - Published Date: 20200101–20211231

Narrow by Language: - English  168

S8 S4 AND S5 AND S6 Limiters - Published Date: 20200101–20211231  168

S7 S4 AND S5 AND S6 179

S6 (MH “COVID-19”) OR (MH “Coronavirus Infections+”) OR (MH “Coronavirus+”) OR (TX ‘severe acute respiratory syndrome coronavirus 2’ or ‘2019 ncov’ or 2019ncov or ‘covid-19’ or ‘2019-ncov’ or ‘sars-cov-2’ or ‘2019ncov’ or ‘novel coronavirus’)  48,402

S5 (MH “Hospitals, Pediatric”) OR (MH “Adolescence+”) OR (MH “Maternal Age 14 and Under”) OR (MH “Child, Preschool”) OR (MH “Child Psychology”) OR (MH “Pediatric Units”) OR (MH “Intensive Care Units, Pediatric”) OR (MH “Rehabilitation, Pediatric”) OR (TX minors or minors* or boy or boys or boyfriend or boyhood or girl* or kid or kids or child or child* or children* or schoolchild* or schoolchild or school child or school child* or adolescen* or juvenil* or youth* or teen* or under*age* or pubescen* or pediatric* or paediatric* or peadiatric*)  1,237,921

S4 S1 OR S2 OR S3  380,492

S3 TX exercise or exercises or sedentary or “screen time” or “screen use” or fitness or “physical activity” or “physical inactivity”  302,701

S2 (MH “Life Style, Sedentary+”)  8,845

S1 (MH “Physical Activity”) OR (MH “Physical Fitness+”) OR (MH “Exercise+”) OR (MH “Dancing+”) OR (MH “Play and Playthings+”) OR (MH “Sports+”) OR (MH “Life Style, Sedentary”) OR (MH “Screen Time”)  242,545

TS=("severe acute respiratory syndrome coronavirus 2" or “2019 ncov” or 2019ncov or “covid-19” or “2019-ncov” or “sars-cov-2” or “2019ncov” or “novel coronavirus”)

AND

TS=(minors or minors* or boy or boys or boyfriend or boyhood or girl* or kid or kids or child or child* or children* or schoolchild* or schoolchild or school child or school child* or adolescen* or juvenil* or youth* or teen* or under*age* or pubescen* or pediatric* or paediatric* or peadiatric*)

AND

TS=(exercise OR sedentary OR “physical activity” OR “physical inactivity” OR “activity level” OR sports OR “screen time” OR “screen use” OR fitness)

Indexes=SCI-EXPANDED Timespan=All years

Total results = 1040

Total duplicates = 367

Total after deduplicating = 673

ReviewRamirez A, et al. Effects of the COVID-19 Pandemic on Physical Activity in Children: A Systematic Review

Cite as Ramirez A, Rapp AB, Santarossa S. Effects of the COVID-19 Pandemic on Physical Activity in Children: A Systematic Review. Int J Med Stud. 2024 Jul-Sep;12(3):311-333.

Copyright © 2024 Alex Ramirez, Ashley B. Rapp, Sara Santarossa

This work is licensed under a Creative Commons Attribution 4.0 International License.

International Journal of Medical Students, VOLUME 12, NUMBER 3, June 2023