ronaldo.experimental@gmail.com

Post-Doctorate at the Faculty of Medicine of the University of São Paulo

Doctor of Science from the Experimental Physipathology Program

Master of Science from the Faculty of Medicine of USP

Lato Sensu Specialization from the Planning, Implementation and Management

of Distance Education course from the Fluminense Federal University

Graduation in Physical Education (Bachelor's and Full Licentiate Degree)

from Universidade São Judas Tadeu

(Brasil)

Reception: 01/14/2022 - Acceptance: 06/14/2022

1st Review: 06/09/2022 - 2nd Review: 06/11/2022

Accessible document. Law N° 26.653. WCAG 2.0

Suggested reference: Silva, R.A. da (2022). Physical Activity Regulates the Symptoms of Psychological Distress in Graduates During the COVID-19 Pandemic. Lecturas: Educación Física y Deportes, 27(290), 18-33. https://doi.org/10.46642/efd.v27i290.3338

 

Abstract

    Background: The COVID-19 pandemic caused a worldwide increase in mental health problems such as anxiety and depression. Objective: Investigate the impact of physical activity on symptoms of anxiety and depression in university students of physical education during the COVID-19 pandemic. Methods: 121 students of the physical education degree course were evaluated in the short and medium term. The students answered the Hospital Anxiety and Depression Scale (HADS) and State-Trait Anxiety Inventory (STAI) questionnaires to measure the levels of symptoms of anxiety and depression; the physical activity level (PAL) was also verified with use of International Physical Activity Questionnaire (IPAQ). The evaluations were made in two moments: 30 to 40 days or Short Term (ST) and 120 to 130 days or Medium Term (MT) after the beginning of social distance. Results: About 52.9% and 59.5% of the students did not show anxiety symptoms at ST and MT, respectively. Most graduates, 74.4% and 66.9% had no symptoms of depression at ST and MT, respectively. More than 50% of students were able to maintain PAL at both times. Conclusion: The maintenance of mental health during the pandemic can be preserved with regular practice of physical activity.

    Keywords: Anxiety. Depression. COVID-19. Pandemic. Physical activity.

 

Resumo

    Introdução: A pandemia do COVID-19 provocou aumento mundial de problemas com a saúde mental como ansiedade e depressão. Objetivo: Investigar o impacto da atividade física nos sintomas de ansiedade e depressão em estudantes universitários de educação física durante a pandemia do COVID-19. Métodos: Foram avaliados a curto prazo e médio prazo 121 alunos do curso de licenciatura de educação física. Os discentes responderam os questionários the Hospital Anxiety and Depression Scale (HADS) e Inventário de Ansiedade Traço-Estado (IDATE) para mensurar os níveis de sintomas de ansiedade e depressão; ainda foi verificado o nível de atividade física (NAF) com uso do Questionário Internacional de Atividade Física (IPAQ). As avaliações foram feitas em dois momentos: 30 a 40 dias ou Curto Prazo (CP) e 120 a 130 dias ou Médio Prazo (MP) após início do distanciamento social. Resultados: Cerca de 52,9% e 59,5% dos alunos não apresentaram sintomas de ansiedade a CP e MP, respectivamente. A maioria dos graduandos,74,4% e 66,9% não tiveram sintomas de depressão a CP e MP, respectivamente. Mais de 50% dos alunos conseguiram manter o NAF nos dois momentos. Conclusão: A manutenção da saúde mental durante a pandemia pode ser preservada com prática regular de atividade física.

    Unitermos: Ansiedade. Depressão. COVID-19. Pandemia. Atividade física.

 

Resumen

    Introducción: La pandemia de COVID-19 provocó un aumento a nivel mundial de problemas de salud mental como la ansiedad y la depresión. Objetivo: Investigar el impacto de la actividad física en los síntomas de ansiedad y depresión en estudiantes universitarios de educación física durante la pandemia de COVID-19. Métodos: Se realizaron evaluaciones de corto y mediano plazo a 121 estudiantes de licenciatura en educación física. Los estudiantes respondieron la Escala de Ansiedad y Depresión Hospitalaria (HADS) y el Cuestionario de Ansiedad Estado Rasgo (STAI) para medir los niveles de síntomas de ansiedad y depresión; también se verificó el nivel de actividad física (NAF) mediante el Cuestionario Internacional de Actividad Física (IPAQ). Las evaluaciones se realizaron en dos tiempos: 30 a 40 días o Corto Plazo (CP) y 120 a 130 días o Mediano Plazo (MP) después de iniciado el distanciamiento social. Resultados: Cerca del 52,9% y 59,5% de los estudiantes no presentaron síntomas de ansiedad a CP y MP, respectivamente. La mayoría de los estudiantes de grado, 74,4% y 66,9%, no presentaron síntomas de depresión en CP y MP, respectivamente. Más del 50% de los alumnos lograron mantener la NAF en ambos momentos. Conclusión: El mantenimiento de la salud mental durante la pandemia se pudo preservar con actividad física regular.

    Palabras clave: Ansiedad. Depresión. COVID-19. Pandemia. Actividad física.

 

Lecturas: Educación Física y Deportes, Vol. 27, Núm. 290, Jul. (2022)

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Introduction 

 

    The cases of infectious diseases caused by the SARS-CoV-2 virus (COVID-19) were identified in Wuhan (China) in December 2019 (WHO, 2019a; Khurshid et al., 2020). The virus quickly spread around the world, what did the World Health Organization (WHO) to declare the pandemic on January 12, 2020 (WHO, 2019a; Wang et al., 2020). A pandemic is considered when an infectious disease occurs worldwide with a high speed of spread reaching regions of different countries. (WHO, 2019a)

 

    In Brazil, the COVID-19 was identified in Brazil in February 2020 (Ministério da Saúde, 2020a), causing the public authorities to take important measures to combat contamination and health problems caused by the COVID-19 virus. Among the measures taken, the isolation and distance socially recommended by WHO (2020b) stands out, conceptualized as "physical distance", which means maintaining a safe space between you and other people who do not belong to your home (CDC, 2020). In the state of São Paulo under the power of decree Nr. 64,881, of March 22, 2020, the closing of trade, services and other economic activities was determined, leaving only those considered to be exceptional services. Following this position, public and private schools and colleges also suspended their classes in March 2020.

 

    Due to the problems described above, the Brazilian population was one of the most affected in the world by the pandemic (WHO, 2020c; Ministério da Saúde, 2020b). In conditions like those of the pandemic, studies have shown that people can also develop mental disorders or psychological distress (Varela et al., 2017), which can occur as a reaction factor to stress-inducing issues, which can be internal and external and contemplates the experience of an unpleasant psychological state associated with high emotional exhaustion (Ritsner et al., 2002), leading to an increase in mental disorders such as anxiety and depression (Varela et al., 2017). Directly associated with the global problem of COVID-19, recent studies have shown that the pandemic has caused an increase in psychological problems (Vindegaard et al., 2020), mainly with increased symptoms of anxiety and depression. (Pappa et al., 2020; Huang, & Zhao, 2020)

 

    Psychological disorders such as anxiety and depression are problems that need treatment, which consists of pharmacological and psychological interventions. Three psychological interventions commonly used in some therapies such as cognitive, interpersonal and support behavioral (Levitan et al., 2011; HQO, 2017). In addition to the therapies described, studies have shown that practicing regular exercise reduced symptoms of anxiety and depression (Mendes et al., 2010; Freitas et al., 2017) or trying to maintain the level of regular physical activity for 150 minutes a week (WHO, 2020d), which seems to help reduce symptoms of psychological distress. (Freitas et al., 2017; Silva et al., 2017)

 

    As previously showed, the pandemic changed the routine of the Brazilian population, created public health and economic problems, and altered the students' routine, as in Brazil, face-to-face classes were suspended and kept at a distance (MEC, 2020), which could induce changes in the psychosocial distress as observed by a previous study that showed increase of anxiety and depression symptoms in the medicine students (Velastegui-Hernández, & Mayorga-Lascano, 2021). All this condition described may have contributed even more to the increase of anxiety and depression difficulties in the Brazilian population, including students. Based on the above, the present study aimed to investigate the impact of physical activity on symptoms of anxiety and depression in university physical education students during the COVID-19 pandemic.

 

Methods 

 

    In the state of São Paulo, the face-to-face classes at graduation institutions were suspended on 03/06/2020. For this reason, students of the Physical Education (PE) undergraduate program abruptly started the distance course in an emergency, as did the other private higher education institutions in the state of São Paulo. In this case, all students in the face-to-face classes PE course at two different colleges in the region of Mauá and Ribeirão Pires in the state of São Paulo were invited to participate in the study.

 

Subjects and criteria for participation 

 

    As participation criteria, students should be enrolled and attend classes regularly since the beginning of the 2020 school year; being of age; both genders. The study was evaluated and approved by the ethics committee of professors of the institution where it was applied or studied. The study respected the ethical principles from the Helsinki Declaration (1964, restructured in 1975, 1983, 1989, 1996 and 2000), from the World Medical Association. In addition, the subjects received, read, and agree and assigned to the free informed consent form.

 

Invitation to participate in the study and online questionnaire 

 

    Comprising the norms of social distance and to avoid contamination, the research subjects filled out a digital questionnaire prepared with the Google Forms tool where they answered closed and open questions about personal questions informing about the situation in two different moments after leaving the classroom classes: short term (ST) (about 30 to 40 days after) and medium term (MT) (about 120 to 130 days after) the face-to-face classes have been forced to migrate to distance classes due to the COVID-19 pandemic. To participate, first the students were invited during the realization of the virtual classes live by applications such as Google Hangouts, Google Meet and Zoom. During the invitation, the students received an explanation about the research and were informed of the consent to use the data to be informed. After the explanations and guidance, all students received the link to the Google Forms to fill in voluntarily. The form was started with the free and informed consent form with all the research information, which should be accepted and confirmed if the student accepted voluntary participation in the research, then the students answered the research questions.

 

    The study questions were filled out with an online version accessed by the Google account (Google Forms), in compliance with the rules of social distance determined by the Government of the State of São Paulo (Decree Nr. 64,881). Students received information and guidance during live virtual classes (“lives”) before completing the questions.

 

Digital questionnaire answered online using the Google Forms platform 

 

    The research method using a digital form has been used by other researches and has good efficiency (Mota, 2019; Silva, 2022). The research subjects answered a series of questions in order to identify the profile of the state public. The questions are divided into blocks, namely:

 

    Block 1. Student authentication 

1. Reading and agreeing with the free and informed consent form.

2. Name.

3. Weight, height, age

4. Course period and semester.

Legend. Figure 1 presents the study timeline from the beginning of classes to the end of the semester during the pandemic. SP, state of São Paulo, ICF, informed consent form; STAI, State-Trait Anxiety Instrument; HADS, Hospital Anxiety and Depression Scale; IPAQ, International Physical Activity Questionnaire. Source: Author

 

    Block 2. Symptoms of anxiety, depression and level of physical activity during pandemic 

1. Answer the HADS questionnaire.

2. Answer the IDATE questionnaire.

3. Answer the IPAQ questionnaire.

Assessment of anxiety and depression levels with the use of HADS 

 

    The symptoms of anxiety and depression and of university students were assessed using the Hospital Anxiety and Depression Scale (HADS) instrument (Zigmond, & Snaith, 1983), a self-assessment questionnaire widely used in clinical research. The questionnaire scale consists of 14 items, seven of which are aimed at assessing anxiety and seven for depression. Each of its items can be scored from 0 to 3, making up a maximum score of 21 points (Marcolino et al., 2007). The following cutoff points were adopted for the subscales: HADS-Anxiety: ≤ 8 without anxiety and ≥ 9 with anxiety; HADS-Depression: ≤ 8 without anxiety and ≥ 9 with depression.

 

Classification of types of anxiety using the STAI instrument 

 

    To identify anxiety levels and classification in students, the State-Trait Anxiety Instrument (STAI) was used (Spielberger, 1979), a version translated into Portuguese (Biaggio, & Natalício, 1979). The questionnaire has two different scales: one aiming to identify the trait and the other the state of anxiety. Each scale consists of 20 questions. The answer possibilities vary from 1 to 4, being: 1 = almost never; 2 = sometimes; 3 = frequently; and 4 = almost always. For each of the scales, the subject is instructed to read each item and mark the answer that best corresponds to his condition (Seok et al., 2018). The tabulation of the data by the sum of the values ​​obtained in each answer (final score) varies from 20 to 80 points and corresponds to the level of anxiety. The low level of anxiety occurs through scores of 20 to 40 points; medium level of anxiety from 41 to 60 points, high level of anxiety from 60 to 80 points.

 

Measurement of the level of physical activity using IPAQ 

 

    To determine the levels of physical activity during the pandemic, the present study used the International Physical Activity Questionnaire (IPAQ), a simplified short version validated by Matsudo et al. (2012). The instrument assesses the frequency (days/week), duration (minutes/day) and the intensity of physical activity of the research subjects during a week, both in occupational activities and in locomotion, leisure or sports, thus classifying students in research as active (classes: very active or active) or sedentary (classes: irregularly active and sedentary). (Freitas, & Pitanga, 2013)

 

Statistical analysis 

 

    The data were analyzed using SigmaPlot 11.0 software (Systal Software Inc., CA, USA) and graphs made with GraphPad Prism 5.0 (GraphPad Software, Inc., CA, USA). Data were presented as mean and standard deviation when the distribution was normal and median and confidence interval when the distribution was non-normal. Continuous data were compared using the non-parametric T test. Proportion analyzes were performed using the Chi-square or Fisher e exact test. The significance adopted was p<0.05.

 

Results 

 

    The Table 1 shows the characteristics of the students who were followed during the pandemic, and 121 students from the physical education degree course participated in the initial short-term (ST) and final medium-term (MT) after the pandemic began, and initially the face-to-face classes that was changed to distance education due to the pandemic. About 50.4% were male (61) and 49.6% female (p>0.05). No difference was observed when comparing age and BMI (p>0.05) (Table 1).

 

University students of physical education (n=121)
Characteristics	Male (n=61)	Female (n=60)
Age (years)	27.6 (±11.3)	26.8 (±8.52)
BMI (kg.m-²)	25.4 (±4.15)	24.8 (±4.79)

Legend. Table 1 shows the characteristics of students of physical education. The study proposal was presented to the students, who agreed with the free and clarified term. The questions were asked remotely via the Internet using a Google Forms respecting the rules of social isolation in the state of São Paulo. Values presented with mean and standard deviation (±). BMI, body mass index; kg.m-², kilograms per square meter. There was no difference when comparing genders (p>0.05)

 

    The Figure 2 presents the study's findings on the level of anxiety and depression symptoms. Graphs A and B show that there was no difference in the levels of symptoms of anxiety and depression when compared to ST and MT (p>0.05). Graphs C and D show the classifications of anxiety in trait and state, respectively, there was no difference when comparing ST and MT (p>0.05).

 

    The data in Figure 3 shows the qualitative assessment of distress symptoms. Graphs A and B show the classifications of students with and without symptoms of anxiety and depression. After the beginning of the pandemic, it was observed that more than half of the students did not show symptoms of anxiety, 52.9% and 59.5% at ST and MT. Even so, it was found that 47.1% and 40.5% had symptoms of anxiety at ST and MT after the start of the pandemic, respectively. About 74.4% and 66.9% did not show symptoms of depression after the start of the pandemic, respectively, and there were no differences when comparing the proportions (p>0.05). Graphs C and D show the classification levels regarding the severity of trait and state anxiety when compared 1 to 3 months after the start of the pandemic. The results showed that there was no difference when compared to ST and MT (p>0.05).

 

    The Figure 4 shows the effects of the pandemic on BMI, level of physical activity at ST and MT after the start of the pandemic in Brazil. Graph A shows that there was no difference when comparing BMI in the short term (ST) and in the medium term (MT) after the start of the pandemic. Interestingly, Chart B shows that physical activity levels were maintained at 183 minutes per week throughout the pandemic. Graph C shows that in the ST of the beginning of the pandemic that more than half of the students were classified as active (57%) and after the time of MT more than half maintained their active behavior (67.7%) regarding the level of physical activity weekly. Although there were no significant changes in BMI and level of physical activity (p>0.05).

 

    The Graph 5 presents the analysis made with the size of the Cohen effect and there was a magnitude of change in BMI, level of physical activity and symptoms of distress that were classified as “great magnitude of change”, mainly in the symptoms of anxiety. There was no change in magnitude for the symptoms of depression.

 

Legend. Figure 2 shows the results of the amount of distress symptoms. The data are presented in the boxplot as median and confidence interval (25-75%). Graph A presents the score of the HADS (Hospital Anxiety Depression Scale) instrument for anxiety symptoms; Graphs B and C show the scores of the HADS instrument for symptoms of anxiety and depression, respectively; ST, Short Term; MT, Medium Term; Graphs C and D show the score of the IDATE instrument (Trait-State Anxiety Inventory) for trait and state anxiety, respectively. There were no differences between ST and MT when comparing proportions (p>0.05). Source: Author

 

Legend. Figure 3 shows the qualitative assessment of students regarding the symptoms of anxiety and depression. ST, Short Term. MT, Medium Term; %, percentage; SEM, without symptoms; Com, with symptoms. Graphs A and B show the classifications of students assessed by the HADS (Hospital Anxiety Depression Scale) anxiety and depression, respectively. Graphs C and D show the classifications of students assessed by IDATE (Trait-State Anxiety Inventory) trait anxiety and state, respectively. There were no differences between ST and MT when comparing proportions (p>0.05). Source: Author

 

Legend. Figure 4 shows BMI (body mass index) and level of physical activity. Graphs A and B show the data in the boxplot as median and confidence interval (25-75%). ST, Short Term. MT, Medium Term; SD, sedentary; AT, active; Graph A shows the BMI; Graph B shows the number of minutes of physical activity per week; Graph C shows the SD or AT classification levels. Graph D shows the magnitude of the changes during the pandemic by the Cohen effect size and classified as small (0.21–0.49), medium (0.50–0.79), and large effect (>0.80).There were no differences between the active and sedentary classifications and in the total number of minutes of weekly physical activity when comparing ST and MT (p> 0.05). It was observed large magnitudes of change for distress symptoms and PAL (Graph D). Source: Author

 

Discussion 

 

    The present study showed that almost half of physical education undergraduates had symptoms of anxiety, but interestingly few had symptoms of depression during the new coronavirus pandemic. In addition, it was observed that more than 50% of students-maintained levels of physical activity above 150 minutes per week since the social distance adopted in the country in the short and medium term. It is possible to speculate that the maintenance of physical activity levels contributed to the preservation of students' mental health during the COVID-19 pandemic.

 

    Due to the pandemic caused by the new coronavirus worldwide, an increase in psychological distress such as anxiety and depression has been associated (Pappa et al., 2020; Vindegaard and Benros, 2020). Other problem was that due to the pandemic, students had to radically change the face-to-face study modality to a hybrid model, but part of the population did not have enough technological tools to continue their studies, which also contributed to increasing frustration and anxiety in students. In this sense, the present study showed that almost half of the students of the undergraduate course studied showed symptoms of anxiety (Figure 2) with a large percentage classified with average level of the disorder (Figure 3) in the short (ST) and medium term (MT) after the beginning of social isolation. A possible explanation for this large number of students with anxiety symptoms is based on previous studies that showed an increase in the symptoms of psychological distress due to the resilience capacity compromised by isolation and loss of social support, risk of infections from friends and relatives, as well as drastic, often disturbing changes in ways of working. (Larios-Navarro et al., 2020; Ruiz et al., 2020)

 

    Despite almost half of the students presenting symptoms of anxiety to ST and MT, the present study showed that even with the advance of the pandemic, the time of extended social distance, the social and economic problems aggravated by the pandemic, the students maintained the same level of anxiety symptoms compared to ST and MT after the distance and interruption of face-to-face classes since March 2020. Added to this, it was also found that about 70% students did not show symptoms of depression in the short and medium term of the installation of the pandemic in Brazil (Figure 3). These differences between the levels of anxiety and depression symptoms can be explained by two important factors described below.

 

    The first hypothesis deals with the differences between these characteristics of psychological distress, since anxiety is defined as an organic response, characterized by apprehension, and increased alertness caused by certain dangerous conditions or due to potential threats to the person's integrity (Leal et al., 2017), as in the pandemic caused by COVID-19 (Ozamiz-Etxebarria et al., 2020). This difference between anxiety and depression disorders shows that students were possibly affected by the social condition of the pandemic as to behavior, but not on the health and functioning of the nervous system, since depression is a mental disorder characterized by depressed mood, loss of interest or pleasure, decreased energy, feelings of guilt or low self-esteem, disturbed sleep or appetite and lack of concentration (Dubovsky et al., 2021), still associated with neurochemical changes in the cortex impairing the functioning of the nervous system impacting on physiological imbalance and body behavior (Dean et al., 2017). Depression can become chronic or recurrent and lead to substantial deficiencies in an individual's ability to take care of his daily responsibilities (Dubovsky et al., 2021). Based on this definition, the present study considers that the low levels of depression observed in physical education students, both ST and MT, show that students do not seem to present this disorder and that mental health seems to be preserved during the pandemic by conditions that preserved the normal neurological functioning of these people.

 

    The second factor that explains the maintenance of anxiety levels, without worsening the condition of students throughout the pandemic and preserving the appearance of depression symptoms, both ST and MT, concerns the levels of physical activity. The present study showed that more than half of the investigated students remained physically active during the health crisis and still controlled their body weight at ST and MT, even with the difficulties caused by the pandemic (Figure 4, Charts B and C). Active behavior may have been the differential for maintaining controlled anxiety conditions and low levels of depression. Although the present study does not show a significant difference, the size of the large effect (Figure 5) shows that there have been changes over time in the increase in the level of physical activity, in the fall of anxiety symptoms, which is also an indication of change that goes beyond significance (Loureiro, & Gameiro, 2011). This hypothesis can be corroborated by other studies that showed the association of worsening physical activity levels with increased symptoms of anxiety and depression (Maugeri et al., 2020; Goethals et al., 2020). Based on our findings and previous studies, the present study considers that the practice of activity was effective to improve mental well-being and enhance the prevention of the emergence of mental health disorders, such as anxiety and depression. (Freitas et al., 2017; Freitas et al., 2018; O’Neil, & Dogra, 2020; Silva et al., 2022)

 

    In light of the results and supported by previous studies, the present study has important practical applications during the pandemic, as well as suggesting that the general population should improve their levels of physical activity at least for 150 minutes a week as recommended by WHO (2020d) and by previous studies such as Guzmán, & Duarte (2020), and Hurtado et al. (2020), also following the rules of safety to avoid contamination respect social distancing and hygiene sanitary rules such as correct use of masks, wash hands with soap constantly, use 70% alcohol gel for cleaning hands, when returning from the street take-off clothes and shoes before entering at home, respect for distance between people, seek medical attention when presenting signs and symptoms such as high fever and respiratory distress (Ministério da Saúde, 2020c). Adding actions, physical activity (Jiménez-Pavón et al., 2020; Woods et al., 2020) and hygiene care (Ministério da Saúde, 2020c) the entire population would have their mental health more protected and preserved during the pandemic, until that an effective vaccine or medication is found to control and treat the problems caused by COVID-19.

 

Study limitations 

 

    Despite the important findings, the study has limitations. Among them, the number of students. Future studies should increase the number of subjects and also investigate other courses. The use of online instruments such as questionnaires for data collection. The sending of online questionnaires, despite being a method normally used in health research with a visa previously (Karbownik et al., 2019), can occur misinterpretation on the part of the research subjects due to the lack of the researcher at the time of filling in, however this was the way found to maintain the social distance and the safety of the researchers and students during a pandemic. The use of the IPAQ questionnaire to determine the level of physical activity. Despite being a validated instrument, recent studies indicate other more precise tools such as accelerometers (Silva et al., 2017; Freitas et al., 2017), future research should expand this research and use these technological instruments.

 

Conclusion 

 

    The present study showed that almost half of the physical education students studied had symptoms of anxiety and low levels of symptoms of depression. The levels of anxiety and depression did not increase with the evolution of the pandemic, the preservation of mental condition seems to have occurred by maintaining the levels of physical activity during the pandemic. For this reason, the study recommends that people try to remain active even with the difficulties caused by COVID-19, because physical activity helps in preventing the appearance of symptoms of anxiety and depression.

 

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Lecturas: Educación Física y Deportes, Vol. 27, Núm. 290, Jul. (2022)