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https://orcid.org/0000-0003-4801-0884
Abstract
Abstract
In this study, researchers aimed to determine exercise habits, physical activity (PA) levels and anxiety levels of postmenopausal women (PMw) during the self-quarantine period of the COVID-19 pandemic. 104 PMw (59.00 ± 6.61 years old) participated in the study. It was found that PMw who had exercise habits before the pandemic period had higher PA levels, and the women with high anxiety levels during the pandemic had lower PA levels (p < .05). Anxiety levels and PA were negatively associated with each other. Numbers of grandchildren also affected the PA and anxiety levels of the PMw negatively. Women should be encouraged to initiate or maintain PA levels in all circumstances.
Background
The COVID-19 outbreak became a global public health problem with many countries applying lock downs. Although national policies varied concerning which behaviors were restricted, all populations experienced consequences from restrictions on movement. Articles have been published recently about the virus and its consequences, but more studies are needed for understanding how the quarantine period affected personal lifestyles, especially those of the older population. Menopause occurs in women at an average age of 50 years, along with a drop in circulating hormone levels. Due to hormonal changes, women may experience a higher level of anxiety symptoms, and menopause is associated with decreased physical activity (PA). Therefore, in this study, we investigated the exercise habits, physical activity levels and anxiety levels of post-menopausal women (PMw) who were self-quarantined. We present results revealing that the PMw with regular exercise habits before the pandemic also had higher PA levels during the pandemic. We also explain that the levels of anxiety and PA were negatively associated.
The coronavirus disease 2019 (COVID-19) outbreak, which started in China and affected the world, has become a major public health problem for the whole world, and it has caused public panic (Wang et al., 2020). The coronavirus outbreak was firstly described in late December 2019 when pneumonia cases of unknown etiology were observed in the city of Wuhan of the Hubei Province (Nishiura et al., 2020). [Ww]orld[Hh]ealth[Oo]rganization (WHO) stated that there was a high risk of coronavirus spreading to other countries around the world, and finally, on 11 March 2020, the COVID-19 outbreak was declared as a pandemic. Many countries applied lockdown, and the public began to stay in houses, even worked and continued schools from their homes. This period varied depending on the state of the pandemic in countries. This lockdown period affected people both physically and psychologically (Jiménez-Pavón et al., 2020).
Menopause occurs in women at an average age of 50 years, along with a drop in circulating hormone levels, and it is often associated with hot flashes, night sweats, sleep problems, mood changes and vaginal dryness. Moreover, a strong association was found between anxiety and severe somatic symptoms in postmenopausal women (PMw) (Núñez-Pizarro et al., 2017). Due to hormonal changes, women experience higher levels of anxiety symptoms in comparison to premenopausal women (Tangen & Mykletun, 2008). At the same time, the menopause period is associated with decreased time of physical activity (PA), and it may cause heightened risk for health outcomes like obesity in this population (Dubnov & Berry, 2005; Hodson et al., 2014). Studies suggested that being physically active reduces the severity of menopausal symptoms and increases psychological well-being in PMw (Elavsky & McAuley, 2005).
As the coronavirus disease (COVID-19) is contagious, it is suggested that people of older age and/or with chronic diseases must stay in an isolated place and practice self-quarantine. During this period, many people have developed anxiety due to fear of death and worry during or after their isolation/self-quarantine (Liu et al., 2020). Psychological results such as stress, anxiety, and depression caused by the outbreak were found to be more common in the female gender (Wang et al., 2020). Additionally, due to the limited activity area in houses, the PA levels of adults have been affected during lockdown (López-Sánchez et al., 2020). However, it is not clear how the physical activity levels and anxiety levels of women in the postmenopausal period were affected during the pandemic period.
Since Northern Cyprus is a small country, it is easier to control the rules. Moreover, people have a high education level, follow the news from the world and take new responsibilities which have come along with the pandemic. Any wrong behavior by a person is announced very fast via all media channels, so, people are alert about themselves. Moreover, the worst factor affecting the psychological and social lives of people is the inadequate number of physicians. Due to these factors, although the COVID-19 positive numbers are not too high, still, people have fear of getting this disease.
Currently, there are no vaccines for prevention or treatment of the disease caused by the virus, and the outcome of this outbreak is unknown. Many articles have been published recently about the virus and its consequences, but more studies are needed for understanding how the quarantine period has affected different populations. Therefore, in this study, we investigated the exercise habits before and during pandemic, PA levels and anxiety levels during the pandemic and factors related to the PA levels of PMw who were self-quarantined and did not go out of their houses for a month.
Materials and methods
An online survey was conducted with PMw living in Northern Cyprus. Data collection started on 23 April 2020 and was completed on 27 April 2020, with confirmed menopause or post-menopause cases. A sociodemographic and self-quarantine-related questionnaire, the International Physical Activity Questionnaire, and the Beck Anxiety Inventory were included in the survey. The participants were contacted by two of the researchers and requested to participate.
Participants
The survey was shared online, and women were asked to participate. Women who volunteered to participate were asked to answer the shared survey. The inclusion criteria were determined as being between 50 and 75 years old, having a PM period of at least 1 year and being in self-quarantine for 1 month. Conditions affecting ovarian function, including bilateral ovariectomy and estrogen-containing hormonal preparation were determined as the exclusion criteria. According to the inclusion and exclusion criteria, 180 PMw were reached, and 104 people answered all questions and completed study.
Measures
Information on Sociodemographic Characteristics and Self-Quarantine
The first part of the survey which consisted of 24 questions was created for the objective of the study by one of the researchers. This part included questions on the sociodemographic information of the participants, as well as questions about their lifestyle in the self-quarantine period.
Physical activity level
The Turkish version of the International Physical Activity Questionnaire-Short Form (IPAQ-SF) was used to determine the level of PA (Craig et al., 2003). It consists of 7 questions evaluating levels of PA in the past week and provides information on the amount of time spent walking, during moderate-intensity activities and during high-intensity activities (Saglam et al., 2010). The level of activity is evaluated as light, moderate or vigorous depending on participants’ total score in IPAQ-SF.
Anxiety
The anxiety levels of the participants were evaluated with the Turkish version of the Beck Anxiety Inventory. It is a self-assessment scale used to determine the frequency and severity of anxiety symptoms (Ulusoy et al., 1998). It is a Likert-type scale consisting of 21 items and scored between 0 and 3. The possible total score in the Inventory is between 0 and 63. For the total score, 0–7 points indicate minimal symptoms of anxiety, 8–15 points indicate mild, 16–25 points indicate moderate, and 26 points and higher scores indicate severe anxiety disorder (Beck et al., 1988).
Statistical analysis
The data obtained from the individuals participating in the study were analyzed using the SPSS 25.0 software package. Arithmetic mean and standard deviation (Mean ± Std. Dev.) were used for the quantitative data, and n (%) was used for the qualitative data. Independent-Samples t-Test was used to compare the exercise habits of the participants before and during the pandemic. Mann-Whitney U Test was used to find the difference between the exercising and non-exercising participants. McNemar’s Test Exact Sig. (2-sided) was used to indicate a change in the habit of exercising, and Pearson’s Correlation test was used to determine the relationships between the PA levels and BAI scores and the sociodemographic data. For statistical significance, α = 0.05 was determined in a 95% confidence interval.
Results
A total of 104 women (mean age 59 ± 6.62 years) participated in this study. The mean menopause duration of the women was 10.17 ± 6.70 years. We categorized the participants based on their exercise habits before and during the pandemic. Table 1 summarizes the sociodemographic characteristics of all participants according to the groups. 35.6% of the participants stated that the risk ratio in their city was low, 49.0% stated it as medium, and 15.4% stated it as high. None of the participants stayed in a quarantine hotel. 8.7% of the participants stated that they lived alone, while the remaining 91.3% stated that they lived with at least one other person. 7.7% of the participants stated that they had positive cases in their family/close friends.
Table 1. Sociodemographic characteristics of participants.
In our study, exercise habits before the pandemic were recorded depending on going to sports centers, and exercise habits during the pandemic were recorded depending on doing sports at home during the quarantine period. 54 women (52%) were doing regular exercise before the pandemic, whereas 31 women (30%) were doing exercise during the self-quarantine period of the pandemic. Twenty-seven (26%) women reported to be doing regular exercise before the pandemic, and 27 (26%) reported doing exercise during the pandemic. Four (4%) women started doing exercise during the self-quarantine period. Our study revealed that the pandemic affected the exercise habits of the PMw. Table 2 shows the exercise habits of the participants.
Table 2. Exercise habits of participants before and during pandemic (n = 104).
The women who had exercise habits before the pandemic period had higher PA levels during the pandemic (p < .05). The women with high anxiety levels during the pandemic had lower PA levels (p < .05) to the participants’ mean IPAQ-SF score was 534.04 ± 653.43, which indicated a low level of PA during self-quarantine, whereas 67.3% (70 women) had low and 32.7% (34 women) had moderate PA levels.
The participants’ mean BAI score was 10.36 ± 8.95, which indicated a low level of anxiety, whereas 44.2% (46 women) had minimal anxiety levels, 31.7% (33 women) had low anxiety levels, 19.2% (20 women) had medium anxiety levels, and 4.8% (5 women) had severe anxiety levels. The PA levels of those who took part in sports before the pandemic were higher than those who did not, and their anxiety levels were lower than those who did not. Similar results were observed in those who took part in sports during the pandemic. The results on the PA and anxiety levels of the groups determined based on their exercise habits before and during the pandemic are shown in Table 3.
Table 3. PA and anxiety levels of the groups according to exercise habits before and during pandemic.
There was no significant difference between the IPAQ-SF and BAI values of those who exercised before and during the pandemic. However, although there was no statistically significant difference, the IPAQ-SF mean (MET) score increased, and the BAI mean score decreased. The results on the IPAQ-SF and BAI scores of the groups determined based on their exercise habits before and during the pandemic are shown in Table 4.
Table 4. IPAQ-SF and BAI values of the groups divided according to their exercise habits before and during pandemic.
We conducted a Pearson’s Correlation analysis to examine the factors affecting the PA and anxiety levels, and a negative relationship was found between the numbers of grandchildren that the participants had and their physical activity levels (p < .05), while there was a positive relationship between the numbers of grandchildren and anxiety levels (p < 0.05). Accordingly, as the number of grandchildren increased, physical activity decreased, and anxiety increased. The results of the Pearson’s Correlation analysis are presented in Table 5.
Table 5. Factors affecting physical activity and anxiety levels (N = 104).
Discussion
In this study, we aimed to determine the exercise habits, PA levels and anxiety levels of PMw during the self-quarantine period of the COVID-19 pandemic. We also analyzed factors affecting the PA and anxiety levels. The results showed that the PMw with regular exercise habits before the pandemic had higher PA levels during the pandemic. Furthermore, the levels of anxiety and PA were negatively associated with each other. Additionally, the PMw with more grandchildren had lower PA levels and higher anxiety levels.
The COVID-19 pandemic has created an environment that promoted reduced amounts of PA because of quarantine requirements and fewer opportunities to be physically active (Hipolito Rodrigues & Carneiro, 2020). PA is beneficial for the mental and physical health of older adults, and recent commentaries have called for therapy programs to help increase PA levels to overcome the negative psychological and physical consequences of the COVID-19 quarantine period for older people (Jiménez-Pavón et al., 2020). López-Sánchez et al. (2020) reported that moderate-intensity PA significantly decreased in Spanish people with chronic conditions during COVID-19 quarantine, and this decrease was significant in both males and females. This decrease was also significant in the age group between 55 and 64 years (López-Sánchez et al., 2020). Our results were in parallel with the recent literature, as the PA levels of our sample were also low.
The COVID-19 pandemic has caused panic and psychological consequences in individuals due to the risk of death. Moreover, in postmenopausal women, the effect of menopause is also added. When we look at the literature, it is seen that low estrogen levels cause anxiety, stress and depression in postmenopausal women (Ballinger, 1990). In postmenopausal women, exercise is crucial to both reducing stress and improving health. Likewise, examining the effects of exercise on stress in Thai postmenopausal women, a study found that aerobic exercise significantly reduced stress (Sunsern, 2002). A recent study by Antunes et al. (2020) reported that higher PA levels in adults were associated with lower anxiety levels during the COVID-19 pandemic. Another study by Callow et al. (2020) stated that there is a strong relationship between higher levels of PA and reduced symptoms of depression in older adults who survive COVID-19. Specifically, they found that a greater total amount of PA was associated with lower depression symptoms, but not anxiety-like symptoms (Callow et al., 2020). Although we did not investigate depression, differently to Callow et al., we found that the PMw with lower PA levels during the pandemic had higher anxiety levels, which was a parallel result to the literature. Additionally, Jurak et al. suggested that being physically active is a simple and effective way to counteract the negative effects of COVID-19 (Jurak et al., 2020). Ammar et al. (2020) stated that COVID-19 had a negative effect on PA levels due to social isolation and quarantine, and daily sitting time increased. Consistent with these findings, it was observed in our study that the individuals with high PA levels also had low anxiety levels. We think that the COVID-19 pandemic affected the postmenopausal women in addition to the effect of menopause.
The importance of PA in the postmenopausal period is known as the decreased risk of the negative effects of inactivity. PA has also been shown to widen benefits to people’s wellbeing, quality of life, and importantly, physical and psychological health (Schuch et al., 2016). In a study conducted this year, it was stated that peri- and postmenopausal women may experience the worsening of preexisting diseases during social isolation periods in the COVID-19 pandemic, emphasizing that strategies should be adopted to minimize these problems and provide appropriate guidance to women to better manage their health (Hipolito Rodrigues & Carneiro, 2020). Similarly, as we mentioned exercises due to their positive impact on both physiological and psychological aspects earlier, we recommend an exercise habit to provide postmenopausal women with protection and improvement of their health.
Our study revealed that the PMw who were doing regular exercise before the pandemic had higher PA levels during the pandemic than those who were not doing regular exercise before. It is universally accepted that exercisers at all levels and genders should try and maintain their PA levels as much as they can at home, without changing their routine if they are healthy. Our results suggested that the women tried to protect their exercise routine during the pandemic. The importance of providing awareness training for PMw about physical activity has been shown by a recent study conducted by Kurbonboyev and Kaygisiz (2019). We think that, as the COVID-19 pandemic still has unknown consequences for the future, the awareness of women about the importance of physical activity should be increased by healthcare workers, as well as associations and NGOs concerned with women’s issues.
Goethals et al. (2020) stated that COVID-19 has affected the number of older adults attending group PA programs before the quarantine measures. We similarly found a decrease of in the exercise habits in the PMw during self-quarantine. Although the exercise habits of the participants changed during the pandemic, there was no significant difference between the physical activity levels and anxiety levels of those who exercised before and during the pandemic. Nevertheless, although there was no statistically significant difference, physical activity levels increased, and anxiety levels decreased.
Raising grandchildren may be a stressful form of caregiving that may worsen older adults’ health conditions that already exist (Young & Sharpe, 2016). Research has shown that grandparents who provide care for their grandchildren might not participate in regular exercise (Taylor et al., 2008). In our study, as the number of the grandchildren that the participants had increased, their physical activity decreased, and anxiety increased. We think this may have been because of two reasons as worrying that their grandchildren would get sick and worrying that they would get sick and unable to care for their grandchildren during this pandemic. During the pandemic, there may be many barriers to increase PA at the very time it may be most beneficial. Anxiety about leaving the house, the closure of fitness centers and fewer opportunities to exercise with a group are considered to be these barriers for reduced PA. The limitation of taking part in PA outdoors could highly contribute to this reduction in the PA levels of the PMw in our study, as Cypriot people mostly prefer to take part in PA outdoors rather than indoors. Further research with more social, cultural, and demographic variables is needed to find more factors (barriers/facilitators) related to the PA level of PMw during the pandemic.
One of the limitations of this study was the sample size. Although the surveys were distributed online, the rate of replies was not as high as expected. Since internet fraud has increased in recent years, individuals of this age group do not want to click on a link they are unsure of. Moreover, this study involved a convenience sampling of PMw who used smart phones and/or technological devices, which likely resulted in a non-representative sample, limiting the generalisability of the results. Still, due to the self-quarantine rules, an in-person survey was not possible to conduct. We preferred to include participants from one country which might have also limited the generalisability of the results. However, we thought that PMw with different cultures may react differently during a pandemic. Further studies which assess the exercise habits of PMw in different countries and cultures are recommended.
Conclusions
Although people at younger ages are starting to return to their lives outside in many countries, most old people still tend to protect themselves from going outside for any reason except for essential situations. These results should be considered to develop effective strategies of PA promotion in order to avoid decreases in the PA levels of populations that are more at risk. Because of the restrictions applied during the quarantine period, promotion of suitable home-based exercise is required, and it may be best to encourage these exercise programs during the quarantine period online. Based on the results of this study, we concluded that PMw should be encouraged to initiate or maintain their physical activity levels in all circumstances. Although this study was conducted in one country, menopause has similar consequences for almost all women living around the world. So, more research and strategies should be considered for this population who are physically and psychologically at risk and need health protection mechanisms during this pandemic. A governmental plan is also recommended for countries to increase awareness among healthcare providers, families of PMw, in addition to the PMw population.
| EXERCISE HABITS BEFORE PANDEMIC | EXERCISE HABITS DURING PANDEMIC | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Yes (n = 54) | No (n = 50) | Yes (n = 31) | No (n = 73) | Total (n = 104) | ||||||
| Min–Max | Mean ± Std. Dev. | Min–Max | Mean ± Std. Dev. | Min–Max | Mean ± Std. Dev. | Min–Max | Mean ± Std. Dev. | Min–Max | Mean ± Std. Dev. | |
| Age (year) | 50.00–72.00 | 59.96 ± 6.52 | 50.00–75.00 | 57.96 ± 6.64 | 50.00–72.00 | 60.16 ± 6.25 | 50.00–75.00 | 58.51 ± 6.75 | 50.00–75.00 | 59.00 ± 6.62 |
| Height (m) | 1.50–1.73 | 1.62 ± 0.05 | 1.47–1.72 | 1.61 ± 0.06 | 1.50–1.73 | 1.62 ± 0.06 | 1.47–1.72 | 1.62 ± 0.06 | 1.47–1.73 | 1.62 ± 0.06 |
| Weight (kg) | 55.00–90.00 | 68.56 ± 7.44 | 47.00–90.00 | 70.48 ± 9.54 | 58.00–80.00 | 66.77 ± 5.91 | 47.00–90.00 | 70.63 ± 9.21 | 47.00–90.00 | 69.48 ± 8.52 |
| BMI (kg/m2) | 20.20–35.16 | 26.14 ± 3.36 | 19.56–37.66 | 27.07 ± 3.62 | 20.76–34.63 | 25.71 ± 3.10 | 19.56–37.66 | 26.96 ± 3.61 | 19.56–37.66 | 26.59 ± 3.50 |
| Menopause age (year) | 40.00–55.00 | 49.33 ± 4.02 | 35.00–58.00 | 48.10 ± 4.25 | 41.00–55.00 | 49.48 ± 3.48 | 35.00–58.00 | 48.42 ± 4.40 | 35.00–58.00 | 48.74 ± 4.16 |
| Years in menopause (year) | 1.00–30.00 | 10.65 ± 6.60 | 1.00–30.00 | 9.66 ± 6.84 | 2.00–30.00 | 10.65 ± 6.32 | 1.00–30.00 | 9.97 ± 6.89 | 1.00–30.00 | 10.17 ± 6.70 |
n: number of size, BMI: body mass index, m: meter, kg: kilogram, std. dev.: standard deviation.
| Exercise habits during pandemic | Total | |||
|---|---|---|---|---|
| No | Yes | |||
| Exercise habits before pandemic | No | 46 | 4 | 50 |
| Yes | 27 | 27 | 54 | |
| Total | 73 | 31 | 104 | |
| McNemar Test Exact Sig. (2-sided) | χ2=21,888 | p = .000* | ||
* p < .05.
| Exercise habits before pandemic | Independent samples test | Exercise habits during pandemic | Independent samples test | |||||
|---|---|---|---|---|---|---|---|---|
| Yes (n = 54) | No (n = 50) | Yes (n = 31) | No (n = 73) | |||||
| Mean ± Std. Dev. | Mean ± Std. Dev. | t | p | Mean ± Std. Dev. | Mean ± Std. Dev. | t | p | |
| IPAQ-SF | 808.92 ± 725.17 | 237,28 ± 394.46 | −4.937 | .000* | 1009,26 ± 775.90 | 332.31 ± 470.62 | −5.469 | .000* |
| BAI | 8.70 ± 7.75 | 12.16 ± 9.86 | 1.995 | .000* | 6.71 ± 5.27 | 11.92 ± 5.27 | 2.802 | .006* |
*p < .05 (IPAQ-SF: International Physical Activity Questionnaire-Short Form, BAI: Beck Anxiety Inventory).
| Having exercise habits | Mann Whitney U Test | Not having exercise habits | Mann Whitney U Test | |||||
|---|---|---|---|---|---|---|---|---|
| Having exercise habits before pandemic | Having exercise habits during pandemic | Not having exercise habits before pandemic | Not having exercise habits during pandemic | |||||
| Mean ± Std. Dev. | Mean ± Std. Dev. | Mean ± Std. Dev. | Mean ± Std. Dev. | |||||
| n = 54 | n = 31 | Z/U | p | n = 50 | n = 73 | Z/U | p | |
| IPAQ-SF | 808.92 ± 725.17 | 1009.26 ± 775.90 | −1.137/713.0 | .256 | 237.28 ± 394.46 | 332.31 ± 470.62 | −1.031/1635.0 | .302 |
| BAI | 8.70 ± 7.75 | 6.71 ± 5.27 | −0.339/732.5 | .339 | 12.16 ± 9.86 | 11.92 ± 5.27 | −0.168/1792.5 | .867 |
* p < .05 (IPAQ-SF: International Physical Activity Questionnaire-Short Form, BAI: Beck Anxiety Inventory).
| Number of children | Number of grandchildren | Menopause duration | ||
|---|---|---|---|---|
| IPAQ-SF | Pearson correlation (r) | −0.190 | −.226 | 0.065 |
| p | 0.053 | 0.021* | 0.513 | |
| BAI | Pearson correlation (r) | 0.078 | .216* | 0.075 |
| p | 0.432 | 0.028* | 0.448 |
*p < .05 (IPAQ-SF: International Physical Activity Questionnaire-Short Form, BAI: Beck Anxiety Inventory).
Conflict of interest
The authors have no conflicts of interest to declare.
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