Boxed in: changes in apartment residents’ health behaviours following the COVID-19 lockdown – a longitudinal cohort study

ABSTRACT Australia’s housing context has long been characterised by low-rise detached homes, but rapid population growth has prompted a recent boom in apartment construction. Apartment residents may be more vulnerable to the negative impacts of COVID-19 stay-at-home orders due to the distinct constraints and stressors of apartment housing, but empirical research on this population is scarce. This study adds to the literature on the health impacts of lockdowns by examining longitudinal changes in the health behaviours of Australian apartment residents. Participants (n = 159) completed a survey between 2017–2019 and a follow-up survey in 2020 following a six-week national lockdown. Residents reported increased walking for recreation, sleep duration, and home cooking frequency, but decreased walking for transport, greater sitting time, and weight gain. Alcohol consumption remained stable. The findings highlight the complex and multifaceted impact of the pandemic, with some health behaviour changes highlighting the benefits of having more time to devote to certain activities, and others showing the unintended negative health consequences of lockdowns. Given the likelihood of future pandemics, a renewed policy focus on apartment space and layout provisions that better facilitate home-based activity is required to mitigate the health risks of lockdown conditions for those living in apartments.


Introduction
The coronavirus (COVID-19) pandemic and mitigation strategies transformed daily life around the world.In Australia and internationally, lockdown restrictions stipulated that populations stay at home as much as possible, with a shift to work from home (WFH) arrangements and the closure of public venues (Australian Bureau of Statistics 2021b).While successful in reducing the risks of SARS-CoV-2 transmission and associated disease burden, this unprecedented disruption to daily life had other unintended health consequences.International studies have shown that both mental health (Liao et al. 2021, Dickerson et al. 2022, Griffiths et al. 2022, Quirk et al. 2022) and health behaviours, including physical activity and sedentary behaviour (Savage et al. 2020, 2021, Barr-Anderson et al. 2021, Costello et al. 2021), alcohol consumption (Gonzalez-Monroy et al. 2021, Xu et al. 2021, Buizza et al. 2022), and diet (Gonzalez-Monroy et al. 2021), were negatively impacted by lockdown restrictions.These are established risk factors for a plethora of chronic diseases, including cardiovascular disease, diabetes, obesity and cancer (Australian Institute of Health & Welfare 2022), and were cause for public health concern in Australia even before the pandemic.However, few studies have focused on Australians' health behaviour changes following lockdown restrictions (Brindal et al. 2022), particularly in the context of the home environment to which people were confined.
Detached housing has historically dominated Australia's urban landscape, however the last two decades have seen an influx of apartment development in urban areas to sustainably house a growing population.Over 2.5 million Australians (10.3% of the population) now reside in apartments (Australian Bureau of Statistics 2021a), but there is little understanding of how lockdowns impacted this population.The health behaviours of these residents may be disproportionately impacted by lockdown restrictions due to the unique characteristics of their homes, communal building spaces and facilities, and their neighbourhood context.
Apartments offer significantly less private indoor and outdoor space than traditional suburban homes and have less versatile layouts (Peters and Halleran 2020).The bulk of new apartments developed in Australia have only one or two bedrooms (City of Melbourne 2013), while the average floor area of apartments shrunk 15% between [2005][2006][2007][2008][2009][2010][2011][2012][2013][2014][2015][2016][2017][2018][2019][2020] to what is now roughly half the size of a detached house (Australian Bureau of Statistics 2020).There can also be considerable variation in their design quality (Foster et al. 2022).Some states have apartment design policy standards that stipulate a minimum internal area for apartments based on the number of bedrooms, but not all states specify minimum standards (Foster et al. 2020), and indeed, not all apartments meet these requirements where they are stipulated (Foster et al. 2022), with concerning implications for apartment quality.As such, apartment dwellers may be at greater risk of health behaviour declines in lockdown conditions because they are confined to smaller spaces that are less conducive to home based physical activity.
To compensate for less private indoor and outdoor (i.e.balcony or courtyard) space, apartment complexes often include a range of communal spaces and facilities (e.g.outdoor areas, gyms), although the amount and quality can vary (Kleeman et al. 2021, Foster et al. 2022).Importantly, the use of these communal spaces and facilities was largely prohibited during lockdown to minimise infection (Peters and Halleran 2020).This could have further inhibited opportunities for apartment residents to be active, as they were restricted to their apartment (with its space and layout limitations) or their neighbourhood environment (with some localities restricting outdoor exercise to just one hour per day at the peak of the pandemic) (Chamas 2020).Indeed, while apartment buildings are typically located in more vibrant, walkable neighbourhoods with accessible destinations and frequent public transport (Giles-Corti et al. 2012), the closure of non-essential shops and services due to stay-at-home orders eroded many of these locational benefits.Paired with this, the mixed land uses in more urban locations also increases the availability of takeaway food and alcohol outlets (Arundel et al. 2017), which could potentially enable poorer dietary habits among apartment residents during lockdown conditions.
Despite the increasing predominance of apartments in Australia and the unique limitations and stressors of this housing type, no studies to date have explored this population's health behaviours in the context of the pandemic.Therefore, the purpose of this study was to investigate the health behaviours of Australian apartment residents during the COVID-19 lockdown to identify potential risks to their long-term health.

Sample and data collection
The HIGH LIFE study explores the relationship between apartment design and residents' health and wellbeing in three Australian cities -Sydney, Melbourne and Perth.The study protocol is described in detail elsewhere (Foster et al. 2019).Briefly, residents from 115 apartment complexes (n = 31 in Sydney, n = 32 in Melbourne, and n = 52 in Perth) were invited to participate in a survey on their apartment/building design and health between 2017-2019.In total, 1326 surveys were returned from an overall sample of 10,560 targeted households.Residents who agreed to be followed-up for future research (n = 790) were contacted again in May 2020, after the six-week national COVID-19 lockdown restrictions had been implemented in March 2020, and invited to participate in a follow-up survey if they still lived in an apartment.After accounting for missing data, the analytic sample for this study comprised n = 159 participants who completed a baseline and follow-up survey and lived in an apartment at both timepoints.The study timeline and sampling process in summarised in Figure 1

Health behaviours
Residents were asked about their health behaviours using validated scales, including: (1) physical activity (hours/week spent walking/cycling for transport and recreation) (Burton et al. 2009); (2) leisure sitting time on weekdays and weekends (hours/day spent sitting watching TV and using computer) (Marshall et al. 2010); (3) meal preparation habits (frequency of cooking at home, or eating ready-prepared meals at home, or purchasing takeout meals, with six response options, including: never; less than once a week; once/week; two-three times/week; four-six times/ week; and daily) (Pettinger et al. 2006); (4) alcohol consumption (standard drinks consumed/day) (Government of Western Australia 2019); (5) sleep duration on weekdays and weekends (hours/night) (Bleicher et al. 2023); and (6) self-reported height and weight, from which a body mass index (BMI) measure was computed.

Sociodemographic data
Residents' sociodemographic characteristics included: sex, age, country of origin, living with a partner and/or children, educational attainment, household income, tenure type, length of residence, city and area disadvantage based on the Australian Bureau of Statistics Index of Relative Socioeconomic Disadvantage (IRSD) 2011 state decile rankings at the SA1 level (Australian Bureau of Statistics 2013b), stratified into three groups: deciles 1-4 (higher relative disadvantage); deciles 5-7 (mid-range disadvantage); and deciles 8-10 (lower relative disadvantage).Descriptive data on building/apartment characteristics (including the average number of storeys and apartments within buildings, and average apartment sizes) was sourced from the approved development applications of buildings.Residents also provided data on the number of bedrooms in their apartment and the presence of communal outdoor space in their apartment complex.

Statistical analysis
Sociodemographic differences between those who completed only the baseline survey and those who completed both surveys were assessed using Pearson's chi-squared tests (χ2) for categorical variables and independent samples t-tests for continuous variables.Differences in health behaviours pre-and post-pandemic were compared using paired sample t-tests.

Results
Study population characteristics are described in Table 1, including a comparison of those who completed the baseline survey against those who completed both the baseline and follow-up surveys.The sample included in this study comprised more females (59%) and was generally well educated (77% had a bachelor's degree).Almost half the sample (47%) reported having to work from home during the lockdown.Residents who completed both surveys were more likely to have been born in Australia (p < 0.001), have a higher education level (p = 0.005), and own their apartment outright or with a mortgage (p < 0.001).
Some descriptive characteristics of residents' home environment are outlined in Table 2.In terms of the scale of residents' apartment developments, buildings were 10 storeys on average, with almost 100 apartments per building.The majority of participants (60%) reported having two-bedroom apartments and the average apartment size increased with the number of bedrooms provided (studios were 48 m 2 , 1-bedrooms were 56 m 2 , 2-bedrooms were 75 m 2 , and 3+ bedrooms were 101 m 2 on average).Most residents (79%) reported having a communal outdoor space present in their complex.
Table 3 presents residents' health behaviours, with several notable changes evident between pre-and post-lockdown timepoints.Walking for transport decreased from an average of 2.2 to 1.2 hours per week following the COVID-19 lockdown (p < 0.001) but walking for recreation increased from 3.1 to 4.3 hours per week (p < 0.001).Sitting time for leisure activities also increased considerably, including watching TV on weekdays (p = 0.004) and weekends (p < 0.001) and using the computer on weekdays (p < 0.001) and weekends (p < 0.001).Residents cooked meals at home more frequently in the lockdown period (p < 0.001), but consumption of ready-prepared meals, takeaway meals, and alcohol did not significantly differ between the two time periods.However, residents' BMI did increase from 25.3 at baseline to 25.7 during the lockdown period (p = 0.032).Finally,  residents reported greater sleep duration on weekdays in the lockdown period (p = 0.015) but no change on weekends.

Discussion
The proliferation of apartment construction in Australia over the last two decades has seen a rapidly growing proportion of people now living in apartments.But the COVID-19 pandemic and associated stay-at-home orders call into question whether apartment residents could be vulnerable to some unintended consequences of lockdown conditions, given the unique characteristics (and limitations) of their living environments.Utilising longitudinal data, this study explored the impact of lockdown restrictions on Australian apartment residents' health behaviours.
The results demonstrated that behaviours were both positively and negatively impacted.Residents reported increased walking for recreation, sleep duration, and home cooking frequency, but also reported decreased walking for transport and greater sitting time.
Similarly, weight/BMI also increased.
Our findings highlight the complex and multifaceted impact of the pandemic.While there were undoubtedly harmful psychological and social consequences to being 'boxed in' at home (Liao et al. 2021, Dickerson et al. 2022, Griffiths et al. 2022), in our study, lockdowns had co-benefits for residents' weekday sleep duration and meal preparation habits.The erosion of workplace commutes (almost 50% of our sample reported a shift to WFH arrangements) and suspension of social and organised physical activities outside the home presumably allowed residents to sleep longer during the week.However, this is at odds with evidence from the UK that found sleep duration worsened significantly for some following the pandemic, largely attributed to poorer mental health (Villadsen et al. 2021).Furthermore, the combination of spending more time at home and hospitality business closures appeared to increase the home preparation of meals from about two-three times/ week to four-six times/week.This is consistent with other longitudinal studies that reveal similar positive changes following the lockdown restrictions, including an increased frequency of households engaging in whole-family shared meals (Berge et al. 2021), and improved dietary habits via increased fruit and vegetable intake (Berge et al. 2021, Villadsen et al. 2021).However, a review of longitudinal studies also showed an overall trend of increased snack frequency and a stronger preference for sweet and processed food as a psychological means to cope with the uncertainty and discomfort caused by the pandemic (Gonzalez-Monroy et al. 2021).While our study did not measure snack frequency or diet, the increase in BMI observed between timepoints suggests home meal preparation could have been offset by increased snacking and unhealthy food choices.Indeed, it was also notable that alcohol consumption did not significantly differ pre-and post-pandemic in our study.Recent studies on the association between lockdown restrictions and alcohol consumption are mixed.Reviews of longitudinal studies have indicated that alcohol intake, or the risk of problematic intake, increased following the pandemic (Gonzalez-Monroy et al. 2021, Xu et al. 2021, Buizza et al. 2022), while several other longitudinal studies point to a decrease in alcohol consumption due to the suppression of socialization opportunities and venues that serve alcohol (Minhas et al. 2021, Vasconcelos et al. 2021, Vera et al. 2021, Villadsen et al. 2021, Larsson et al. 2022).Our findings do not reflect either of these scenarios, suggesting that alcohol consumption may not have been a problematic coping mechanism for our sample, nor discontinued completely in the absence of social events.
For our sample of apartment residents, the significant increases in recreational walking compensated for the declines in transport walking.Numerous longitudinal studies on physical activity changes due to the pandemic demonstrate declines in moderate-tovigorous exercise (Savage et al. 2020, 2021, Barr-Anderson et al. 2021, Costello et al. 2021, McCarthy et al. 2021, Quirk et al. 2022) and overall daily steps (Wang et al. 2020, Costello et al. 2021, Hino and Asami 2021, Obuchi et al. 2021), but longitudinal studies of walking for recreation or transport are scarce.A longitudinal Canadian study with young adults showed that total walking time dropped after lockdown, but they did not distinguish between walking types (O'Loughlin et al. 2022).However, a national English survey on physical activity revealed that adult walking (and cycling) for recreation increased following lockdown restrictions, whereas walking for transport was considerably lower compared to previous years (Strain et al. 2022).While a repeat crosssectional design, the study benefited from a very large sample size (>70,000 seasonally matched respondents) to minimise sample/selection bias (Strain et al. 2022).This is consistent with the behaviour changes observed in our apartment resident sample and aligns with the intended purpose of lockdown restrictions (i.e. to facilitate social distancing via remote, webbased work, while still allowing for recreational exercise outside the home).
Nevertheless, the significant increases we found in apartment residents' leisure sitting time and weight raises concerns about the potential long-term health consequences of the pandemic.As residents were unable to leave their homes as regularly, they appeared to depend more on electronic devices (i.e.television and computer screen time) to alleviate boredom and social isolation (Barr-Anderson et al. 2021).Indeed, it is plausible the smaller private indoor and outdoor spaces provided in apartments, and limited access to building communal areas, may have further increased participants reliance on screens for recreation.Compared to the national average time (approximately four hours/day) spent on sedentary leisure activities in Australia (Australian Bureau of Statistics 2013a), our results are particularly alarming.Combining television and computer time, our sample's weekday leisure sitting time increased from 4.3 hours/day pre-lockdown to 6.8 hours/day postlockdown, while weekend sitting time increased from 5.6 hours/day pre-lockdown to 7.2 hours/day postlockdown.Prolonged sitting, low physical activity levels and weight gain are risk factors for many chronic diseases (Australian Institute of Health & Welfare 2022).Our findings are not atypical, with other longitudinal research also reporting increased sedentary (or screen time) behaviour (Savage et al. 2020, 2021, Barr-Anderson et al. 2021, Costello et al. 2021, Rees-Punia et al. 2021, Buizza et al. 2022) and weight gain (Mason et al. 2021, Alshahrani et al. 2022) as a result of the pandemic across a myriad of population groups.Together, this suggests the need for targeted interventions, such as home exercise programs, to promote physical activity and reduce sitting time during and after lockdown restrictions.However, this is contingent on the design of apartments, the amount of space provided and the ability to repurpose that space during extended periods at home.It is therefore essential that apartment design policies emphasise the importance of minimum space provisions -and indeed, that the development industry delivers on these policy aspirations -to provide spacious, versatile apartment stock that is better suited to occupants' prolonged and intensified exposure.The World Health Organisation has flagged the inevitability of future global health emergencies (World Health Organisation 2020), further underscoring the importance of key apartment design and health behaviour strategies that better enable residents to adapt to changing conditions.
An important strength of this study is the longitudinal examination of a cohort of apartment residents using data collected pre-and post-mandatory stay-at-home orders.Further, our study does not focus on a single outcome, but a wide range of health and lifestyle behaviours.Other studies have also focused on multiple health behaviour outcomes in specific population groups (Gibbs et al. 2021, Larsson et al. 2022) or in the general population (Villadsen et al. 2021, Slurink et al. 2022), but none have explored a national sample of Australian apartment dwellers.The findings underscore the importance of understanding the specific impact of the pandemic on different populations, including apartment residents, to inform public health policies and interventions.However, our study also has limitations.The small sample who completed the COVID-19 survey was more socio-economically advantaged than those who did not complete both surveys.Baseline data was collected 1-3 years before the pandemic, so it is possible that other factors may have impacted residents' behaviours in this period.Indeed, it is possible that the behaviour changes noted in our study may only be temporary and alleviated by loosened restrictions (COVID-19 data collection occurred immediately after the national lockdown had ended, though many restrictions were still in place at this time).Finally, all measures were based on self-report data, which may be subject to bias.While not the focus of the present study, we recommend that future research explores the role of apartment design in predicting residents' health behaviour changes.

Conclusion
Our findings show that COVID-19 lockdown restrictions had a significant impact on the health behaviours of apartment residents.While some positive changes were evident, residents' leisure sitting time and weight increased, signalling the unintended negative consequences of lockdowns.Given the potential for other global health emergencies in the future, and the influx of apartment developments in Australian cities, it is imperative that governments develop long-term strategies to mitigate the health risks associated with stayat-home orders.A renewed policy focus on the delivery of spacious apartments with flexible layouts, paired with targeted population health strategies (e.g.advocation for exercise programs that can be done at home and ways to encourage more movement throughout the day) is crucial to promoting healthy habits among individuals living in compact spaces with limited access to outdoor areas.

Figure 1 .
Figure 1.Flow diagram of study timeline and sampling process.

Table 1 .
Demographic characteristics of participants who completed the HIGH LIFE survey at baseline (2017-2019) versus participants who completed both baseline and COVID-19 surveys.
P values comparing differences from Pearson Chi-Square (categorical variables) and independent sample t-test (continuous variables).a Mean and standard deviation (SD) for continuous variables.

Table 2 .
Descriptive characteristics of apartment residents' building and home environment.
a Mean and standard deviation presented.b Proportion (%) and sample size (n) presented.c Apartment dimensions measured from scaled pdfs of available endorsed architectural or development plans of buildings (Hooper et al. 2022).

Table 3 .
Apartment residents' health behaviours pre-and post-lockdown.
a Mean and standard deviation (SD) for continuous variables.b Responses based on six-point scale (1 = never; 6 =daily).