Introduction
Physical inactivity is responsible for up to 5 million deaths per year globally [
1], with an estimated 20 to 30% increased risk of death for people who are not active enough compared to those who are [
2]. Despite being a major share of the global burden of disease that is potentially preventable, as much as one in four of the global adult population still do not meet the recommended level of physical activity of 150–300 min of aerobic, moderate-intensity physical activity per week [
2].
The coronavirus pandemic (COVID-19) that emerged in 2020, also brought about further challenges for health promotion by physical activity. The lockdown measures implemented by many governments to prevent the spread of the virus [
3] may also have had an unintended impact on population health by restricting physical activity behaviour [
4]. For example, the opportunities to regular leisure time and commuting physical activity were disrupted by limited gym access [
5] and widespread orders to work from home [
3], which may have contributed to a more sedentary lifestyle within the confines of the home. Nevertheless, studies have shown inconsistent results regarding the changes in physical activity during the pandemic. For instance, while research from the USA reported an increase in physical activity during the pandemic [
6], another study from the United Kingdom observed an increase only among older adults, with a decrease in physical activity among young people [
4]. Researchers have also found that changes in physical activity may vary depending on the pandemic wave being studied, with greater reductions in daily physical activity during the first compared to the second wave [
7].
In addition, some studies have reflected how social inequalities in physical activity changed during the pandemic. For example, before the pandemic, women in the USA did less exercise than men, and the gender gap increased during the pandemic [
6]. In contrast, an analysis of five British cohort studies also presented fewer active women before the pandemic, but displayed a decreased gender inequality during the pandemic [
8]. However, another study from the same country did not find an association between gender and change in physical activity during the pandemic [
4]. Further studies from the USA have also shown an increased inequality in physical activity between the high and low educated, as well as between high- and low-income earners, as a consequence of the pandemic [
6,
9].
In Sweden, one third of the adult population do not reach the recommended level of physical activity, and this is a public health concern [
10]. To complicate the picture, the most socially disadvantaged tend to engage in less activity along a social gradient [
11]. In response to the COVID-19 pandemic, the authorities in Sweden lacked the legal capacity to enforce compulsory and universal lockdown measures, and instead opted for a less restrictive strategy which relied on voluntary recommendations of social distancing [
12]. Despite this comparatively lenient pandemic strategy, the Public Health Agency of Sweden foresaw that the already existing inequalities would be aggravated during the COVID-19 pandemic [
13]. However, to our knowledge, only one study has explored social inequalities in physical activity during the pandemic in Sweden; it reported less favourable development of physical activity among women in comparison to men and among blue (manual) compared to white-collar (non-manual) workers during the pandemic [
7]. However, the study outcomes were based on perceived change in physical activity without a pre-pandemic measure, increasing the risk of bias. To overcome these shortcomings, and to increase knowledge in this field, the present study aimed to assess the prevalence of physical activity and the socioeconomic inequalities in physical activity before and during the COVID-19 pandemic using two waves of a population-based Swedish national survey.
Discussion
This study assessed the physical activity prevalence and changes in social inequalities in physical activity before and during the COVID-19 pandemic. The recommended level of physical activity increased between 2018 and 2021 for all the categories that were studied, but the social inequalities persisted. The social inequality in physical activity increased during the pandemic for all the other variables that were studied (age, education, income, occupation, and place of birth) with the exception of gender.
Overall, an increase in physical activity during the pandemic was observed for the total study population and the different social categories. Similarly, several studies from high income countries have reported an increase in physical activity during the pandemic [
6,
20]. In contrast, a study from the USA found a decrease in physical activity [
21], which could possibly be explained by these studies being carried out at different stages of the pandemic, and with generally stricter pandemic responses than in Sweden. During the early stages, people might have avoided gyms and sporting activities to prevent the viral spread, whereas in later stages, people probably adapted their physical activity behaviour due to immunisation coverage and/or the easiness of the lockdown measures. For instance, this was observed in a Swedish study that indicated greater reductions in daily physical activity during the first pandemic wave (April to June 2020) compared to the second wave (September to December 2020) [
7].
In contrast to patterns in other countries [
6,
8], in this study, women did more exercise than men in 2018 and 2021, but there was no significant increase in gender inequality over time, which is similar to a study from the UK [
4]. In contrast, a Swedish study reported a 38% higher risk of decreased physical activity during the pandemic for women compared to men [
7]. Different study designs, time periods, and outcome definitions could explain these differences.
Further, in this study, the elderly (65–84) were more active than younger people (16–29) in both 2018 and 2021, with increasing inequality over time. This finding is similar to a UK study that showed a decrease in physical activity among young people, but an increase among those above 65 [
4]. Even though people over 70 were urged by the UK government not to go outside, they managed to increase their level of physical activity [
4]. The greater worries about COVID-19 among the young compared to the old were suggested as a possible reason for these findings [
4].
Highly educated people with a low level of occupation, low-income earners, and people born in Sweden did more exercise than their counterparts in 2018 and 2021. During the pandemic, the socioeconomic gap in physical activity increased with more socially advantaged groups doing more exercise than the disadvantaged ones. In parallel to these results, studies from the USA have shown an increased inequality in physical activity between the high and low educated, as well as between high- and low-income earners during the pandemic [
6,
9]. Even in Sweden, an increased inequality by occupation has been reported [
7].
When lockdown measures were introduced, gyms and sports facilities had to limit the number of visitors [
5] which made some physical activity less accessible for the population in Sweden. However, in contrast to blue-collar workers, white-collar ones could work from home [
3] which decreased commuting time and permitted a flexibility which probably generated more time for physical activity.
We could not find any research investigating place of birth and change in physical activity during the pandemic. However, the low socioeconomic status in Sweden associated with those who are foreign born [
22,
23] could explain the increasing inequality found.
Strengths and limitations
The national representativeness of the study, the presence of two self-reported physical activity measurements over time, the use of register data for certain socioeconomic variables, and the relatively large sample can be considered to be strengths of the study. However, this study has several limitations that should be considered when interpreting the results. The design does not disentangle between any changes in inequities in physical activity caused by the pandemic, pandemic-related restrictions, potential competing interventions, or secular trends, and attribution of the observed changes to pandemic-related causes should therefore be done with caution. Given the self-reported nature of the study design, recall bias, particularly of the outcome, could have been present. The outcome was based on how much time the participants spent each week on everyday activities such as walks, biking, or gardening, and it might have been difficult to remember the exact time spent on each of them. Selection bias could also have been present due to the moderate response rates (42% in 2018 and 44% in 2021), thus challenging the generalisability of the study to the rest of the Swedish population. Further, work-related activities that can generate a certain level of exercise were not included in this study and the outcome focussed only on moderate but no vigorous-intensity physical activity which could have underestimated its prevalence. However, it was not possible to assess the extent of these potential impacts on the results.
Conclusions
This study, conducted on the Swedish population, has shown an increase in physical activity during the COVID-19 pandemic. However, social gradients that already existed in the level of physical activity increased across age, education, occupation, income, and place of birth, but not with regard to gender. Interventions to increase physical activity among the young, those of low socioeconomic status, and those born outside Sweden should be prioritised in order to improve their wellbeing, and to reduce the social inequalities in physical activity. Special attention should be devoted to preventing increases in these social inequalities in times of pandemics, such as that of COVID-19.
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