An international physical activity and public health research agenda to inform coronavirus disease-2019 policies and practices

Physical activity (PA) has strong relevance for limiting the harms to human health and well-being due to the coronavirus disease-2019 (COVID-19) pandemic.1 Active muscles produce chemicals that improve immune functioning, which in turn reduces the extent of infections, and decreases inflammation, and these are the main causes of the lung damage from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. PA is a powerful preventive and therapeutic intervention for the most common pre-existing chronic conditions that increase risk of severe COVID-19 infections and mortality.2,3 PA's effectiveness in preventing and treating anxiety and depression could have worldwide benefits during this stressful global crisis.2 PA enhances the efficacy of vaccines,4 so active lifestyles will continue to be relevant through every phase of the pandemic. Worldwide, about 23% of men and 32% of women are at risk for the underlying conditions of COVID-19, severe COVID-19 infections, and stress-related psychological symptoms, because they do not meet PA guidelines, based on self-report measures.5,6 It is likely that prolonged shelter-at-home measures will lead to reduced PA and increased sedentary behaviors that adversely affect immune function and enhance risk for chronic health conditions.7,8 Many people, especially with low incomes, do not have equipment, Internet access, or indoor space to make at-home PA realistic. Thus, the current pandemic is almost certain to exacerbate socioeconomic inequities in PA.9, 10, 11 The pandemic is changing the places where people can be physically active because many jurisdictions closed or restricted access to common indoor and outdoor places for PA.12, 13, 14 Though some jurisdictions allowed people to exercise outdoors on the streets, others did not, so for millions of people, being active at home was the only option. As limitations are eased, policies related to indoor and outdoor PA places vary across jurisdictions.15,16 If spikes occur in COVID-19 cases and deaths, movement restrictions may be put back in place. It is unknown how long this dynamic ebb and flow of limits on people's ability to be physically active will last and what the impact will be on PA. There are many unanswered questions about how pandemic-related policies in each jurisdiction are affecting PA. Therefore, it is important to identify the most pressing scientific questions that could be translated to policy and practice aimed at favorably impacting population health outcomes. There is ample evidence to justify making PA promotion a global public health priority during the coronavirus pandemic.1,17 One pathway to increasing the prominence of PA as a solution is to set a public health research agenda for promoting scientific studies to document any health and societal benefits during the COVID-19 pandemic, and to evaluate public health strategies for effectively promoting PA under crisis conditions. We consider research on PA and COVID-19 to be an urgent global public health need. Within this context, relevant PA research can span a broad range from basic science covering in vitro laboratory studies and human studies, to clinical studies with diagnosed patients, to public health studies focusing on prevention. Among the many research needs, the present paper focuses on studies with the potential to guide public health policy and practice, with a secondary focus on studies that could guide clinical practice. Our international author team has proposed priority areas for PA and public health research relevant to the COVID-19 pandemic. Although the current literature provides strong scientific premise for the public health relevance of PA for COVID-19,1,4,8 no research has specifically examined the impact of PA on SARS-CoV-2 infections or produced data directly related to the evaluation of infection control strategies that might impact PA. Evidence on these and other emergent topics is needed in a timely manner to inform PA policy and practice locally and internationally. The author team includes a senior researcher who has studied PA for decades (JFS) and 3 early-career investigators who bring research skills related to PA, the creativity of youth, and diverse geographic and cultural experience, having grown up in India (DA), Nigeria (AO), and Mexico (DS). We have interdisciplinary expertise in behavioral science, spatial epidemiology, urban health, physiotherapy, and health promotion. Our goal is to stimulate research studies that should be started now in multiple countries, especially among those countries most affected by the SARS-CoV-2 virus, to inform effective PA promotion strategies to be applied during the current pandemic, as well as to improve preparedness for future pandemics. Each author nominated study ideas, and consensus was reached on the highest priorities based on the need to conduct the study during the pandemic, direct relevance to practice or policy, and feasibility. The 7 research topics selected for inclusion in the present paper are just a few of those initially nominated by the authors. We encourage investigators to plan studies on the topics suggested here and identify additional questions related to PA and COVID-19 that deserve to be investigated. For each research topic below, we briefly explain the purpose of the study, though few methodological details are provided, on the assumption investigators will bring their own skills and creativity to each study. We provide a rationale for the importance of each topic and summarize the significance for policy or practice. We also highlight a few challenges likely to be encountered in conducting each type of study.