Background

On March 11, 2020, the World Health Organization declared coronavirus disease 2019 (COVID-19) a pandemic. To tackle viral spread, person-to-person exposure was limited by imposing public movement restrictions. As a result, individuals' physical activity was impacted; there was a drastic change in exercising, walking, and bicycling for transportation and leisure [1]. Sedentary behavior often replaced time spent engaging in physical activity, as the stay-at-home restrictions reduced such opportunities. Even when restrictions were lifted, public facilities (indoor and outdoor) were closed or limited to curtail crowding [2].

The immediate impact of stay-at-home orders on physical activity has been documented through self-reported and device-based metrics. For example, in a convenience sample of 13,503 adults from 14 countries, self-reported moderate-to-vigorous physical activity declined by 41% following pandemic-related restrictions [3]. The decline was greater for work activities than leisure activities, for those with more baseline physical activity compared to those with lesser physical activity, and for younger adults compared to older adults. Other studies using activity trackers indicated immediate declines in step counts (i.e., an indicator of walking levels) attributable to the pandemic in Japan [4], Singapore [5], the United States [6], and worldwide [7,8,9,10], although the magnitude of results varied between countries. There is evidence of similar impacts on physical activity among children [1, 11].

The immediate impact of stay-at-home orders has also been documented for sedentary behaviors, characterized as activities while awake with an energy expenditure of 1.5 metabolic equivalents or less while sitting, reclining, or lying [12]. A systematic review found five studies of apparently healthy children and 26 studies of apparently healthy adults, all of which reported increased sedentary behavior primarily due to the pandemic [11]. Another review included 19 studies of children/adolescents and 45 studies of adults and found consistent increases in sedentary behavior during the pandemic period, with larger gains among children compared to adults [13]. The acute global declines in physical activity and increases in sedentary behavior are of concern since engagement in physical activity improves bone health and weight status for children (age 3 to 5 years), improves cognitive function for children/adolescents (age 6 to 13 years), and reduces the risk of mortality, chronic diseases (e.g., certain cancers, cardiovascular disease, obesity), excessive weight gain, fall-related injuries, and dementia for adults [14]. Engagement in sedentary behavior acutely induces vascular dysfunction [15] and, in the long term, increases the risk of mortality, cardiovascular disease, and type 2 diabetes [14, 16].

Physical activity is one of the priority goals of Saudi Arabia’s Vision 2030 given its importance in chronic disease prevention and health benefits [17]. The Saudi Sports for All Federation outlines the vision, framework, goals, and corresponding strategies to help people of all ages become more physically active [18]. The 2021 Household Sports Practice Survey indicated that 48% of the Saudi Arabia population engaged in at least 30 min/week of physical activity, which was higher than the 2019 prevalence of 45% [19]. Two reviews that included studies through early 2018 found that the prevalence of physical inactivity in Saudi Arabia ranged from 55%-96% among children/adolescents, 73%-91% among female adults, and 50%-85% among male adults [20]. A third review included studies published between 2018–2021 that used population-based sampling in the Saudi Arabia population [21]. Among children and adolescents, approximately 80–90% did not attain at least 60 min/day of moderate-to-vigorous physical activity, while for adults approximately 50–95% had a low or insufficient physical activity that did not meet the World Health Organization’s recommendations [22, 23]. In this same review, about 50–80% of children and adolescents engaged in at least two hours/day of screen time or sedentary behavior, while for adults about half had a sitting time of five hours/day or more.

Due to the COVID-19 pandemic, in Saudi Arabia stay-at-home orders were implemented on March 15, 2020, with a suspension of travel for non-essential work, followed by a nationwide curfew from March 23 to April 5, 2020 [24]. The curfews were extended until May 28, 2020, when most regions began easing the curfews. We conducted a scoping review to systematically describe physical activity and sedentary behavior (i.e., physical behaviors) among people of all ages in Saudi Arabia from the pre-COVID-19 pandemic period to the post-movement restriction period. A review focused on Saudi Arabia can bring an understanding of the impact of the pandemic on physical behaviors, identify groups that may not have returned to their pre-pandemic levels, and highlight potential needs for future research and surveillance.

Methods

Search methods

The scoping review protocol was developed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) statement [25]. Since this review focused on documenting the pandemic-induced change in the prevalence of physical activity and sedentary behavior, and was a scoping rather than a systematic review [26], the protocol was not required to be registered with any platforms. The completed PRISMA-ScR checklist can be found in Supplement 1 [25].

We searched six databases (Cochrane Library, Global Health [EBSCO], PubMed, Scopus, SPORTDiscus [EBSCO], and the World Health Organization Global Index Medicus) on March 3, 2022, with the search strategy detailed in Supplement 2. After manually removing duplicate citations with reference management software, two authors independently screened all titles/abstracts and full-text articles for inclusion using Covidence systematic review software (www.covidence.org; Veritas Health Innovation; Melbourne, Australia), with discrepancies resolved by consensus.

Inclusion and exclusion criteria

Inclusion criteria were studies that either assessed physical activity or sedentary behavior before and during the pandemic, or asked participants to recall how their physical behaviors changed due to the pandemic. We included studies published between March 1, 2020 and March 3, 2022 that reported on physical activity or sedentary behavior in Saudi Arabia. We included observational studies published in either English or Arabic. Both self-reported and device-based measures of physical activity and sedentary behavior were included in the review.

We excluded studies that did not collect data from March 2020 to March 2022 or did not report the impact of the COVID-19 pandemic on physical behaviors. We also excluded studies that did not report data specifically for Saudi Arabia. We excluded studies that did not include a measure of physical activity or sedentary behavior. For example, studies that discussed “intention to exercise” were excluded since that was not a direct measure of physical behaviors, such as in Alshareef et al. [27]. We excluded studies of hospitalized or institutionalized adults. Grey literature, dissertations, commentaries, and conference proceedings were also excluded.

Abstraction and analysis

Once the study inclusion was confirmed, one rater abstracted study details and a second rater checked the abstraction, with discrepancies resolved by consensus. The abstraction tool included the study name, study purpose, data collection period, region, sampling methods, target population, inclusion and exclusion criteria, and sample size. Information abstracted on the sample included age, gender, and nationality. We classified age groups based on the predominant age included in the study: children 1 to 12 years, adolescents 13 to 17 years, and adults 18 years and older [28]. For physical activity and sedentary behavior, we collected results at various time points (e.g., before and during lockdown) and the methods used (e.g., questionnaire and definitions).

The quality of each study was assessed to identify strengths and weaknesses. This was performed by having two reviewers answer ten questions about each study, with disagreements between the raters resolved by consensus. We used the Joanna Briggs Institute Prevalence Critical Appraisal Tool Checklist for Prevalence Studies to assess study quality [29], making modifications and additions to fit the purposes of this review (Supplement 3). In recognition that objective quality assessment tools treat each threat to validity equally, [30] we did not intend to provide a total score for each study. Instead, we used the quality assessment results to focus on the specific threats to validity identified across the included studies.

Results

A total of 286 records were found; after manually removing 77 duplicates across databases, 209 records were screened for inclusion (Fig. 1). In the title and abstract screening stage, 162 records were excluded as irrelevant. After a full-text review of 47 reports, we included 19 studies [24, 31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48], all published in English.

Fig. 1
figure 1

PRISMA flow diagram of the search strategy and results for the scoping review. From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. https://doi.org/10.1136/bmj.n71. For more information, visit: http://www.prisma-statement.org/

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Most studies were cross-sectional in design, except for four studies that collected data at two [35, 36, 45] or seven [43] time points (Table 1). Data collection mainly occurred in 2020, except for the study by Abdulaziz et al.[32] (data collection: September 2020 to February 2021) and Almugti et al. [38] (data collection: July 2021 to August 2021). Most data collection occurred for three months or fewer, except for Abdulaziz et al. [32] that collected data over five months. Analytic sample sizes ranged from 65 [46] to 30,134 [43], with a median of 363 (interquartile range 262 to 640).

Table 1 Description of each study included in the review (n = 19)
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Studies were conducted in certain regions of Saudi Arabia such as Al-Ahsa [45], Jeddah [33, 34, 46], Qassim [32], Riyadh [35, 36, 47], or in multiple regions [31, 40,41,42]. Other studies included participants from the entire country, either stated explicitly [37, 38, 43, 44] or implied [24, 39, 48]. The most common sampling procedure was some combination of convenience sampling through social media platforms, email, radio, or mailing lists [24, 31, 33, 38,39,40,41,42, 44, 46, 48]. Other studies used country-level proportional quota [43] or simple random sampling through health clinics [32, 34, 35], universities [36, 45], or municipal forum groups [47]. The sampling technique was not reported for one study [37].

Three studies included children and adolescents [34, 38, 44], 1 study included participants aged 15 to 75 years (which we assigned to the adult group) [24], and the remaining 15 studies included adults at least 18 years of age [31,32,33, 35,36,37, 39,40,41,42,43, 45,46,47,48]. All studies enrolled both males and females, except Al-Musharaf et al. [36] who enrolled females only. Some studies enrolled only participants of Saudi nationality [36,37,38, 43, 46], while others included Saudi and non-Saudi nationalities residing in the country [24, 40, 41, 47]. Ten studies did not report the nationality of participants [31,32,33,34,35, 39, 42, 44, 45, 48].

Impact on physical behaviors of children/adolescents

Three studies recruited children/adolescents through social media platforms [38, 44] or a pediatric endocrine clinic [34]. The age range was wide for all three studies, from a minimum age of 2 [34], 3 [38], or 6 [44] to a maximum age of 15 [38, 44] or 18 years [34]. All relied on parental reports, although one study also allowed self-reporting [34] (Table 2). The questionnaires were administered online and asked about the daily duration of physical activity [34], daily duration of moderate-to-vigorous physical activity [38], or frequency of participation in physical activity [44] before and during the lockdown. All three studies conducted measurements at a single time point.

Table 2 Physical activity results from the scoping review (n = 19)
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The lockdown was associated with a 20-percentage point decrease in moderate-to-vigorous physical activity of at least one hour/day [38] and a three-percentage point decrease in the percent classified as physically active [44]. The third study among participants aged 2 to 18 years with diabetes reported that the lockdown was associated with decreased physical activity for 66.1% of the sample, increased physical activity for 19.0%, and no change for 14.9% [34].

Two studies assessed sedentary behavior by asking parents to report time on digital screens [38] or time spent playing video games and watching television [44] (Table 3). Compared to the pre-lockdown period, the lockdown period was associated with 24.0, 35.0, and 22.5 percentage point increases in the proportion of children/adolescents on screens for > 2 h/day [38], video games for >  = 3 h/day [44], and watching television for >  = 4 h/day [44], respectively.

Table 3 Sedentary behavior results from the scoping review (n = 8)
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Impact on physical behaviors of adults

Three studies recruited adults through health clinics [32, 35], and the remaining studies recruited through social media platforms [24, 31, 33, 39,40,41,42, 46, 48], universities [36, 45], municipal forum groups [47], proportional quota sampling from throughout the country [43], or was not reported [37]. All but one study relied on self-reported physical activity assessed using questionnaires (Table 2). These included the International Physical Activity Questionnaire [31, 37], the Global Physical Activity Questionnaire [36, 45], or some other questionnaires that experts designed and pilot tested [24, 33, 40, 43], assessed for reliability [48], or not pilot tested (or unreported as such) [32, 39, 41, 46, 47]. The exception was Al Fagih et al. study [35] that enrolled patients with cardiac implantable devices and relied on the accelerometer embedded in those devices for assessing the duration of physical activity for just over a month immediately before and after lockdown. Among 82 patients, median total physical activity declined from pre-lockdown (2.4 h/day) to lockdown (1.8 h/day). The other clinic-oriented study found that 30.1% and 76.7% reported decreases in exercise and park visits, respectively, during the lockdown than before the lockdown [32].

Studies found that fewer adults met recommendations for physical activity [36, 39, 45] or fewer classified themselves as “active or very active” compared to before the lockdown [48]. Studies also found that the lockdown was associated with lower daily or weekly physical activity levels [31, 33, 41,42,43, 45,46,47], lower exercise [37], and less daily walking and participation in household activities [24]. Other studies found an increase in swimming [24] and an increase in time spent exercising at home [40] associated with the lockdown. One study explored the results by gender and found that lower physical activity during the lockdown compared to the pre-lockdown period was similar for both women (n = 90) and men (n = 154) [42].

Six studies assessed sedentary behavior using a questionnaire (Table 3). They found that sitting time increased, both overall [31, 33, 36, 45] and while at work [47], and daily screen time increased, all attributable to the lockdown [48]. Specifically, two studies using continuous measures reported an increase in sitting time of 33.5 min/day [36] or 69.1 min/day [45]. Three studies using a categorical measure reported that the proportion of adults with > 6 or ≥ 6 h/day of sitting time [31] or screen time [33, 48] increased by 20.5 to 24.0 percentage points.

Quality assessment

The quality assessment tool, comprising ten questions and applied to the 19 studies, is provided in Table 4, with the corresponding questions itemized in Supplement 3. All studies had data analysis with sufficient coverage (n = 19, question 5), and most measured physical behaviors in a standard way for all participants (n = 17, question 8). Most studies described study subjects and the setting in adequate detail (n = 14, question 6) and used a valid method to assess the volume of physical behaviors (n = 13, question 7). Twelve studies summarized physical behaviors using appropriate analytic methods (question 10), and about half of the studies provided sample size justification (n = 10, question 3). However, few studies sampled participants appropriately (n = 4, question 2) or provided an appropriate sampling frame to address the target population (n = 1, question 1), with most studies recruiting participants through social media platforms, professional networks, health clinics, or universities. Few studies also assessed physical behaviors at least once before and once after lockdown (n = 4, question 9) or reported an adequate response rate or appropriately managed non-response (n = 3, question 4; 15 did not report on response rate).

Table 4 Quality assessment results with studies listed in alphabetical order by the first author's last name (n = 19)
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Discussion

This scoping review, based on 19 studies from Saudi Arabia, found consistent evidence across the available literature indicating that physical activity declined and sedentary behavior increased during the COVID-19 lockdown period compared with before. This was most consistent for children, adolescents, and adults across all studies, and was similar for men and women, as reported in one study [42]. For adults, physical activity was lower with the lockdown by approximately 5 to 15 percentage points when considering the studies that classified the proportion as either “active” or “meeting physical activity guidelines” and sedentary behavior was higher by approximately 20 to 25 percentage points for studies that classified the proportion with ~ 6 h/day or more of sitting or screen time.

For children/adolescents, all three studies indicated lower physical activity or moderate-to-vigorous physical activity with the lockdown [34, 38, 44], while two studies indicated a higher proportion of children/adolescents spent time on digital screens [38], playing video games [44], and watching television during the lockdown [44].

There were a couple of notable exceptions among adults, wherein the lockdown was associated with a self-reported increase in swimming [24] and an increase in time spent exercising at home [40]. The higher time spent exercising at home was expected, since time for exercising elsewhere may have been spent at home. Another study reported home exercise among adults but found fewer home activities with the lockdown [24].

We identified four reviews of the global impact of COVID-19 on physical behaviors to compare our results. These reviews found that studies consistently reported lower self-report or device-measured physical activity [1, 11, 49] and higher sedentary behavior [1, 11, 13] associated with lockdown policies. People who were more active prior to the pandemic had larger declines in physical activity [11]. As noted by Stockwell et al.[11], these findings are despite health practitioners and various government organizations guiding how to stay active in self-quarantine and during a lockdown.

The detrimental impact of the lockdown on physical activity was also documented among children/adolescent patients with diabetes [34] and adult patients with heart failure [35] in Saudi Arabia. Other reviews identified studies from different countries that indicated similar declines in physical activity as a result of the lockdown among patients with diabetes, heart failure, congenital heart disease, obesity, and neuromuscular disease [1, 11, 49].

Our review findings are also consistent with an online cross-sectional survey of 2970 adults conducted in April 2020 from the Middle East and North Africa (MENA) region, wherein no physical activity engagement increased from before the pandemic (34.9%) to during the pandemic (39.1%) [50]. Additionally, they found other adverse health impacts over the short term, including weight gain, longer sleep time, and higher reporting of irritability, physical and emotional exhaustion, and tension. Other studies in Saudi Arabia or the MENA region found detrimental impacts of the pandemic on physical health, including changes in eating habits [51], weight gain [51, 52], diabetes [27, 34, 53], and mental health [54,55,56]. Awareness of increasing physical activity is needed for children, adolescents, and adults in Saudi Arabia [21] since there has been a recent upward trend in obesity and diabetes [57,58,59]. Taken together with the findings from this review, there is concern over the long-term impact of these observations on physical behaviors. Increasing physical activity and decreasing sedentary behavior is a worthwhile endeavor, given its potential benefit in reducing hospitalizations, admission to an intensive care unit, and death among those with COVID-19 [60, 61].

Physical activity is impacted by the physical environment, including built and natural surroundings [62]. For example, parks provide a crucial place for physical activity and general recreation, particularly in more temperate areas of Saudi Arabia and seasonably cooler times of the year. In our review, one study in the Qassim region found that adults self-reported fewer park visits during the lockdown than before the lockdown [32]. A prospective study in the United States found an increase in park visits at the start of the pandemic, followed by a marked decline in lockdown near closed parks but not near open parks [63]. Once closed parks opened again, their usage increased to levels found at the start of the pandemic. From a worldwide perspective, park visits increased with the start of the pandemic and were lower when the government levied stay-at-home restrictions [2]. If park observation or usage data exist in Saudi Arabia, it would be valuable to investigate whether the patterns followed global trends. Furthermore, an investigation into the impact of the built environment on changing physical behaviors during the pandemic would be worthwhile [64].

Limitations of the studies included

We found several notable limitations in the current literature that were reviewed, both from the quality assessment (Table 4) and from our observations. First, most studies were cross-sectional, relying on participants to self-report activities before and during the lockdown. Recency bias is a threat to these studies, whereby activities occurring more recently might be easier to report than those occurring more distant in time. Prospective measurement, accomplished in four studies, reduces the risk of bias [35, 36, 43, 45]. This limitation is especially pertinent for two studies that collected data in 2021 [32, 38]. Second, many studies used convenience and nonrepresentative samples, particularly relying on social media platforms for recruitment. While these studies offer the advantage of lower costs and quick access to participants, they also limit participation to those without access to social media platforms and those unwilling to participate using those recruitment channels. This further limits the generalizability of the results.

Third, assessments were mostly based on self-reporting or parental-reporting using a wide variety of questionnaires, precluding our ability to summarize findings with meta-analytic techniques accurately. In fact, many questionnaires appeared non-standardized and did not provide information about the total volume of physical activity. Using valid and reliable metrics for this population would be preferred. Fourth, many studies lacked information on the nationality of their sample, and most studies did not report findings by potential modifiers, such as gender, age, socioeconomic status, region of the country, nationality, or health-associated metrics, possibly due to sample sizes. Fifth, since the period before the COVID-19 pandemic and during the lockdown were not the same seasons of the year, seasonality could confound the relationships observed. Finally, although we included three studies on children and adolescents, the age range was wide and primarily based on parental reporting, which is limited [65]. It would be helpful to document the impacts by narrower age groups to discern any differences that might have a lasting effect on physical behaviors in the future. However, despite these limitations, the findings of the lockdown’s impact on physical behaviors were largely consistent. Future studies are needed to prospectively document physical activity and sedentary behavior changes from pre-pandemic to post-lockdown.

Strengths and limitations of this review

This scoping review was comprehensive, with searches conducted in six databases, which included Arabic studies, although there were none. To our knowledge, this is the first review to describe the impacts of the COVID-19 pandemic on physical activity and sedentary behavior in Saudi Arabia among children, adolescents, and adults [66]. Based on our inclusion criteria, we accepted all papers regardless of study quality but quantified study quality using a previously developed tool. Despite the strengths of this review, several limitations also exist. The questionnaires used across studies were heterogeneous, as was how they were analyzed, limiting our ability to meta-analyze findings to summarize results. The lack of reporting of findings by sociodemographic and health-related metrics also precluded our ability to summarize across subpopulations.

Conclusions

In 2021, the Saudi Sports for All Federation set a target to decrease the prevalence of physical inactivity by 30% in adults by 2030 [18]. The findings from this scoping review stress the need to improve physical activity and curtail sedentary behavior in Saudi Arabia, particularly in light of the apparent decline in physical activity and increase in sedentary behavior during and following the COVID-19 lockdown period. This is in agreement with recent worldwide reports on physical activity among children, adolescents, and adults [67,68,69]. Colleagues have identified the global pattern of unhealthy lifestyle behaviors (including physical behaviors) and the COVID-19 pandemic as a “syndemic”, wherein two or more health conditions or diseases negatively interact [70].

Major areas of focus to support physical activity were designated by the World Health Organization [71] and the International Society for Physical Activity and Health [72]. Some of the Gulf Cooperation Council countries have national policies and strategies to promote physical activity, but implementation is generally low [73]. Others have called for a coordinated regional effort to promote physical activity and reduce sedentary behavior [73]. Consideration should also be given to the specific barriers and facilitators of physical activity and sedentary behavior in Saudi Arabia [74, 75] and the socio-ecologic correlates relevant to this unique time period [76]. Given the widespread impact of the COVID-19 pandemic on other health behaviors, it would be important to continue tracking behaviors and identify subpopulations that may not have returned their physical activity and sedentary behavior to pre-pandemic levels to focus on intervention efforts.