Artigos

Introduction
The COVID-19 pandemic had far-reaching social, health, and economic impacts on a global scale1. In particular, when considering population health, the effects can be categorized as direct (i.e., those directly related to infection, hospitalization, and mortality) and indirect (i.e., consequences associated with the social restrictions implemented to curb the virus spread) 2.

One of the most notable effects of the pandemic social distancing measures was decreased physical activity3. During the initial months of the pandemic, there was a significant decline in people’s engagement in physical activity, raising concerns about the potential consequences for their physical and mental well-being 4–6. Simultaneously, there was an increase in anxiety and depression symptoms, highlighting the growing concerns regarding mental health issues within the population during this period 7–9.

The COVID-19 pandemic had a profound impact on healthcare systems worldwide. The urgent focus on treating COVID-19 patients resulted in compromised management of other medical conditions, particularly in developing countries such as Brazil, where demand for public healthcare services is substatial10. A specific concern arose about individuals with chronic health conditions (e.g., hypertension, diabetes) who faced challenges accessing medications and effectively managing their diseases 11.

As vaccination efforts commenced in January 2021 in the Rio Grande do Sul state, restrictions gradually eased. Before the third wave (June 2021), immunization had been initiated in Brazil, with nearly 40,000 individuals in the Rio Grande do Sul state receiving their first vaccine dose12. Even though 79.7% of the Brazilian adult population has completed the COVID-19 vaccination protocol, the long-term effects of the pandemic might still exert an impact on people's health and the public healthcare system, both directly and indirectly. The PAMPA Cohort was designed to evaluate the long-term impact of the COVID-19 pandemic on the physical and mental health outcomes of adults residing in the southernmost state of Brazil. Here, we presented the data from the wave 4, the updated cohort profile and methodology.

Methods
Study design and sample
The PAMPA Cohort is a prospective cohort study designed to assess the long-term impacts of the COVID-19 pandemic on the physical, mental, and behavioral well-being of adults. The study protocol was approved by the ethics board of the Physical Education faculty at the Federal University of Pelotas, Brazil (CAAE: 31906920.7.0000.5313). The study occurs in the Rio Grande do Sul, the southernmost Brazilian state bordering Argentina and Uruguay. As of September 2022, the state had reported more than 2,728,937 confirmed cases of COVID-19 and 41,029 deaths 13.

Initially, we planned to conduct three data collections: June 2020 (assessed before [retrospectively] and during the COVID-19 pandemic), December 2020, and June 2021. With the pandemic progression, three additional data collection waves were planned, with the first in June 2022 (wave 4), followed by waves 5 and 6 in the same months in 2023 and 2024, respectively. Briefly, the study sample consists of adults aged 18 years and over living in Rio Grande do Sul state. We conducted a sample size calculation aiming to balance the sample within all the state regions, and after accounting for losses and refusals, the required sample size was 1,767. More details about sample size calculation can be found elsewhere 14.

Participant recruitment
The recruitment was conducted in two phases, each lasting four weeks. Briefly, a four-arm approach was adopted to reach participants in all regions of the state (Missioneira, Norte, Sul, Centro-Oeste, Serra, Vales, Metropolitana, in Portuguese). This approach involved sending messages to researchers personal contacts, creating social media campaigns to disseminate the questionnaire link, sending a press release to local media and state agencies (i.e., health departments), and sending messages to universities to be shared with their students, faculty, and staff.

The second recruitment phase involved following up with participants who had completed the questionnaire during the first data collection in June/July 2020. Participants who provided contact information (n=1,132) were contacted via email, SMS, or WhatsApp/Instagram messages, with three attempts made on each network on each network over a three-day interval. Those who did not respond were considered lost to follow-up.

Questionnaire
An online-based, self-administered questionnaire was created using the RedCap platform 15. Participants answered questions on mental health, physical activity, low back pain (LBP), chronic disease management, sleep, COVID-19, and food security. The assessment for each variable is presented in Table 1, and further details are outlined below.

Participants were asked about LBP in the last six months. LBP was assessed by participants experience (i.e., yes/no), pain intensity (i.e., numerical pain rating scale), activity limitation related to LBP (i.e., yes/no), and care-seeking behavior (e.g., General Practitioner, Physiotherapist) 16.

Mental health was assessed through the Hospital Anxiety and Depression Scale (HADS), which has 14 items, seven in each domain (i.e., depression and anxiety). The maximum score is 21 points, as each item can be scored from 0 to 3. Thus, participants are classified, based on their scores, as follows: non-cases (less than 7 points), mild (between 8 and 10 points), moderate (between 11 and 14 points), and severe cases (between 15 and 21 points) 17,18. In addition, a single question on self-rated memory was included, aiming to identify subjective cognitive decline 19,20.

We assessed chronic diseases (e.g., diabetes, high blood pressure, cancer, heart disease, HIV/AIDS) through questions used on the Brazilian Surveillance of Risk and Protection Factors for Chronic Diseases by Telephone Survey (VIGITEL) 21 and the National Health Survey 22. A binary variable was built considering participants who report at least one disease and those who report none. Additionally, we asked participants about medication-related (e.g., access, adherence to treatment, and reasons not to take), healthcare characteristics (e.g., type), and access (e.g., reasons not to seek care) 11.

Participants also provided data on moderate-to-vigorous leisure-time physical activity practice (i.e., yes or no), frequency (i.e., days per week), and time (i.e., minutes per day) in the last seven days 23. In addition, we included questions on physical activity type (e.g., walking/running, strength exercises), place (i.e., at or out of home) 24, motivation to practice, and use of digital platforms. Participants were classified as active or inactive based on the WHO 150 min/week recommendation 25.

Sleep time was assessed by asking participants about their average nightly sleep duration over the past two weeks. We also evaluated the use of sleep medication during the same period, with responses classified as “No” or “Yes” 26. Body mass index (BMI) was calculated based on self-reported weight and height, and participants were classified as normal (<18.5 km/m2), overweight (18.5 or < 25 km/m2), or obese (25 or < 30 km/m2).

We used the Brazilian Household Food Insecurity Measurement Scale (Escala Brasileira de Insegurança Alimentar, EBIA), a validated tool designed to assess food insecurity within the Brazilian population 27. Our assessment utilizes a concise version composed of eight items. Each item is a dichotomous question; the possible answers are “yes” or “no.” Based on the cumulative scores derived from these responses, we categorized the food situation into the following levels: food security (0 points), mild (1-3 points), moderate (4-5 points), and severe food insecurity (6-8 points)27. For analysis purposes, we simplified this variable into two categories: “food security” (0 points) and “food insecurity” (1-8 points), grouping participants who exhibited any level of food insecurity.

Participants reported whether they did COVID-19 tests and, in case any of these, had a positive result. A list of symptoms (e.g., fatigue, cough, headache) was displayed for those participants who reported a positive test for COVID-19. For each symptom, there were the following answering options: 1) did not have, 2) three months, 3) six months, 4) 12 months, 5) 15 months, and 6) 18 months or more. Based on this information, we defined long COVID as experiencing any COVID-related symptoms that lasted at least three months28.

Data analyzes
Data were exported to Stata 15.0 (StataCorp, College Station, Texas). We performed descriptive analyses, and data were reported in proportion with their respective 95% confidence interval (95%CI). Significant differences between prevalences were considered when there was no overlap between 95%CI categories.

Results
Table 2 shows the sociodemographic and nutritional characteristics of the 2,691 participants in wave 4. Most of the participants were female (74.5%), mid-age (59.1%), white (88.8%), lived with a partner (64.0%), had tertiary education (68.9%), and were classified as overweight/obese (55.8%).

Table 3 presents the study outcomes in wave 4 (June/July 2022) and compares them with wave 1 (June/July 2020). The prevalence of participants meeting recommended physical activity levels was higher in wave 4 than in wave 1 (32.7% and 23.9%, respectively), and health was the main reason reported for practicing physical activity. Also, we observed an increased prevalence of participants practicing physical activity out of home in wave 4 compared to wave 1 (49.3% and 31.0%). No differences were observed in LBP prevalence within waves, and 75.1% of participants reported LBP in the last survey.

Regarding mental health outcomes, fewer participants in wave 4 were classified as having moderate-to-severe anxiety (29.9%) and depressive symptoms (19.0%) compared to wave 1. However, a higher proportion of participants reported bad/very bad subjective memory in wave 4 (36.5%) (Table 3).

Overall, 70.8% of participants reported having a diagnosed chronic disease, and 42.6% used medication to manage their condition, which was higher than in wave 1. Healthcare access increased from wave 1 to 4, and most participants reported seek care in the private system. In Wave 1 fear of being contaminated with COVID-19 was the most reported reason for not seeking care, and financial issues was the most reported reason in wave 4. Most participants reported sleeping between 7 and 8 hours (55.7%). Roughly one-third reported any level of food insecurity (29.3%) (Table 3).

Regarding COVID-19 outcomes, 84.2% of participants had at least one COVID-19 test, and 59.9% had a positive result (Table 3). Among participants with positive tests, 75% lived with long COVID-19. The most common symptoms reported were fatigue (56.7%), headache (41.9%), memory impairment (41.4%), and cough (40.0%) (Figure 1).

Discussion
The COVID-19 pandemic has left a lasting impact on global populations, both directly and indirectly, necessitating ongoing vigilance. We revealed that even 27 months after the commencement of social restrictions in the state of Rio Grande do Sul, the population is still experiencing adverse effects of the pandemic, including a high prevalence of LBP, reduced levels of physical activity, and moderate-to-severe cases of anxiety and depression.

At the onset of the COVID-19 pandemic, concerns centered around physical inactivity and mental health issues (i.e., depression and anxiety). Previous studies primarily focused on the early pandemic months or specific periods, such as lockdowns 29. Although long-term surveillance of physical activity is vital, studies in high-income countries reported fluctuations in activity levels throughout the pandemic, and data on low/mid-income countries are still needed 30,31. In Brazil, we observed an initial decrease in physical activity during restrictions, followed by a gradual increase 24. However, even after 27 months of the restrictions onset, activity levels in Rio Grande do Sul remained below pre-pandemic levels 6.

Depression and anxiety symptoms surged during the initial restriction period and persisted for nearly ten months 4,5. In contrast to countries such as the UK, where these symptoms decreased post-lockdown, moderate-to-severe symptoms remained elevated in Brazil due to the absence of federal social distancing measures24. This situation contributed to increased COVID-19 cases and deaths in Brazil, economic instability, and an uncertain future 32. These findings underscore the urgency for policymakers to prioritize mental health as a public health concern.

LBP poses a significant challenge, causing substantial productivity losses in Brazil 33,34. The prolonged periods of staying at home and changes in work routines raised concerns about LBP. However, few studies have investigated the prevalence and effects of LBP during the pandemic 35,36. Worryingly, LBP prevalence remained stable compared to initial data collected in 2020, potentially leading to increased physical, psychosocial, and economic burdens associated with LBP.

This is the first study to prospectively investigate the prevalence of long COVID in a large Brazilian adult population, revealing that three out of four adults in Rio Grande do Sul experienced this condition. Long COVID has emerged as a significant consequence of the pandemic, with fatigue and cognitive/memory issues being prominent symptoms. 37,38,39 Crunfli et al. (2022) recently highlighted structural changes in the cerebral cortex associated with COVID-19, potentially leading to “brain fog,” memory complaints, and attention deficits40,41. Previous studies have also suggested the role of vascular-related proinflammatory biomarkers in fatigue symptoms 42. Thus, it is imperative to continually monitor the consequences of COVID-19 to prepare the healthcare system to address the needs of those living with long COVID.

Adequate sleep is crucial for overall well-being 43. Sleep disturbances were more prevalent during lockdown (42.5%) compared to non-lockdown (37.9%) periods and in 2021 compared to 2020 (47.1% and 36.2%, respectively) 44. Both short and long sleep durations, as well as sleep disturbances, have been linked to chronic diseases and multimorbidity 45,46. We showed that nearly 45% of the participants failed to achieve the recommended hours of sleep (i.e., between 7 and 8 hours), raising concerns about future health consequences.

The pandemic disrupted healthcare provision for individuals with chronic conditions (e.g., diabetes, cardiovascular diseases) and became a concern since the systems were primarily focused on managing COVID-19 patients. Furthermore, the upheaval in daily routines was expected to contribute to an increase in chronic diseases such as obesity, cardiovascular diseases, and multimorbidity 47,48. We revealed a significant rise in the prevalence of chronic diseases (70.8%) compared to the initial assessment, indicating a concerning prospect for long-term health conditions.

Ensuring sufficient, abundant, and safe food access to meet the nutritional needs of all individuals is known as food insecurity 49. The COVID-19 pandemic has exacerbated food insecurity in Brazil and globally50,51. Food insecurity affected 29.2% of the population, underscoring the need for government intervention through social and public health policies to address this problem.

Some limitations of our study should be acknowledged. Firstly, although in-person research is currently allowed, we opted for a self-reported online-based approach to ensure data comparability with the previous cohort waves. Secondly, our study design precluded an equiprobable sample. While our sample represents a mid/high-income and educated population, it should be noted that in a low-income and less educated population, the scenario should be worsened. Thirdly, online assessments usually have reduced responses from older and less educated/income individuals due to internet restrictions or the inability to use technology. Nevertheless, the demographic characteristics of our sample correspond with the Rio Grande do Sul state population (i.e., most are white and women)52. However, the PAMPA cohort is the only ongoing, prospective study initiated during the COVID-19 pandemic involving over 10,000 adults in southern Brazil. The data collected will inform public health policies and help prepare the healthcare system for future needs. We are to continue monitoring the population of Rio Grande do Sul state until 2024.

Conclusion
Our data shows that this sample continues to grapple with the enduring impacts of the COVID-19 pandemic on both their physical and mental well-being. Remarkably, even 27 months into the pandemic-era restrictions, physical inactivity, LBP, and mental health issues persist at levels higher than those observed before the pandemic onset.

In light of these findings, it is evident that robust public health strategies are imperative. These strategies should aim to enhance the overall health of the population and mitigate the lingering consequences of the pandemic. Notably, such measures can help safeguard against the indirect effects that may arise in future pandemic scenarios necessitating social restrictions.

Acknowledgements
This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior—Brasil (CAPES)—Finance Code 001.

Authors’ contributions
ELC, NF, FFR, MCS, and AJR conceived the study. ELC performed all analyses and led the writing of the manuscript. FMD, NS, IAP, LSS, JSL, JC, JQSR, CN, and YPV conducted the data collection and revised the manuscript. All authors approved the final version of the manuscript.

Funding
None.

Ethics approval and consent to participate
This research was conducted in accordance with the Declaration of Helsinki on human research. The study was approved by the ethics institutional board of the School of Physical Education, Federal University of Pelotas, Brazil (CAAE: 31906920.7.0000.5313). All participants gave informed consent before taking part in the study.

Consent for publication
Not applicable.

Availability of data and materials
The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.

Competing interests
The authors declare that they have no competing interests.


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