impact of covid 19 on athletes essay

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Psychological Impact of the COVID-19 Pandemic on Athletes

Clifford c. uroh.

1 Youth Sports Club, Akoka Study Centre, Lagos, Nigeria

2 Human Kinetics and Health Education, University of Lagos, Lagos, Nigeria

Celina M. Adewunmi

Associated data.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

This study explored the influence of athletic identity and sports participation on the psychological well-being of athletes during a pandemic. The objective of the study was to understand the psychological impact of the coronavirus lockdown measure on athletes who were not able to carry out their normal daily routine. Athletes from nine different sports completed an online survey during the sixth week of the total lockdown in Nigeria. The online survey consists of an athletic identity scale and the Kessler Psychological Distress Scale (K10). Data collected were analyzed using Multiple regression and the Mann-Whitney test at 0.05 level of significance. The result of the findings revealed that category of sports (individual and team) ( M = 0.73, β = −6.116) and athletic identity ( M = 59.16, β = −0.166) predicts psychological distress to some degree. Few individual sports athletes and athletes with low athletic identity are prone to higher levels of psychological distress than team sports athletes and athletes with high athletic identity during the coronavirus pandemic lockdown. Individual sports athletes reported elevated levels of psychological distress compared to team sports athletes ( z = −2.186, p = 0.03, r = 0.27). In conclusion, the results have confirmed that some athletes competing in individual sports experience elevated levels of psychological distress during the coronavirus pandemic, therefore they need the support of a sports psychologist during such periods to help in maintaining their psychological well-being.

Introduction

Pandemics have been around for more than a century, and they continue to impact humanity negatively. There have been pandemics such as the H1N1 in Mexico, which rapidly spread to the whole world (Cowling et al., 2010 ), the MERS-COV, Ebola, and SARS which came later. These pandemics cause enormous negative economic, social, and security impacts on the global community (Qiu et al., 2017 ), but their psychological influence is hardly recognized. Recently, the world started to experience another pandemic caused by the novel coronavirus-19 that originated in Wuhan, China (Toresdahl and Asif, 2020 ). The coronavirus has a similar mode of transmission to SARS and MERS (Dong and Bouey, 2020 ), but it has spread so fast to many other countries, including Nigeria.

With the large-scale spread of this coronavirus and the knowledge of its transmission, most governments introduced heightened measures to control its spread (Taylor et al., 2008 ; Dong and Bouey, 2020 ). These measures include the use of protective equipment and the introduction of non-pharmaceutical protocols such as social distancing, hygiene guidelines, and, in more severe cases, a total lockdown (Cowling et al., 2010 ; Schinke et al., 2018 ). The consequence of these measures implied that gatherings of people were not welcome (Dong and Bouey, 2020 ), and as a result, many sports events earlier scheduled were cancelled or suspended due to the high risk of spreading the virus. The major events postponed include the Olympics slated to be held in Tokyo, UEFA Euro Cup, UEFA Champions League, and CAF Nations Cup qualifiers (Samuel et al., 2020 ). Most football leagues and competitions were also affected by safety measures. In Nigeria, the National Sports Festival was postponed indefinitely, pending advice from the Nigeria Centre for Disease Control (Okpara, 2020 ). As expected, the postponement of these competitions came with a lot of economic hardships on host cities and sports event organizers. Sports fans also had their fair share. These postponements also have a significant psychological influence on the athletes who are to participate in these competitions.

Most studies have focused on the psychological implication of pandemics on the general population (McAlonan et al., 2007 ; Taylor et al., 2008 ), with very few paying attention to special populations like athletes in recent times (Turbeville et al., 2006 ; Pillay et al., 2020 ). Recent research on home confinements as a result of the coronavirus have shown that athletes experience negative psychological effects (Dong and Bouey, 2020 ; Toresdahl and Asif, 2020 ). In fact, some studies have revealed that athletes experience mental health challenges just like the general population and are therefore not immune (Gouttebarge and Kerkhoffs, 2018 ; Schinke et al., 2018 ; Pillay et al., 2020 ). On the other hand, other studies have stated that sports provide a protective effect that prevents psychological disturbances. For example, a study was carried out to compare general health in athlete and non-athlete women (Alamdarloo et al., 2019 ). The study found out that athletes differed from non-athletes in anxiety and severe depression, with the mean scores for these two variables lower in athletes compared to non-athletes. Similarly, another study suggested that physical activity in the right quantity has the potential to reduce symptoms of anxiety and depression (Siefken et al., 2019 ). It seems that there is no agreement as to the existence of mental health problems among sports athletes due to the belief that sports prevent ill mental health. However, recent studies on mental health in sports among elite athletes have revealed that, compared to the general population, athletes are under-diagnosed, and the culture of mental toughness promotes this situation (Schinke et al., 2018 ). Many athletes who exhibit these ill mental health symptoms, such as distress, burnout, depression, or sleep disturbance, adverse feelings or thoughts, and drug abuse (Gouttebarge and Kerkhoffs, 2018 ), hide it from their teammates and coaches due to the mental toughness culture that pervades the atmosphere.

Furthermore, athletes who suffer from these conditions may not inform their coach or teammates for fear of losing their playing position. If they compete in individual sports, they may not want to be deprived of competing against an opponent. Studies have shown that individual sports athletes are at a greater risk of psychological distress than team sports athletes (Tasiemski and Brewer, 2011 ; Purcell et al., 2019 ). Mental health challenges have been suggested to be more prevalent in individual sports athletes compared to team sport athletes (Pluhar et al., 2019 ), owing to the nature of individual sports. Specifically, individual sports athletes have to deal with both success and failure on their own, while team sports athletes enjoy a shared responsibility (Mladenović, 2019 ). Furthermore, team sports provide more social opportunities compared to individual sports in which there is no peer support. This situation may be tougher for athletes who are much younger and inexperienced (Nicholls et al., 2016 ). For instance, studies have emphasized the high risk which college athletes are exposed to, including the inability of college athletes in dealing with the challenges that they encounter. In fact, youth athletes who are unable to deal with perceived failure prefer to drop out of sports participation (Crane and Temple, 2015 ), hence experiencing a depletion in their athletic identity. Similarly, a study on collegiate athletes' reaction to loss revealed that unsatisfied athletes tended to decrease their athletic identity compared to athletes who were satisfied by their performance (Brewer et al., 1999 ). Athletes reduced their self-identification with their athletic role as a response to poor performance.

Athletic identity refers to the degree to which an individual attributes or identifies with the athletic role. Although it is developed through social interaction and validation, it is accompanied by both negative and positive outcomes (Verkooijen et al., 2012 ; Reifsteck, 2013 ). This identity with the athlete's role is confirmed by others and motivates the individual involved to be more committed to training and sports goal achievement. Athletes who are high in athletic identity exhibit behaviors such as going regularly to the gym and sports field and even buying mostly athletic gears and equipment. However, an overemphasis on athletic identity may lead to negative outcomes as stated earlier. Studies have stated that a reduction in the opportunity to participate in sports harms the mental health of athletes and their athletic identity levels (Masten et al., 2006 ; Miller and Hoffman, 2009 ). Consequently, when an athlete is not regularly allowed to express himself/herself, there is a high tendency for that athlete to experience a reduced athletic identity (Fraser-Thomas et al., 2008 ; Altintaş and Kelecek, 2017 ). This phenomenon is expected more in youth athletes, who may drop out of sports (Nicholls and Polman, 2007 ; Hall et al., 2017 ; Lewis et al., 2017 ), than in elite professional athletes who may cope with such a situation. In addition, it has also been revealed in other studies that when athletes, especially those high in athletic identity, are unable to engage in their daily routine as a result of injury (Mittly and Nemeth, 2016 ), they start to resent their identification as athletes (Hadiyan and Sheikh, 2015 ). This makes athletic identity a critical factor that should be considered especially in athletes as they go through the period of home confinement during the coronavirus pandemic.

Although recent studies are beginning to investigate the psychological well-being of athletes during the coronavirus pandemic (Costa et al., 2020 ; Mehrsafar et al., 2020 ; Pillay et al., 2020 ), most of these studies are from Europe and the USA. More studies are required to better understand athletes' experience from other climes like Africa and, specifically, Nigeria. There is limited knowledge about the influence of athletic identity and sports participation on the psychological well-being of athletes, especially during a pandemic. A recent study explored the differences in gender, type of sport, and competitive level in athletic identity during the coronavirus lockdown and found out that elite athletes and team sports athletes showed higher athletic identity (Costa et al., 2020 ). However, this study did not investigate the influence of extrinsic rewards on psychological well-being and how athletic identity interacts with well-being in athletes during the coronavirus lockdown. Based on this, our study aims to investigate differences by competitive level, extrinsic rewards, and category of sports participation in athletes and understand how athletic identity, age, category of sport participation, and the number of years participating in sports interact with the psychological well-being of athletes during the coronavirus lockdown.

Methodology

Participants and procedure.

The sample comprised 64 athletes from nine different sports: two team sports (football and basketball) and seven individual sports (athletics, cycling, taekwondo, tennis, gymnastics, badminton, and table tennis). The participants were classified as professional athletes ( n = 20), which included athletes who compete in national and regional tournaments, and non-professional athletes ( n = 44) who compete in state tournaments. The authors contacted coaches known to them through voice calls and WhatsApp messages to help in reaching their athletes about the possibility of taking part in the study. This was done during the home confinement period of the total lockdown which started at the end of March 2020. A weblink to the consent form and online survey was made available to coaches and some athletes via WhatsApp from May 5, 2020, during the height of the pandemic lockdown in Nigeria. The online survey was open for 4 weeks from the May 5, 2020 to June 2, 2020. Due to the circumstances at that period, the authors could not determine which sports athletes could take part in the study. Hence, those who responded to the survey by completing it were regarded as study participants, and the participation was anonymous. Since we were interested in athletes all over the country, we did not request their location. The ethical approval board of the Department of Human Kinetics and Health Education was contacted by email, and they approved the study.

The full survey comprised 26 questions covering a range of subject areas; those reported here include demographic information: gender, age category, type of sport, and level in sport. In addition, the respondents were asked about their years of sports participation as well as earnings from sports.

Anxiety and Depression During the Viral Pandemic

To measure psychological distress during the pandemic, the 10 items from the Kessler Psychological Distress Scale (K10) were employed (Andrews and Slade, 2001 ; Kessler et al., 2002 ; Sampasa-Kanyinga et al., 2018 ). The K-10 was developed and validated as a screening tool for assessing the likelihood of common mental disorders in the general population and clinical samples (Kessler et al., 2002 ; Slade et al., 2011 ; Sunderland et al., 2012 ). The K-10 demonstrates strong psychometric properties (Pereira et al., 2019 ) and has been used across different populations and cultures (Chan and Fung, 2014 ; Sampasa-Kanyinga et al., 2018 ). The K10 is a 10-item scale that asks respondents how often they have experienced certain symptoms during the preceding 4 weeks. The participants responded on a five-point scale depending on how frequently they experienced each symptom. The five-point scale ranges from none of the time (1) to all of the time (5). The K10 has items such as item 1 (In the past 4 weeks, about how often did you feel tired out for no good reason?) and item 5 (In the past 4 weeks, about how often did you feel restless or fidgety?). Past research has shown that K10 has satisfactory psychometric properties (Taylor et al., 2008 ; Sampasa-Kanyinga et al., 2018 ). In this study, the internal consistency was satisfactory (α = 0.86).

Athletic Identity

To measure athletic identity, the original 10-item scale for athletic identity measurement was used (Brewer et al., 1993 ; Hadiyan and Sheikh, 2015 ; Tunçkol, 2015 ). This test was chosen because of its ability to measure levels of athletic identity and its high internal consistency index test–retest reliability. The Athletic Identity Measurement Scale is supported as a unidimensional and multidimensional instrument (Brewer and Cornelius, 2001 ). The evaluation of the unidimensional scale can be performed by using the total score to produce a single self-evaluation score that represents the athletic identity, with higher scores indicating a strong athletic identity. The multidimensional scale contains four scales: self-identity, social identity, exclusivity, and negative affectivity (Brewer et al., 1993 ). Self-identity items capture reports that are self-referenced. Social identity items express the degree to which individuals view themselves as occupying the athletic role. Exclusivity measures the self-worth of an individual established through participation in the athletic role. Negative affectivity is the degree to which individuals experience negative emotions from undesirable sporting outcomes such as injury or retirement. The participants were asked to indicate their agreement with each item by responding on a seven-point scale from “strongly agree” to “strongly disagree.” The scale comprised 10 items measuring self-identity (e.g., “I have many goals related to sport”), social identity (e.g., “Most of my friends are athletes”), negative affectivity (e.g., “I feel bad about myself when I do poorly in sport”), and exclusivity (e.g., “Sport is the most important part of my life”). The internal consistency of this questionnaire was satisfactory (α = 0.93).

Data Analysis

The characteristics of the participants were described using frequency distribution, while group differences were subjected to Mann–Whitney tests since the data collected did not meet the assumptions of parametric tests such as small samples and normality of data. To understand whether one group experiences psychological distress more than the other during the coronavirus lockdown, the Mann–Whitney test was conducted to test the difference between professional and non-professional athletes, team and individual sports athletes, and athletes who earned financial rewards from sports participation and athletes who do not earn from sports participation. Multiple regression analysis was performed in order to determine the possible effect of the interaction among athletic identity, years participating in sports, age, and psychological distress scores (criterion variable). We used STATA version 14 for all statistical analysis. All statistical tests were performed at 0.05 level of significance.

Sample characteristics are displayed in Tables 1 and ​ and2. 2 . Results from the Mann–Whitney tests are shown in Table 3 . Analysis by competitive level (non-professional and professional) did not yield any significant difference on psychological well-being between professional and non-professional athletes ( z = 0.63, p = 0.53, r = 0.08). Specifically, professional athletes were not different from non-professional athletes based on psychological distress. There was a significant difference between individual sports athletes and team sports athletes ( z = −2.19, p = 0.03, r = 0.27), but with a small effect size. Financial opportunities did not reveal any significant difference. Athletes who earned from their participation in sports did not differ significantly in psychological distress from those who did not earn from sports participation ( z = 0.46, p = 0.65), and the effect size of the analysis was small ( r = 0.06).

Sample description.

Prevalence of psychological distress by sample characteristics.

Mann-Whitney tests for psychological distress.

Results from the multiple regression with psychological distress as the dependent variable and athletic identity, age, sport type, and years participating in sports as predictor variables are displayed in Table 4 . The results show that the categories of sport participation ( b = −6.116, SE = 2.610, p = 0.023) and athletic identity ( b = −0.166, SE = 0.075, p = 0.03) have significant but negative relationships with psychological distress. The other variables had no significant relationship with psychological distress.

Regression result for psychological distress.

This study sought to investigate the influence of athletic identity on the psychological well-being of athletes during the COVID-19 pandemic. In this study, we were interested in finding out the differences in psychological distress between professional and non-professional athletes, between individual and team sports athletes, and between athletes who earned from sports participation and those who do not earn from sports participation during the COVID-19 pandemic lockdown. There were two significant findings of this study. The first is that individual athletes differed significantly from team sports athletes in their psychological response to the COVID-19 pandemic lockdown. Secondly, we found out that athletic identity has a significant relationship with psychological distress.

Our study revealed that individual sports athletes experienced high psychological distress compared to team sports athletes who experienced low psychological distress. However, our result should be interpreted with caution, owing to the number of individual athletes who participated in the study. Individual sports athletes are at a higher risk of experiencing psychological distress due to the pandemic lockdown that prevents participation in regular sporting activities. Studies have shown that individual sports athletes are at a greater risk of psychological distress than team sports athletes (Tasiemski and Brewer, 2011 ; Purcell et al., 2019 ). Furthermore, other studies have suggested that individual sports provide little or no social opportunities and a lot of personal responsibility for both success and failure, hence making individual athletes more prone to psychological distress compared to team sports athletes (Dias et al., 2010 ; Mladenović, 2019 ; Pluhar et al., 2019 ). For instance, individual sports athletes attribute failure to themselves more than athletes in team sports where there is a diffusion of responsibility, and this situation makes them more prone to psychological distress when compared to team sports athletes (Nixdorf et al., 2016 ).

Based on the result from the multiple regression analysis, our study showed that the age of athletes and the number of years spent participating in sports did not predict psychological distress. However, athletic identity and category of sport participation were able to predict psychological distress to some degree. Athletes who competed in individual sports experienced higher psychological distress compared to those who competed in team sports. This finding is supported by a number of studies (Dias et al., 2010 ; Pluhar et al., 2019 ). The circumstances surrounding the nature of individual sports make the athletes who take part in individual sports prone to psychological distress than team sports athletes (Nixdorf et al., 2016 ; Purcell et al., 2019 ). Furthermore, athletes who reported higher athletic identity experienced lower psychological distress compared to those who reported lower athletic identity. Although there are no studies that have directly reported this finding, our findings are similar to a previous study which showed that an increase in self-identity decreases anxiety levels (Masten et al., 2006 ). The abrupt end to sports events and activities brought about by the COVID-19 lockdown is associated with a loss of aspects that contribute to one's sense of self, which can negatively affect self-identity and lead to depressive symptoms (Tasiemski and Brewer, 2011 ).

We found out that both professional and non-professional athletes do not differ in the symptoms of psychological distress that they reported. This result has been confirmed in a study that sought to investigate the effect of soccer on mental health (Heun and Pringle, 2018 ). It was concluded that participants in football are not different from the general population in mental health problems. Specifically, there are general risk indicators such as negative life events in which both athletes and the general population experience comparable psychological distress (Rice et al., 2016 ; Purcell et al., 2019 ).

With regards to financial compensation, there was no significant difference in psychological distress between athletes who earned from sports participation and other athletes who did earn from their participation in sports. Previous studies have highlighted the importance of non-monetary rewards to athletes over monetary rewards (Podlog et al., 2015 ; Maier et al., 2016 ). Hence, our study suggests that the absence of extrinsic rewards from sports during the COVID-19 pandemic lockdown did not influence the psychological reaction of athletes who usually received financial reinforcement.

The findings of this study have implications for coaches and athletes who compete at state, regional, and national sports tournaments in Nigeria. Nigerian athletes, especially individual sports athletes who depend largely on their sport as a means of achieving their goals, may suffer the consequences of this over-dependence during the COVID-19 lockdown. Sports psychologists are not usually present as part of the support staff to athletes in most sports federations. For this reason, local sports coaches work with athletes based on their experience alone, without any knowledge of mental health, thereby increasing the chances of mental health problems in athletes. Nigeria sports federations should engage the services of sports psychologists as part of the support staff to athletes, include courses that emphasize psychological education in the training programs of coaches, and organize online mental health seminars as part of athlete education during and beyond the lockdown period.

Limitations

The main limitation of this study was the size of the sample, which is relatively low and had more respondents from one sport (football). In addition, most of our samples were from team sports. Hence, the data cannot be easily generalized. More studies with larger samples are needed to be able to generalize the findings. Our study was not able to compare gender differences due to the low number of female athletes responding; more studies are required in this regard. Furthermore, the study included a self-report psychological distress scale which was not validated for the intended population. Hence, we cannot draw any causal conclusion based on the current findings.

In conclusion, the results of this study indicate that individual sports athletes experienced high psychological distress as a result of the COVID-19 pandemic lockdown. The number of individual sports participants in the study were fewer compared to team sports participants, and this may have contributed to this result. Hence, this result should be interpreted with caution. Furthermore, this result should inform practitioners to pay closer attention to athletes who compete in individual sports. For example, the COVID-19 pandemic lockdown is a peculiar situation in which athletes had to be in isolation, away from their sport without any certainty of resumption or any form of real social support from relatives and friends. It might have led to feelings of sadness and hopelessness in some individual sports athletes. For this reason, coaches and the other staff who work with individual sports athletes should regularly keep in touch with the athletes using online interventions during the pandemic lockdown to help them have a sense of belonging. Further research should focus on determining, by comparing different sports, the highest prevalence of psychological distress.

Our data showed that athletic identity and category of sports participation predict, to a certain extent, the level of psychological distress athletes experience during the COVID-19 pandemic lockdown. These findings may have important implications for practitioners, coaches, and athletes. A number of studies have suggested that individual sports athletes experience anxiety and psychological distress more than team sports athletes (Pluhar et al., 2019 ). With regards to athletic identity, it is important to note that athletes may reduce their connection with the athletic role as a means of protecting their self-image (Brewer et al., 2010 ). When some athletes begin to divest or reduce their athletic identity during a pandemic, it may be a sign that they are experiencing psychological distress. However, this might not be the case for other athletes. Nevertheless, it demands some level of awareness from coaches and sports psychologists. Hence, athletic identity should be considered not as the cause of psychological distress but as a potential predictor of psychological distress during pandemic lockdowns. Sports federations in Nigeria should employ sports psychologists who can support athletes in readjusting their goals and adapting to changing circumstances like the coronavirus pandemic lockdown, using accessible online interventions. More research is needed to understand the interaction between athletic identity and psychological distress.

Data Availability Statement

Ethics statement.

The studies involving human participants were reviewed and approved by Department of Human Kinetics and Health Education. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

CU and CA wrote the Introduction, discussion and conlusions. Data collection and analysis was mainly done by CU. The authors approved the submitted version.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Impact of COVID-19 outbreak on the mental health in sports: a review

Affiliations.

• 1 Department of Physical Education, Banaras Hindu University, Varanasi, UP India.
• 2 Department of Physical Education, Janta Degree College, Patla, Ghaziabad, UP India.
• 3 Department of Physical Education, Hindu Girls College, MDU, Sonipat, Haryana India.
• PMID: 37360974
• PMCID: PMC10116474
• DOI: 10.1007/s11332-023-01063-x

Global pandemic, lockdown restrictions, and COVID-19 compulsory social isolation guidelines have raised unprecedented mental health in the sports community. The COVID-19 pandemic is found to affect the mental health of the population. In critical situations, health authorities and sports communities must identify their priorities and make plans to maintain athletes' health and athletic activities. Several aspects play an important role in prioritization and strategic planning, e.g., physical and mental health, distribution of resources, and short to long-term environmental considerations. To identify the psychological health of sportspeople and athletes due to the outbreak of COVID-19 has been reviewed in this research. This review article also analyzes the impact of COVID-19 on health mental in databases. The COVID-19 outbreak and quarantine would have a serious negative impact on the mental health of athletes. From the accessible sources, 80 research articles were selected and examined for this purpose such as Research Gate, PubMed, Google Scholar, Springer, Scopus, and Web of Science and based on the involvement for this study 14 research articles were accessed. This research has an intention on mental health issues in athletes due to the Pandemic. This report outlines the mental, emotional and behavioural consequences of COVID-19 home confinement. Further, research literature reported that due to the lack of required training, physical activity, practice sessions, and collaboration with teammates and coaching staff are the prime causes of mental health issues in athletes. The discussions also reviewed several pieces of literature which examined the impacts on sports and athletes, impacts on various countries, fundamental issues of mental health and the diagnosis for the sports person and athletes, and the afterlife of the COVID-19 pandemic for them. Because of the compulsory restrictions and guidelines of this COVID-19 eruption, the athletes of different sports and geographical regions are suffering from fewer psychological issues which were identified in this paper. Accordingly, the COVID-19 pandemic appears to negatively affect the mental health of the athletes with the prevalence and levels of anxiety and stress increasing, and depression symptoms remaining unaltered. Addressing and mitigating the negative effect of COVID-19 on the mental health of this population identified from this review.

Keywords: Athletes; COVID-19; Isolation; Mental health; PRISMA; Pandemic; Sports.

© The Author(s), under exclusive licence to Springer-Verlag Italia S.r.l., part of Springer Nature 2023, Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

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The Impact of COVID-19 Restrictions on Youth Athlete Mental Health: A Narrative Review

• Published: 11 April 2023
• Volume 25 , pages 193–199, ( 2023 )

Cite this article

• Peter Kass   ORCID: orcid.org/0000-0002-9287-2687 1 , 2 , 3 &
• Tyler E. Morrison 1 , 4  

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Purpose of Review

We discuss current research on the mental health effects of COVID-19 sports restrictions on youth athletes, highlighting the largest problems, as well as how organizations can help youth athletes by preparing for and responding to these problems.

Recent Findings

Millions of children and adolescents worldwide participate in organized sports, which has significant physical and mental health benefits. In 2020, the COVID-19 pandemic triggered large-scale, public restrictions that forced the closure and cancelation of organized youth sports across the world. Sports cancelations not only removed these protective benefits, but also worsened the mental health of youth athletes who were no longer able to participate in their sports.

Youth athletes are even more vulnerable than adults to the negative mental health effects of sports restrictions. The unexpected loss of sports from COVID-19 restrictions disrupted these youths’ athletic identities and worsened youth athlete depression, anxiety, anger, sleep, and quality of life. Restrictions particularly affected certain high-risk subpopulations of youth athletes including females, high school upperclassmen, those from low socioeconomic backgrounds, and those from team sports. Sports organizations could limit the negative mental health impacts of future sports cancelations by implementing at-home training opportunities, remote check-ins with teammates, discussions about athletic identity with coaches and sports psychology professionals, and mindfulness skill-building.

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Introduction

COVID-19, the illness caused by the novel coronavirus SARS-COV-2, was first diagnosed in Wuhan, China, in December of 2019 [ 1 ]. On March 11th, 2020, the World Health Organization declared COVID-19 a worldwide pandemic, which triggered large-scale public restrictions to limit the spread of the illness [ 2 ]. These unexpected regulations had multiple public health consequences, including negative impacts on mental health. During initial COVID-19 restrictions, adults showed increased mental health distress [ 3 , 4 •], including elevated levels of depression and anxiety [ 5 ], while throughout the pandemic, one in four and one in five children experienced elevated levels of depression and anxiety, respectively, with prevalence rates two times higher than those pre-pandemic [ 6 ]. The mental health impacts of COVID-19 restrictions varied across different populations. Elite adult athletes were uniquely affected by the pandemic as COVID-19 social regulations forced professional sports organizations around the world to abruptly cancel competitions, thus impacting both the physical and mental health of elite adult athletes [ 7 •, 8 ].

COVID-19 lockdowns not only impacted adults, but also significantly affected youth athletes’, athletes ages 17 and younger, physical and mental health. During the 2017–2018 US academic year, over seven million high school students participated in interscholastic sports [ 9 ]. Youth sports participation is known to improve physical health [ 10 , 11 ], decrease levels of depression and anxiety [ 12 , 13 ], and improve overall quality of life [ 14 ]. Children and adolescents lost these protective benefits when public health measures shut down most organized youth sports leagues, restricting millions of young athletes’ access to organized sports. The abrupt loss of sports disrupted youth athletes’ physical activity, socialization, and personal identity, which negatively affected their mental health [ 15 , 16 ].

This review summarizes research on the impact that COVID-19 restrictions had on youth athletes’ mental health. We will discuss the effects on youth athletes in general, as well as on specific athlete subpopulations with a higher risk of mental health complications from unexpected sports shutdowns. This review will also discuss the practical implications of this research, including how sports leaders can use this data to re-shape youth sports and limit the negative effects of future shutdowns or restrictions.

Mental Health Effects of COVID-19 Restrictions on Youth Athletes

The COVID-19 pandemic caused numerous psychological and physiological impacts on children and adolescents worldwide. Early pandemic lockdowns caused social isolation stress, aggression, and an increase in adolescent suicide. Children also demonstrated increased rates of obesity during pandemic-related school closures, with greater rises in obesity among boys and non-Hispanic black children [ 17 ].

Youth athletes’ mental health appears to be even more affected by COVID-19 restrictions than that of higher-level adult athletes. Clemente-Suarez et al. posited that youth athletes have fewer physical and psychological resources than adults to draw on when facing unexpected changes, increasing their vulnerability [ 17 ]. While adult athletes have more experience navigating unexpected challenges, youth athletes have not yet had adequate athletic and real-world experience to develop such emotional resilience. Researchers used both qualitative and quantitative methods to explore such effects on youth athletes.

Several studies on youth athletes’ mental health during COVID-19 used a qualitative, phenomenological approach. During Canada’s initial COVID-19 lockdown, researchers interviewed 20 adolescent high school athletes [ 18 •]. The majority of these athletes reported “anxiety,” “fear,” and “shock” following the cancelation of their sports. Many of these athletes also highlighted how losing sports reduced their social connectedness, further exacerbating their anxiety symptoms during COVID-19 lockdowns. Sports departments attempted to keep athletes engaged through social media, but these adolescents stated that social media was not a replacement for in-person connection. Elliott et al. used reflexive theme analysis on data from semi-structured interviews and focus groups with athletes between 15 and 18 years old, their parents, and their coaches to identify how sports cancelations impacted the youth athletes’ mental health. Researchers saw four themes emerge, in a spectrum of emotions that athletes experienced from initial distress to eventual recovery: “recognizing struggle,” “reconnection,” “re-engaging after restrictions,” and “reimagining sport.” Athletes consistently noted the negative impact sports cancelations had on their mental health. They cited feelings of “mourning,” “severe mood changes,” and “anger,” all possible symptoms of depression or anxiety in adolescents. Athletes and parents reported that the primary cause of their mental health symptoms was the loss of physical activity and socializing created by sports cancelations. When sports did return later in the pandemic, athletes also noted how decreases in “fitness and skill” often led to “a decrease in confidence and self-efficacy” [ 19 ].

Other studies used quantitative approaches to evaluate the mental health effects of COVID-19 sports restrictions on youth athletes. One such study surveyed Spanish adolescent athletes using the Profile of Mood States Questionnaire at three time points during Spain’s COVID-19 lockdown: the start of total lockdown (week 0), the transition to partial lockdown (week 6), and the end of lockdown (week 10) [ 20 ]. At the start of total lockdown, when youth athletes felt the loss of sports most acutely, the athletes had significantly higher mood disturbance, depressive symptoms, and confusion, compared to the transition and end time points during lockdown. In a similar study of 544 adolescent Spanish athletes during Spain’s initial COVID-19 lockdown, athletes experienced significantly elevated anxiety symptoms, depressive symptoms, and social dysfunction on domains assessing dual careers (balance of sports, studies, and social life) and health (mental and physical) from the Holistic Monitoring Questionnaire and General Health Questionnaire [ 21 ••]. Bazett-Jones et al. also used similar approaches to compare youth athletes’ mental health before and during COVID-19 lockdowns. They surveyed youth long-distance runners on various measures of mental and physical health 6 months before the COVID-19 pandemic as well as during COVID-19 lockdowns. Compared with their pre-COVID responses, youth runners demonstrated lower motivation to run during lockdowns, as well as different motives for running, including stress relief. Compared to their pre-COVID responses, runners also reported less enjoyment of running, increased anxiety symptoms, and lower food quality consumed [ 22 ••].

Mental Health Effects of COVID-19 Restrictions on High-Risk Youth Subpopulations

While sports restrictions had widespread general impacts on youth athletes’ mental health during the pandemic, they also particularly affected certain high-risk subpopulations of youth athletes (Table 1 ). Female youth athletes, one such high-risk group, had a higher incidence of negative mental health outcomes during COVID restrictions than did male athletes. In one study, researchers used the Holistic Monitoring Questionnaire and General Health Questionnaire-12 to evaluate how severely COVID-19 restrictions impacted youth athletes’ mental health and quality of life [ 21 ••]. Researchers used the questionnaire data to cluster respondents by how severely (mild, moderate, severe) COVID-19 restrictions affected their mental health. The study found that female athletes made up a significantly higher proportion of the severely impacted group than male athletes, 72% versus 28%, respectively, and therefore appeared at higher risk for mental health impacts of COVID-19 restrictions than their male peers. In a separate study of 13,000 adolescent American athletes during early COVID-19 restrictions in America, researchers evaluated athletes’ anxiety, depression, physical activity, and quality of life, using the General Anxiety Disorder 7-Item Screener, Patient Health Questionnaire 9-Item Screener, Pediatric Functional Activity Brief Scale, and Pediatric Qualify of Life Inventory 4.0 [ 23 ••]. Results showed that females reported a higher prevalence of anxiety and depressive symptoms than their male peers. Additional research showed that female youth athletes’ anxiety was considerably higher during the pandemic than it was prior [ 24 ]. Studies of female youth athletes during the COVID-19 pandemic also demonstrated that female athletes had 3.2 and 2.4 times the odds of reporting anxiety and depressive symptoms than male peers respectively [ 25 ]. While there is little research evaluating why female youth athletes reported higher levels of anxiety and depression symptoms during COVID-19 restrictions, there has been research on this phenomenon in female adult athletes. Bowes et al. showed that female adult athletes have comparatively less financial stability and access to home training equipment than their male peers [ 26 ]. Additional studies of female athletes during the pandemic considered the effect of contextual body image, the concept that someone’s body image may differ between the context of their sport and the real world, on female athletes’ mental health. Researchers hypothesized that female athletes who are typically proud of their bodies within the context of their sport may have developed increased body image issues, disordered eating, and depressive symptoms when displaced from their sport and forced to confront socially acceptable body standards outside of athletics [ 27 ]. Further studies of female youth athletes should determine if the underlying causes of their elevated anxious and depressive symptoms are different than the causes in female adult athletes. Such research may also help create support systems that protect female youth athletes from these harmful effects during future restrictions.

Upperclassman athletes, students in their last 2 years of American high school, were another high-risk population. They reported higher Generalized Anxiety Disorder-7 and Patient Health Questionaires-9 scores, as well as lower Pediatric Quality of Life Inventory 4.0 scores, compared to their younger peers [ 23 ••]. Only 7% of US high school athletes will play university-level sports [ 28 ], so upperclassman, especially high school seniors, are likely to view the unexpected cancelation of a senior season as psychologically similar to a career-ending injury, as opposed to a less-distressing planned retirement. On the other hand, high school freshmen, those in first year of American high school, reported less severe symptoms on the Generalized Anxiety Disorder-7 and Patient Health Questionaire-9 during COVID-19 sport cancelations, and had the lowest rates of moderate to severe depression and anxiety among surveyed high school athletes [ 23 ••]. These lower rates were explained by younger high school athletes having years of remaining sports eligibility and viewing these lockdowns as a temporary loss of sports rather than a permanent one. Future studies should further explore how coaches and organizations can best support upperclassman in these circumstances to prevent these negative mental health outcomes.

Low socioeconomic status (SES) youth athletes also suffered disproportionately during COVID-19 sports restrictions, compared to those from higher SES demographics. Pons et al. found that low SES athletes made up a significantly greater proportion of athletes with severe mental health impacts from COVID-19 sports restrictions than those from higher SES backgrounds [ 20 ]. Similarly, McGuine et al. reported that athletes from US counties with the highest poverty levels demonstrated higher prevalence of anxiety and depression and lower quality of life ratings than athletes from counties with lower poverty levels [ 23 ••]. These results parallel findings for all youths, including non-athletes [ 29 , 30 ]. While these studies did not statistically examine causal links, researchers hypothesized that this effect was mediated by low SES youth athletes’ limited access to remote training resources during lockdowns, leading to disconnectedness from their sport, as well as decreased physical activity [ 21 ••, 23 ••]. Future studies should explore the connection between SES and mental health outcomes to aid organizations and teams in helping low SES athletes maintain their mental health during future unexpected restrictions.

Team sport athletes were particularly impacted by the pandemic. Studies prior to the pandemic reported that individual sport athletes had higher rates of mental illness than team sport athletes [ 31 – 33 ]. However, research during COVID-19 sports restrictions found that team sport athletes had significantly worse symptom scores than individual athletes on several Profile of Mood States Questionnaire subscales, including tension, depression, total mood disturbance, anger, and confusion [ 21 ••]. The lower rates of mental illness among individual sport athletes during the early COVID-19 pandemic suggest individual sport may offer protection against mental illness during COVID-19 restrictions. This protective effect is due to individual athletes’ ability to train and compete while still following all COVID-19 social distancing regulations, something most team sport athletes were not able to do. Individual sport athletes also experienced a less dramatic decrease in social interaction from sports cancelation than team sport athletes did, thus blunting some of the negative emotional impacts [ 23 ••]. Given these findings, team sport athletes are more likely to experience negative mental health outcomes than individual sport athletes if COVID-19 forces future restrictions on organized sports.

Potential Interventions to Minimize the Mental Health Impacts of Sports Restrictions

Given indications that the SARS-COV2 virus will continue to circulate, youth sports will likely continue to face challenges created by the virus and could be interrupted by future threats. Finding practical interventions for youth athletes could reduce the significant mental health burden of future restrictions (Table 2 ). As mentioned, COVID-19 restrictions impacted the mental health of low SES athletes more than that of well-resourced peers [ 18 •, 21 ••, 23 ••]. This effect is partially due to low SES athletes’ limited access to home equipment and public training facilities. Low SES athletes’ lack of home training infrastructure during social restrictions limits exercise and engagement with their sports, directly impacting their mental health. Less home training also makes it harder for athletes to return to their sports in appropriate condition when restrictions are lifted [ 21 ••, 23 ••]. This sub-par conditioning increases risk of injury and makes low SES athletes’ transition back to competition more physically difficult, which we suspect would further worsen these athletes’ mental health. To address this issue, sports organizations should help low SES athletes gain access to training equipment, either at home or in safe, public settings, to ensure these athletes continue conditioning and avoid the serious mental health consequences of losing their sports.

Fostering social connections with family, friends, and athletes’ sports club, through physically distanced activities or social media, also mitigated the mental health impacts of sports restrictions on youth athletes [ 18 •, 19 ]. While athletes noted that virtual communication was not a replacement for in-person social contact, these connections did still bolster athletes’ mental health by allowing them to engage socially during restrictions, hold one another accountable to remote training regimens, and share emotional experiences about the pandemic and sports cancelations. Now that effects of the COVID-19 pandemic are lessening in severity, sports organizations can plan for future social regulations or public health threats. They can identify physical spaces to facilitate physically distanced, in-person meetings, invest in social media and teleconference technology to engage athletes, and can educate families on emotional support during unexpected sports disruptions [ 18 •].

Preservation of athletic identity, how deeply someone embraces and defines themself by their role as an athlete, can improve athletes’ mental health outcomes during difficult periods [ 34 ]. When athletes experience an unexpected loss of sports, this identity becomes disrupted, thus increasing the risk of depression [ 35 , 36 ]. The unexpected and prolonged cancelation of youth sports during the COVID-19 pandemic paralleled the process athletes go through during season or career-ending injuries. Youth athletes with greater teammate and organizational support experienced greater preservation of their athletic identity, greater psychological well-being, and fewer depressive symptoms [ 37 ]. Therefore, sports organizations can support athletes through future sports disruptions by designating time for in-person or virtual team meetings with coaches and sports psychology professionals focused on discussing and reinforcing youths’ athletic identity. Similarly, organizations like the National Collegiate Athletic Association or Amateur Athletic Union can create training modules to teach coaches and youth sports leaders best practices for incorporating discussions about athletic identity into team activities. These interventions can help support athletes’ athletic identities and mental health during future disruptions to organized sports.

Mindfulness, a practice characterized by non-judgmental awareness and attention to present-moment thoughts and emotions [ 38 ], is increasingly used to address mental health challenges in youth populations [ 39 ]. Mindfulness has also been used to improve performance and recovery in both adult and youth athletes [ 40 , 41 ]. Recent research looked at how mindfulness may protect against the mental health impacts of COVID-19 restrictions in elite adult athletes. In a study of high-level, European rugby athletes, about 60% of whom were transitional age youth, during the initial COVID-19 lockdown, and subsequent return to sports, mindfulness traits significantly predicted protection against both depression and anxiety [ 42 •]. Higher trait mindfulness also predicted athletes reporting fewer depressive and anxious symptoms after lockdown, compared to individuals with lower trait mindfulness. While this study did not look specifically at youth athletes, those ages 17 and younger, the majority of the participating athletes were transitional age youth, individuals less than 26 years old. Given this high proportion of transitional age youth, and that previous research already demonstrated a similar effect of mindfulness on youth sports performance [ 43 ] and mental health [ 39 , 44 ], these are low harm interventions likely to help athletes under 18 years old as well. Accordingly, organizations could incorporate mindfulness into youth sports training, which may both enhance sports performance and improve youth athlete mental health, especially during unexpected sports disruptions.

COVID-19 restrictions caused unexpected worldwide cancelations of organized sports and placed unique mental health stress on athletes. Youth athletes are at particularly high risk of negative mental health outcomes during these disruptions, as they often have lower emotional resilience than adult athletes and rely on sports’ mental health protective benefits. COVID-19 sports cancelations led to worsened youth athlete depression, anxiety, anger, sleep, and quality of life, especially among females, high school upperclassman, those from low socioeconomic backgrounds, and those who play team sports. Research and expert opinions suggest that the mental health impacts could be mitigated by increasing athletes’ access to at-home training resources, fostering their social connections with teammates, and protecting their athletic identities. Therefore, sports organizations can potentially limit the negative mental health outcomes during future sports restrictions by arranging remote training opportunities, remote social check-ins with teammates, and discussions about athletic identity with coaches and sports psychology professionals. Studies also showed that transitional age professional athletes with higher trait mindfulness experienced less anxiety and depression during pandemic shutdowns. While further research on younger athletes is needed, mindfulness is a safe, evidence-based mental health treatment in non-athlete youth populations that may similarly improve mental health symptoms in youth athletes. Amidst the evolving pandemic, and with predictions of future COVID-19 variants, sports organizations should consider implementing these interventions to protect youth athletes’ mental health during future unexpected sports cancelations.

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• Published: 26 August 2023

Retrospective study of COVID-19 experiences in elite multinational aquatic athletes

• Vencel Juhász 1   na1 ,
• Emese Csulak 1   na1 ,
• Liliána Szabó 1 ,
• Zsófia Ocsovszky 1 ,
• Dorottya Balla 1 ,
• György Nagy 1 ,
• Alessandro Zorzi 3 ,
• Andy I. M. Hoepelman 4 ,
• Béla Merkely 1 , 2 ,
• Hajnalka Vágó 1 , 2   na2 ,
• Nóra Sydó 1 , 2   na2 ,
• World Aquatics, Sports Medicine Committee &

World Aquatics, COVID-19 Task Force

Scientific Reports volume  13 , Article number:  13978 ( 2023 ) Cite this article

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• Epidemiology
• Viral infection

This study assessed the experiences of elite aquatic athletes with coronavirus disease 2019 (COVID-19) during the first World Championship conducted without social distancing and an isolation “bubble”. An online questionnaire was completed by 812 athletes (22.7 ± 5.9 years, 467 females) to provide data on demographics, sports activity, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection rates, symptoms, reinfection, vaccination status, and psychological aspects. The answers revealed that 49.4% of athletes had experienced SARS-CoV-2 infection. The infection rates varied significantly across different aquatic sports, with open water swimmers having the lowest (28%) and water polo players (67%) and artistic swimmers (61%) having the highest infection rates (p < 0.0001). The majority reported mild (51%) or moderate (27%) symptoms, while 16% remained asymptomatic. Reinfection occurred in 13%, and 10% of initial infections led to long COVID, with fatigue (65%) and shortness of breath (48%) being the most common long-term symptoms. Significantly, 92% of athletes received at least two vaccine doses and reported a positive vaccination experience (median score of 8 out of 10 for each shot). Mood changes and subjective performance drops significantly correlated with the overall experience scores (rho: 0.617, p < 0.0001, and rho: 0.466, p < 0.0001, respectively). In conclusion, most athletes experienced a benign disease course despite a relatively high infection rate. This study provides valuable insights into the COVID-19 experiences of elite aquatic athletes. The findings emphasize the importance of vaccination initiatives, monitoring psychological well-being and the need to fortify athletes’ resilience in the face of future health challenges.

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Introduction.

The recurring Coronavirus Disease 2019 (COVID-19) waves have changed the world of sports in terms of specific regulations and concerns for athlete health. Evaluating the global impact of the COVID-19 pandemic on athletes is challenging, given the international variability in incidence and disease intensity 1 .

The first wave of the COVID-19 pandemic carried the risk of unforeseen health issues, which raised the question of the optimal return to play and potential cardiac and respiratory complications 2 , 3 , 4 .

However, the most significant questions regarding possible cardiac involvement have been answered 5 , 6 .

In addition, athletic performance may be influenced by the long COVID syndrome, which may lead to a delayed return to play 5 , 7 , 8 . In contrast with the initial extensive post-COVID screening practice 2 , 9 , 10 , current recommendations do not require comprehensive return-to-play examinations for all athletes 11 , 12 , as nowadays, the course of SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) infection is predominantly mild, without complications 13 , 14 , 15 , 16 .

Athletes participating in water sports have been particularly affected by the consequences of SARS-CoV-2 infection and long COVID syndrome. This has involved the postponement or cancellation of numerous international events, including the 2020 Tokyo Olympics 17 . However, the experience gained from the postponed Tokyo Olympics informed the organization of other significant sports events, including the 2022 FIFA World Cup 18 .

In addition, training opportunities were significantly limited due to the temporary closure of training sites, including swimming pools 17 . These factors altered periodised training programmes, affecting athletes’ physical performance and mental health 19 , 20 .

Fortunately, the development of vaccines has significantly reduced the number of severe cases 21 , 22 . Some concerns have arisen regarding vaccination-related myocarditis, and vigilant monitoring seemed rational, considering myocarditis’ implication in athletes 23 . Nevertheless, one must also consider optimal timing for vaccination to mitigate potential side effects and the impact on athletic performance 24 .

Currently, there is a dearth of data regarding aquatic athlete experiences during the pandemic. Athlete infection and reinfection rates and disease course relative to the general population are unknown, as are their vaccination status and ability to cope with added psychological hardship. In addition, most surveys and studies focus on local trends, with little application to global experiences and disease patterns.

This study aimed to assess the COVID-19 experience of a unique multinational cohort of elite aquatic athletes competing in the first global sports event without the imposition of an isolation “bubble”. We used a digital questionnaire to collect data on the infection rate, disease course, symptoms of SARS-CoV-2 infection, vaccination experiences and psychological well-being.

As a part of a collaboration between the World Aquatics (AQUA—formerly Fédération Internationale de Natation (FINA)) Sports Medicine Committee, the AQUA COVID-19 Task Force and the Semmelweis University, we created an anonymised questionnaire focusing on the basic demographics, sports activity, previous SARS-CoV-2 infection(s), vaccination status and psychological aspects of the pandemic. This study presents cross-sectional, retrospective data. Hereafter, we use the term “COVID-19” to refer to the disease with clinical symptoms. Correspondingly, we employed the term “SARS-CoV-2 infection” to encompass both symptomatic and asymptomatic presentation.

Questionnaire

Accredited athletes voluntarily completed the questionnaire during the 19th FINA 2022 World Championship in Budapest, Hungary, between June 13 and July 13, 2022, adding 10 extra days after the end of the event. The link and QR code pertaining to the form were distributed by volunteers during the event and were forwarded to the teams. The athletes filled in the English-language forms on their own electronic devices, usually taking 5–10 min to complete.

The questionnaire comprised 60 single-choice, multiple-choice, scale-type (1–10 points) and open questions. Firstly, we assessed the sociodemographic factors such as age, sex, nationality, aquatic discipline (swimming, water polo, artistic swimming, diving, open water swimming), training hours and years spent in training. We asked about previous SARS-CoV-2 infection(s), including their course and severity. Athletes were asked to identify the time of their infection(s) within six-month periods, starting with the end of 2019, the first half of 2020, and so on. Furthermore, we explored athlete vaccination status and collected psychological data concerning individual perceptions of the pandemic. The questionnaire used for data collection is found in Supplement 1 . This study did not involve any SARS-CoV-2 screening or test results from the event. We excluded answer sheets with significant incompleteness or apparently contradictory information.

Athletes were categorised according to symptoms. Mild symptoms involved smell or taste disturbance, cough, fever, headache, fatigue (or significant weakness), palpitations (sensation of fast heart rate), eye pain, muscle or joint pain, and rhinorrhoea. Shortness of breath, chest pain and loss of consciousness without hospitalisation were regarded as moderate symptoms. Those who needed hospital care were identified as participants with a severe disease course, regardless of symptoms and symptom count. Symptom severity categories were created as follows: asymptomatic (1), mild (2), moderate (3), and severe (4). Based on the answers, we created an ordinal variable with seven categories regarding symptom length [no symptoms (1), maximum 24 h (2), 1–3 days (3), 4–6 days (4), 1–2 weeks (5), 3–4 weeks (6), beyond 4 weeks (7). Missed training time intervals had six different categories: no days (1), 1–3 days (2), 4–6 days (3), 1–2 weeks (4), 3–4 weeks (5) or more than 4 weeks of missed training (6). Symptoms that persisted beyond 4 weeks after the start of the infection fell into the category of long COVID symptoms 25 .

Mandatory quarantine duration was not uniform in time or location, and home training programmes might have been applied. For this reason, we decided to use only one pertinent variable of missed training time (Table 2 ) to identify those who kept training during quarantine and also those who had to extend training cessation beyond quarantine time for any reason. We excluded answer sheets containing contradicting information.

The athletes reported overall well-being during the pandemic from 1 to 10. A higher mark indicated a worse experience (1 point indicates the athlete experienced no effect from the pandemic, while 10 points reflects a terrible experience). Other psychologically oriented questions included rating mood changes, subjective performance drop and psychological support.

All methods complied with relevant guidelines and regulations. Informed consent was obtained from all participants and/or their legal guardian(s). Participants included in the calculations consented to anonymous data usage as part of the questionnaire. All experimental protocols and ethical approval were approved by the National Public Health Center (5200-6/2020/EÜIG) under the ethical standards laid out in the 1964 Declaration of Helsinki and its later amendments. No use of artificial intelligence was employed in this study.

Participants or the public were not involved in the design, conduct, reporting, or planned dissemination of the research findings.

Statistical analysis and data management

Answers were analysed using descriptive statistics methods with MedCalc v.20.112 software. A p-value less than < 0.05 was considered significant. The Shapiro–Wilk test for normality was used. Continuous variables are shown as mean ± standard deviation or median with interquartile range as appropriate. Comparison between two independent groups was performed by t-tests or the Mann–Whitney test. Chi-squared and Fisher’s exact tests were used to study non-random associations between two or more categorical variables. Correlation between non-normal distribution variables was analysed using the Spearman rank correlation. Logistic regression was applied to predict dichotomous outcomes.

Participants

Of the 907 responders, 92 did not permit data usage and were excluded from the calculations, and 3 answer sheets were not included in the calculations due to apparent inconsistencies. The final cohort comprised 812 athletes (39% of all World Championship competitors) with a mean age of 22.7 ± 5.9 years, of whom 57.5% were recorded as female. Swimmers (n = 333, 41%) were the most prevalent respondents across the aquatics disciplines, followed by artistic swimmers (n = 162, 20%), water polo players (n = 133, 16.4%), divers (n = 124, 15.3%), and open water swimmers (n = 60, 7.4%). The average weekly training time was more than 20 h (22.7 ± 10.1 h) with 14.6 ± 5.8 years of training history.

SARS-CoV-2 infection incidence

Altogether 398 (49%) of the athletes had a SARS-CoV-2 infection at least once since the end of 2019. An additional 13% (n = 52, 6.4% of the total cohort) contracted SARS-CoV-2 twice (Fig.  1 ). The majority (68%) tested positive after developing symptoms suggestive of the infection. SARS-CoV-2 infection was detected during a routine screening in 24% of the cases, while 8% of the participants had a positive test during competition screening. Open water swimmers were the least (28%), while water polo (67%) and artistic swimming (61%) were the most likely to acquire the infection (p < 0.0001). A logistic regression model based on biological plausibility to predict SARS-CoV-2 contraction was developed. Increasing age (OR 1.04, CI 1.01–1.06) and being a team player (OR 2.18, CI 1.58–3.00), were independent predictors of acquiring SARS-CoV-2, while sex and training volume were not (overall model performance AUC 0.639, CI 0.61–0.67, p < 0.0001). The reinfection rate was 13% (n = 52; 28 females, 27 team players).

SARS-CoV-2 infection incidence and vaccination status over time. There was no significant difference in symptom severity frequencies between half-year periods.

Clinical characteristics of SARS-CoV-2 infection and long COVID

Most athletes had mild (54%) or moderate (27%) symptoms, and 17% reported no symptoms during the infection. Of these, only 8 (2%) required hospitalisation with severe COVID-19 symptoms. Detailed symptom frequencies for every 6-month period are shown in Table 1 . Most infections occurred in the first half of 2022 (40.2%); however, the severity of the disease did not differ significantly between the examined periods. On the other hand, the missed training time differed between certain symptomatic categories. For example, in athletes with a mild infection, 1–2 weeks of missed training time was the most frequent (59%) scenario, significantly differing from asymptomatic individuals. As expectedly, an absence of more than 4 weeks from training was the most prevalent finding in athletes with a severe disease course (Table 2 ).

Long COVID symptoms were present in 10% (40/398, 25 female) of the cases after the first infection episode (Table 2 ). The most common long COVID symptoms were fatigue (65%), shortness of breath (48%), cough (35%) and problems with focus and concentration (28%). The median symptom count was 1 (IQR 0–3). The missed training time category median fell into the 1–2-week interval (category 3).

A multivariate logistic regression model was built (AUC 0.76, CI 0.72–0.80, p < 0.0001) to predict long COVID occurrence. Only the symptom count during the acute, symptomatic phase of infection was a reliable, independent predictor (OR 1.4, CI 1.18–1.7), whereas age, sex and severity score did not play a significant role.

Reinfection

Regarding reinfection (n = 52), 46% of the cases were asymptomatic, 37% showed mild symptoms, 13% had moderate, and 4% had severe symptoms. Two athletes (4%) had persisting symptoms beyond 4 weeks after the second infection. Most (65%) of the athletes missed a maximum of 6 training days after the reinfection. Most reinfections occurred during the second half of 2021 (25%) and the first half of 2022 (58%).

The second infection’s disease course was generally milder than the first infection. There was a significant difference between the symptom count and severity of the illness in those with two infections. The median symptom count was 3 (IQR 1–4) in the first and 1 (IQR 0–3) during the second infection (p < 0.0001). The median symptom severity category was “2” (mild symptoms) for both infection episodes, but interquartile ranges differed with 2–3 (mild-moderate) in the first and 1–2 (asymptomatic-mild) in the second infection (p = 0.0001). The missed training time [median category 4 (IQR 3–4) vs 3 (IQR 2–4)] intervals were shorter during the second infection than during the first infection (p = 0.0001).

Vaccination

Ninety-four per cent of the athletes (n = 769) received at least one dose of a COVID-19 vaccine, 92% received a second dose, and 55% a third dose. Detailed vaccination data are presented in Fig.  1 and Table 3 . The scores regarding vaccination experience did not differ between the subsequent rounds of shots. However, when comparing mRNA and vector vaccines, upon receiving the first shot, athletes reported slightly worse experience scores with vector vaccines than with mRNA vaccines (6 vs 8 points, p < 0.0001). During the second (9 vs 8, non-significant) and third (9 vs 8, non-significant) rounds of vaccination, experience scores were comparable.

Psychological aspects

The athletes provided a median of 6 (IQR 4–7) points for the overall well-being score during the pandemic. The median point for mood changes was 6 (IQR 4–8), and reduced physical performance was 5 (IQR 3–7). The severity of (the first) infection weakly correlated with the overall experience scores (rho: 0.146, p = 0.0042). Mood changes showed a strong, and subjective performance drop showed a moderate correlation with the overall experience scores (rho: 0.617, p < 0.0001 and rho: 0.466, p < 0.0001, respectively). Female athletes reported slightly worse mood change scores than male athletes (median 7 vs 6, p = 0.0002). Regarding psychological support, 19% reported a need and subsequently received psychotherapy, while 17% required assistance but could not access psychological support. However, 14% of the athletes were provided support despite not requiring it. The remaining half of the study cohort did not need or receive any help.

In this paper, we present the results of a comprehensive COVID-19 survey of aquatic athletes who participated in the FINA 19th World Championship, which was the first world aquatic championship after major COVID-19 waves subsided. The principal findings of this paper include a high SARS-CoV-2 infection rate in athletes, with a higher incidence in team sports. The symptoms were mostly mild; however, long COVID syndrome was detected in 10% of the athletes. High symptom counts predicted a higher burden of long COVID syndrome. The second SARS-CoV-2 infection was mostly reported to be milder, with fewer symptoms and fewer missed training days than the first. The vaccination rate among this athlete population was high (92%), predominantly reporting mild post-vaccination symptoms. Mood changes and subjective drop in performance were important in the athletes’ overall pandemic experience.

Infection rates and clinical characteristics

The COVID-19 disease and its sequelae have affected all levels of society, including the field of professional sports. The course of infection, combined with quarantine and confinement requirements, took a toll on the quality of life of athletes during the period of the pandemic. Reduced physical activity, impaired sleep quality, altered daily activity, increased anxiety, diminished cardiorespiratory fitness, and less desirable nutritional habits were among the reported consequences 26 , 27 , 28 , 29 , 30 . The infection affected 8–10% of the overall population, which proved more frequent in athletes 31 . One of the largest longitudinal studies from 2020, which summarised the results of almost 10,000 athletes from 13 universities, and found a SARS-CoV-2 infection rate of 30.4%, with a 2.3% prevalence of myocarditis 32 . In this study, the overall COVID-19 infection rate was 49.4%, with 3% of severe cases requiring hospitalisation.

The higher perceived infection rate may have been due to an extended observational period and more rigorous screening of athletes. Vigorous training may also impair immune function rendering athletes more susceptible to infections with post-exercise immunosuppression through an altered helper T-cell response and elevated stress hormone levels 33 , 34 . This has distinct application to a cohort of elite aquatic athletes preparing for world championships.

We concluded that close physical contact is one key factor driving the increased SARS-CoV-2 infection rates, particularly among athletes in team sports. Indeed, in this study, the occurrence of infection was the highest among water polo players and artistic swimmers while the lowest among open water swimmers. This aligns with reports of higher transmission of SARS-CoV-2 infection in team sports 35 , 36 .

In a Swiss COVID-19 survey assessing the prevalence and symptoms of the infection in elite athletes, the disease prevalence was less than 20%, with a male predominance 35 . Interestingly, in our cohort, female athletes had higher rates of SARS-CoV-2 transmission, but symptom severity did not differ between the sexes. Other authors suggest that young female athletes have a lower risk of severe symptoms and remain dominantly asymptomatic 37 , 38 .

Similarly, most studies have reported mild to moderate COVID-19 symptoms in athletes 32 , 35 , 39 , 40 , 41 . In our findings, the main symptoms were headache, fever and cough. Different SARS-CoV-2 variants have been linked to distinct symptom profiles and diseases. In a prospective registry of collegiate athletes, the most common symptoms detected between September and December 2020 were loss of taste or smell, headache, muscle pain, cough, fatigue and fever, similar to our data gained about the second half of the year 2020 39 .

However, the exact missed training time interval is scarcely reported in athletes and may be dependent on several factors. In our findings, most athletes missed 1–2 weeks of training which might involve the role of quarantine, symptom severity, and closure of training sites, among others. According to Krzywanski et al.’s findings, COVID-19’s impact has been higher than other respiratory tract infections regarding missed training. The surveyed elite Polish athletes (n = 1073) reported that 12–13% lost training days due to COVID-19, which is expressly lower than what the multinational aquatic athletes showed 42 . Schwellnus et al. associated symptom clustering with different return-to-play times and compared COVID-19 with other acute respiratory illnesses. They found that return-to-play after COVID-19 was significantly longer than in the other group (IQRs 16–40 vs 7–22 days) and, generally, symptom cluster is associated with prolonged missed training times with excess fatigue in particular 43 .

Our study detected long COVID syndrome in 10% of the athletes. A systematic review and meta-analysis of 43 studies covering 11,518 athletes reported a long COVID syndrome rate of 8.3% 7 . A study including 4186 post-COVID patients assessed the prevalence of long COVID syndrome in the average population and found a slightly higher incidence (13.3%) of persistent (> 4 weeks) symptoms 8 . Our previous findings in a prospective cohort of 322 athletes showed a long COVID occurrence of 8%, highlighting differences between age groups, where adult and master athletes were more likely to develop long-standing symptoms 5 . We previously showed that increasing age and a worse symptom severity score predicted long COVID occurrence. Nevertheless, in this dataset, including predominantly young adults, we found that only acute symptom count was an independent predictor of developing long COVID.

The SARS-CoV-2 reinfection of athletes has not been extensively described in the literature, with case reports and low case number studies available 44 , 45 . Good et al. reported that the reinfection rate was as low as 0.8% in a pre-omicron (Delta wave) student-athlete cohort. In our study, the reinfection rate was 13%, with fewer and milder symptoms and fewer missed training days than the first infection. This phenomenon may be related to the different SARS-CoV-2 variants 22 , 46 , 47 . Another explanation might be that athletes encountered the second infection with an already primed immune system either through prior infection or vaccination. Another insight might be that vaccine roll-out helped mitigate the disease severity. In addition, our relatively high reinfection rate may be explained by the fact that most SARS-CoV-2 infections occurred in the first half of 2022 during the Omicron variant outbreak. Furthermore, elite athletes usually have strict medical control due to the pre-competition screenings and regular health check-ups; thus, it is more likely that mild or asymptomatic (re)infections are recognized. In contrast, the reinfection rate in the non-athletic population was relatively low until the Omicron era 37 , 48 .

Almost all (94%) of our participants had been administered at least one dose of a COVID-19 vaccine, and 92% received the second shot as well. With a high vaccination rate, the athletes reported a relatively low burden of adverse side effects and only a few major ones, similar to the general population 21 . The duration of side effects was generally short, lasting no more than three days. An infographic paper by Rankin et al. found that the vaccination in athletes was generally well tolerated, the majority of the side effects were mild, and the missed training period was as low as 4 days 24 , 49 . Oudjedi et al. found that 55% of the surveyed Algerian athletes (n = 273) reported side effects after COVID-19 vaccination, of which fever and local pain were the most prevalent. These findings generally align with our data. Nonetheless, for athletes with the dominant use of the upper extremities, the timing of the vaccine administration may be decisive due to the possible local side effects 24 .

In spite of the increasing SARS-CoV-2 vaccination rate, the number of infected cases also surged, which may reflect the lower efficacy of the vaccines against the newer Omicron variants as described in the literature 47 , 50 , 51 .

The COVID-19 pandemic has brought uncertainty to the lives of athletes and non-athletes, leading to stress, anxiety, depression and other mental disorders 52 . A study examining 310 athletes from different continents and diverse sports disciplines found that maladaptive perfectionism was related to numerous mental health indicators. They also concluded that competitive athletes showed signs of a negative emotional state during the pandemic. Even so, the anxiety, stress, and depressive symptoms were less prevalent in athletes with proper coping strategies 53 . Based on our results, mood changes and subjective performance drop correlated closely with the overall experience during the pandemic; 36% of the athletes reported needing psychological support. Female athletes reported slightly worse mood change scores compared to male athletes. Several studies found similar data regarding the post-COVID mental health of female athletes 20 , 38 , 54 , 55 . Notably, half of the athletes questioned did not need psychological support. However, it is not apparent whether this is reflective of adequate coping skills—such as cognitive restructuring and emotional calm—or not. Also, 17% of the surveyed athletes were unable to obtain psychological support despite their need, reflecting the importance of providing appropriate psychological help in the context of sport.

Limitations

This self-reported, retrospective study is based on a monolingual (English) survey, and the language barrier may have impacted the answers of non-native English speakers. In addition, we do not have any information about the type and methods of SARS-CoV-2 testing, nor could we confirm the validity of other reported health-related variables. Consequently, the potential lack of accuracy and incompleteness of the answer sheets may have slightly influenced the data quality. In addition, the exact date of any positive tests could not be verified through institutional medical sources.

In this multinational cohort study of elite aquatic athletes, despite a high SARS-CoV-2 infection rate, the majority experienced only mild to moderate symptoms, while athletes with more severe disease courses had a higher incidence of long COVID syndrome. Team sports participants presented with a higher infection transmission rate compared to individual athletes, likely due to close bodily contact. The 13% reinfection rate aligns with previously published research findings. Promisingly, nearly all athletes had received at least two doses of the COVID-19 vaccine, indicating a broad vaccination acceptance in aquatic athletes worldwide, with short-term and mild side effects. Notably, psychological aspects significantly influenced athletes’ perceptions of the pandemic. Overall, this study suggests that aquatic athletes have coped well with the physical and moderately well with the psychological consequences of the COVID-19 pandemic. Nevertheless, post-pandemic follow-up will be crucial to assess the complex effects on athletes’ long-term physical and mental health. The findings of the study can offer guidance to sports organizations and health authorities in designing targeted strategies for pandemic preparedness tailored to elite aquatic athletes. The higher infection transmission rates in team sports underscore the importance of implementing specific safety measures during training and competing to minimize viral spread. In addition, the high vaccination acceptance rate among athletes highlights the importance of promoting vaccination in sports communities to ensure a safer and more resilient sports milieu during potential future health crises. Furthermore, the acknowledgement of the impact of psychological aspects on athletes’ pandemic experience emphasizes the need for continued support and psychological interventions to safeguard athletes’ mental well-being during challenging times. These pragmatic implications can enhance the overall health of elite aquatic athletes in the face of future pandemics or health challenges.

Data availability

All data are available upon reasonable request from the corresponding author (Hajnalka Vágó M.D., PhD, [email protected]) and not made available by default due to possible compromise of individual privacy.

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Acknowledgements

The authors want to thank all our volunteers who helped distribute the questionnaire among the athletes. They also want to acknowledge the contribution of the AQUA Medical Manager, Johan Lefebvre and the AQUA Sports Medicine Committee in announcing the study on all AQUA platforms. They would also like to express our gratitude to our Medical Managers (Álmos Gogl, Szabolcs Tóth, Endre Zima, Orsolya Kiss and Gábor Fülöp) and Staff members, who have helped us to distribute the questionnaire. Finally, they would like to acknowledge the continuous assistance of the members of the Local Organizing Committee—Enikő Török, Bence Biczó, László Szögi, Gábor Ralovich, Dávid Szántó and Sándor Wladár.

Open access funding provided by Semmelweis University. Project No. RRF-2.3.1-21-2022-00003 has been implemented with the support provided by the European Union. This study was supported by the National Research, Development, and Innovation Office of Hungary under the Investment in the Future funding scheme (2020-1.1.6-JÖVŐ-2021-00013). This project was supported by grants from the National Research, Development, and Innovation Office (NKFIH) of Hungary (K135076 to B.M.).

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These authors contributed equally: Vencel Juhász and Emese Csulak.

These authors jointly supervised this work: Hajnalka Vágó and Nóra Sydó.

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Authors and Affiliations

Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary

Vencel Juhász, Emese Csulak, Liliána Szabó, Zsófia Ocsovszky, Dorottya Balla, György Nagy, Béla Merkely, Hajnalka Vágó & Nóra Sydó

Department of Sports Medicine, Semmelweis University, Budapest, 1122, Hungary

Béla Merkely, Hajnalka Vágó & Nóra Sydó

University of Padova, Padua, Italy

Alessandro Zorzi

World Aquatics, Lausanne, Switzerland

Andy I. M. Hoepelman, Cees-Rein van den Hoogenband, David Gerrard, Kevin Boyd, Christer Magnusson, Béla Merkely, Jim Miller, Farhad Moradi Shahpar, Edgar Ortiz, Josip Varvodic, Xinzhai Wang, Mohamed Yahia Cherif, Mohamed Diop, David Gerrard & Cees-Rein van den Hoogenband

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• , David Gerrard
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Contributions

Study design and conceptualization was performed by E.C.S., V.J., L.S.Z., Z.S.O., D.B., H.V., N.S. and B.M., members of AQUA Sport Medicine Committee (C.V.D.H., D.G., K.B., C.M., B.M., J.M., F.M.S., E.O., J.V., X.W., M.Y.C.) and COVID-19 Task Force (A.I.H., M.D., D.G., C.V.D.H.). Data collection was performed by E.C.S., V.J., D.B., H.V., N.S. Following authors participated in the statistical analysis and the data curation V.J., E.C.S., L.S.Z., N.S. and V.H. E.C.S., V.J., D.B., L.S.Z., Z.S.O., A.H., A.Z., A.I.H., H.V., N.S. and B.M. wrote the original draft of the paper. E.C.S., V.J., D.B., L.S.Z., Z.S.O., A.H., A.Z., A.I.H., H.V., N.S., B.M., members of AQUA Sport Medicine Committee (C.V.D.H., D.G., K.B., C.M., B.M., J.M., F.M.S., E.O., J.V., X.W., M.Y.C.) and COVID-19 Task Force (A.I.H., M.D., D.G., C.V.D.H.) contributed to reviewing and editing. All authors have read and agreed to the published version of the manuscript. The Sports Medicine Committee and the COVID-19 Task Force of World Aquatics, in addition to ensuring and monitoring competitions, also deal with research tasks. These two committees are not referred to in this article as a consortium but as research committees. There is no financial benefit to World Aquatics in conducting this research.

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Juhász, V., Csulak, E., Szabó, L. et al. Retrospective study of COVID-19 experiences in elite multinational aquatic athletes. Sci Rep 13 , 13978 (2023). https://doi.org/10.1038/s41598-023-40821-2

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UN/DESA Policy Brief #73: The impact of COVID-19 on sport, physical activity and well-being and its effects on social development

Introduction

Sport is a major contributor to economic and social development. Its role is well recognized by Governments, including in the Political Declaration of the 2030 Agenda, which reflects on “the contribution sports make to the empowerment of women and of young people, individuals and communities, as well as to health, education and social inclusion objectives.”

Since its onset, the COVID-19 pandemic has spread to almost all countries of the world. Social and physical distancing measures, lockdowns of businesses, schools and overall social life, which have become commonplace to curtail the spread of the disease, have also disrupted many regular aspects of life, including sport and physical activity. This policy brief highlights the challenges COVID-19 has posed to both the sporting world and to physical activity and well-being, including for marginalized or vulnerable groups. It further provides recommendations for Governments and other stakeholders, as well as for the UN system, to support the safe reopening of sporting events, as well as to support physical activity during the pandemic and beyond.

The impact of COVID-19 on sporting events and the implications for social development

To safeguard the health of athletes and others involved, most major sporting events at international, regional and national levels have been cancelled or postponed – from marathons to football tournaments, athletics championships to basketball games, handball to ice hockey, rugby, cricket, sailing, skiing, weightlifting to wrestling and more. The Olympics and Paralympics, for the first time in the history of the modern games, have been postponed, and will be held in 2021.

The global value of the sports industry is estima­ted at US$756 billion annually. In the face of COVID-19, many millions of jobs are therefore at risk globally, not only for sports professionals but also for those in related retail and sporting services industries connected with leagues and events, which include travel, tourism, infrastructure, transportation, catering and media broadcasting, among others. Professional athletes are also under pressure to reschedule their training, while trying to stay fit at home, and they risk losing professional sponsors who may not support them as initially agreed.

Major sporting organisations have shown their solidarity with efforts to reduce the spread of the virus. For example, FIFA has teamed up with the World Health Organisation (WHO) and launched a ‘Pass the message to kick out coronavirus’ campaign led by well-known football players in 13 languages, calling on people to follow five key steps to stop the spread of the disease focused on hand washing, coughing etiquette, not touching one’s face, physical distance and staying home if feeling unwell. Other international sport for development and peace organizations have come together to support one another in solidarity during this time, for example, through periodic online community discussions to share challenges and issues. Participants in such online dialogues have also sought to devise innovative solutions to larger social issues, for example, by identifying ways that sporting organisations can respond to problems faced by vulnerable people who normally participate in sporting programmes in low income communities but who are now unable to, given restriction to movement.

The closure of education institutions around the world due to COVID-19 has also impacted the sports education sector, which is comprised of a broad range of stakeholders, including national ministries and local authorities, public and private education institutions, sports organizations and athletes, NGOs and the business community, teachers, scholars and coaches, parents and, first and foremost, the – mostly young – learners. While this community has been severely impacted by the current crisis, it can also be a key contributor to solutions to contain and overcome it, as well as in promoting rights and values in times of social distancing.

As the world begins to recover from COVID-19, there will be significant issues to be addressed to ensure the safety of sporting events at all levels and the well-being of sporting organizations. In the short term, these will include the adaptation of events to ensure the safety of athletes, fans and vendors, among others. In the medium term, in the face of an anticipated global recession, there may also be a need to take measures to support participation in sporting organizations, particularly for youth sports.

The impact of COVID-19 on physical activity and well-being

The global outbreak of COVID-19 has resulted in closure of gyms, stadiums, pools, dance and fitness studios, physiotherapy centres, parks and playgrounds. Many individuals are therefore not able to actively participate in their regular individual or group sporting or physical activities outside of their homes. Under such conditions, many tend to be less physically active, have longer screen time, irregular sleep patterns as well as worse diets, resulting in weight gain and loss of physical fitness. Low-income families are especially vulnerable to negative effects of stay at home rules as they tend to have sub-standard accommodations and more confined spaces, making it difficult to engage in physical exercise.

The WHO recommends 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity physical activity per week. The benefits of such periodic exercise are proven very helpful, especially in times of anxiety, crisis and fear. There are concerns therefore that, in the context of the pandemic, lack of access to regular sporting or exercise routines may result in challenges to the immune system, physical health, including by leading to the commencement of or exacerbating existing diseases that have their roots in a sedentary lifestyle.

Lack of access to exercise and physical activity can also have mental health impacts, which can compound stress or anxiety that many will experience in the face of isolation from normal social life. Possible loss of family or friends from the virus and impact of the virus on one’s economic wellbeing and access to nutrition will exacerbate these effects.

For many, exercising at home without any equipment and limited space can still be possible. For those whose home life can involve long periods of sitting, there may be options to be more active during the day, for example by stretching, doing housework, climbing stairs or dancing to music. In addition, particularly for those who have internet access, there are many free resources on how to stay active during the pandemic. Physical fitness games, for example, can be appealing to people of all ages and be used in small spaces. Another important aspect of maintain physical fitness is strength training which does not require large spaces but helps maintain muscle strength, which is especially important for older persons or persons with physical disabilities.

The global community has adapted rapidly by creating online content tailored to different people; from free tutorials on social media, to stretching, meditation, yoga and dance classes in which the whole family can participate. Educational institutions are providing online learning resources for students to follow at home.

Many fitness studios are offering reduced rate subscriptions to apps and online video and audio classes of varying lengths that change daily. There are countless live fitness demonstrations available on social media platforms. Many of these classes do not require special equipment and some feature everyday household objects instead of weights.

Such online offerings can serve to increase access to instructors or classes that would otherwise be inaccessible. However, access to such resources is far from universal, as not everyone has access to digital technologies. For individuals in poorer communities and in many developing countries, access to broadband Internet is often problematic or non-existent. The digital divide has thus not only an impact on distance banking, learning or communication, but also on benefitting from accessing virtual sport opportunities. Radio and television programmes that activate people as well as distribution of printed material that encourages physical activity are crucial in bridging the digital divide for many households living in precarious conditions. Young people are particularly affected by social and physical distancing, considering sport is commonly used as a tool to foster cooperation and sportsmanship, promote respectful competition, and learn to manage conflict. Without sport, many young people are losing the support system that such participation provided. Currently some organizations, and schools have begun using virtual training as a method for leagues, coaches and young people to remain engaged in sport activities while remaining in their homes.

Conclusions and Recommendations

The COVID-19 pandemic has had and will continue to have very considerable effects on the sporting world as well as on the physical and mental well-being of people around the world. The following recommendations seek to both support the safe re-opening of sporting events and tournaments following the pandemic, as well as to maximize the benefits that sport and physical activity can bring in the age of COVID-19 and beyond.

The impact of COVID-19 on sporting events

1. sporting federations and organizations..

Governments and intergovernmental organizations may provide sports federations, clubs and organizations around the world with guidance related to safety, health, labour and other international standards and protocols that would apply to future sport events and related safe working conditions. This would allow all stakeholders to work cooperatively as a team with the objective to address the current challenges and to facilitate future sports events that are safe and enjoyable for all.

2. Professional sport ecosystem.

The sport ecosystem, comprising of producers, broadcasters, fans, businesses, owners and players among others, need to find new and innovative solutions to mitigate the negative effects of COVID19 on the world of sport. This includes finding ways to engage with fans in order to ensure safe sport events in the future while maintaining the workforce, creating new operating models and venue strategies.

1. Supporting physical activity.

Governments should work collaboratively with health and care services, schools and civil society organizations representing various social groups to support physical activity at home. Enhancing access to online resources to facilitate sport activities where available should be a key goal in order to maintain social distancing. However, low-tech and no-tech solutions must also be sought for those who currently lack access to the internet. Creating a flexible but consistent daily routine including physical exercise every day to help with stress and restlessness is advisable.

2. Research and policy guidance.

The United Nations system, through its sports policy instruments and mechanisms such as the Intergovernmental Committee for Physical Education and Sport,7 as well as through its research and policy guidance should support Governments and other stakeholders to ensure effective recovery and reorientation of the sports sector and, at the same time, strengthen the use of sports to achieve sustainable development and peace. Scientific research and higher education will also be indispensable pillars to inform and orient future policies.

3. Technical cooperation and capacity development.

Governments, UN entities and other key stakeholders should ensure the provision of capacity development and technical cooperation services to support the development and implementation of national policies and approaches for the best use of sport to advance health and well-being, particularly in the age of COVID-19.

4. Outreach and awareness raising.

Governments, the United Nations and the sporting community, including the sporting education community, should disseminate WHO and other guidance on individual and collective measures to counter the pandemic. Measures must be taken to reach communities that have limited access to the Internet and social media and that can be reached through cascading the sport education pyramid from the national/ministerial level down to the provincial/municipal level, from the national physical education inspector down to the teacher, from the national sport federation down to the clubs. In turn, escalating the pyramid provides for important feedback to identify needs and share specific solutions. Athletes, while deeply affected by the pandemic, remain key influencers to ensure that – especially young – audiences understand risks and respect guidance.

5. Promoting positive social attitudes and behaviour.

Sport education is a powerful means to foster physical fitness, mental well-being, as well as social attitudes and behaviour while populations are locked down. International rights and values based sport education instruments and tools, such as the International Charter of Physical Education, Physical Activity and Sport, the Quality Physical Edu­cation Policy package and the Values Education through Sport toolkit remain highly relevant references to ensure that the many online physical activity modules that are being currently deployed comply with gender equality, non-discrimination, safety and quality standards.

Authors: Daniela Bas, Melissa Martin, Carol Pollack and Robert Venne, Division for Inclusive Social Development in UN DESA.

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• Volume 56, Issue 1
• Clinical patterns, recovery time and prolonged impact of COVID-19 illness in international athletes: the UK experience
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• http://orcid.org/0000-0003-4697-1526 James H Hull 1 , 2 , 3 ,
• Moses Wootten 4 ,
• Moiz Moghal 2 ,
• http://orcid.org/0000-0002-4123-9806 Neil Heron 5 ,
• Rhodri Martin 6 ,
• Emil S Walsted 7 ,
• Anita Biswas 8 ,
• http://orcid.org/0000-0002-4855-0744 Mike Loosemore 2 ,
• http://orcid.org/0000-0002-5394-975X Niall Elliott 9 ,
• http://orcid.org/0000-0002-3783-0505 Craig Ranson 2
• 1 Department of Respiratory Medicine , Royal Brompton and Harefield NHS Foundation Trust , London , UK
• 2 English Institute of Sport , Manchester , UK
• 3 Sports Respiratory Service , Institute of Sport, Exercise and Health (ISEH), UCL , London , UK
• 4 UK Sport , London , UK
• 5 Sport Institute Northern Ireland , Belfast , UK
• 6 Sports Medicine , Sport Wales , Cardiff , UK
• 7 Respiratory Research Unit, Department of Respiratory Medicine , Bispebjerg Hospital , Copenhagen , Denmark
• 8 Sports Medicine , English Institute of Sport , Manchester , UK
• 9 Sports Medicine , Sport Scotland Institute of Sport , Stirling , UK
• Correspondence to Dr Craig Ranson, English Institute of Sport, 299 Alan Turing Way, Manchester, M11 3BS, UK; craig.ranson{at}eis2win.co.uk

Objectives To report COVID-19 illness pattern, symptom duration and time loss in UK elite athletes.

Methods Observational, clinical and database review of athletes with symptomatic COVID-19 illness managed within the UK Sports Institutes. Athletes were classified as confirmed (positive SARS-CoV-2 PCR or antibody tests) or probable (consistent clinical features) COVID-19. Clinical presentation was characterised by the predominant symptom focus (eg, upper or lower respiratory illness). Time loss was defined as days unavailable for full sport participation and comparison was made with a 2016–2019 respiratory illness dataset from the same surveillance system.

Results Between 24 February 2020 and 18 January 2021, 147 athletes (25 Paralympic (17%)) with mean (SD) age 24.7 (5.2) years, 37% female, were diagnosed with COVID-19 (76 probable, 71 confirmed). Fatigue was the most prevalent symptom (57%), followed by dry cough (50%) and headache (46%). The median (IQR) symptom duration was 10 (6–17) days but 14% reported symptoms >28 days. Median time loss was 18 (12–30) days, with 27% not fully available >28 days from initial date of infection. This was greater than our historical non-COVID respiratory illness comparator; 6 days, 0–7 days (p<0.001) and 4% unavailable at 28 days. A lower respiratory phenotype (ie, including dyspnoea±chest pain±cough±fever) was present in 18% and associated with a higher relative risk of prolonged symptoms risk ratio 3.0 (95% CI: 1.4 to 6.5) and time loss 2.1 (95% CI: 1.2 to 3.5).

Conclusions In this cohort, COVID-19 largely resulted in a mild, self-limiting illness. The presence of lower respiratory tract features was associated with prolonged illness and a delayed return to sport.

Data availability statement

No data are available. No additional data are available.

This article is made freely available for use in accordance with BMJ’s website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.

https://doi.org/10.1136/bjsports-2021-104392

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Introduction

Acute infection with the novel coronavirus, SARS-CoV-2, causing COVID-19 illness, results in a broad range of clinical manifestations in the general adult population. 1 Direct pulmonary involvement, with an inflammatory pneumonitis, is the most common reason for hospitalisation; however, other clinical presentations, such as those focused on the upper respiratory (UR) tract, are now widely recognised. 2 Studies in the UK general population have now revealed that approximately 10% of individuals with COVID-19 exhibit symptoms lasting more than 28 days and approximately 5% for 84 days or longer. 3 The reason an individual may develop a protracted illness course, with delayed recovery, currently remains unclear, but the type of symptoms and/or number of symptoms at presentation, may be indicative. Likewise, while a high level of physical fitness may be protective against the risk of severe disease requiring hospitalisation, it is unclear if this modulates disease course and recovery patterns in mild COVID-19. 4 5

In the context of athlete health, a key focus for sporting organisations and their support personnel is the ability to guide an athlete safely to return to high-intensity training and competition following illness or injury. 6 A successful return to play (RTP) plan acts to inform recovery strategy and manage expectations of the athlete and coaching staff. It is particularly relevant for athletic populations at the elite, international or professional level, where uninterrupted preparation for sporting competition is a key component of athletic and career progression. In this context, RTP decision-making arises from the need to balance the impact of a period of recommended exercise restriction, against the risk of an adverse outcome from infection-related sequelae, including injury risk, following any period of relative rest. 7 8

A number of organisations and academic groups have published recommendations regarding RTP following COVID-19, 9 10 however there are little data describing the clinical pattern, symptom time course and impact of this illness in elite athletes. Shumacher and colleagues 11 reported that in a small cohort of professional footballers (n=15), COVID-19 caused only mild symptoms, lasting less than a week, with no need for hospital care. Similarly, in the questionnaire-based AWARE-I Study, Schwellnus and colleagues 12 reported that in athletes with a broad range of athletic capability, COVID-19 was associated with a mild illness lasting approximately 10 days.

The aim of this report was to extend these findings by describing our experience managing COVID-19 in a cohort of international-level Paralympic and Olympic athletes, many of whom were preparing to compete in the 2020 Tokyo Games, using a clinical dataset from the UK Sports Institutes (of England, Scotland, Wales and Northern Ireland). Our primary aim was to report the type and duration of symptoms and their impact on full training and competition participation, and to compare time loss with our historical illness surveillance data for non-COVID-19 acute respiratory illness. A secondary aim was to characterise the COVID-19 clinical presentation that may be indicative of protracted athletic recovery from COVID-19.

Methodology

Study design and subjects.

This study was a retrospective case review of all elite athletes diagnosed with symptomatic COVID-19 between 24 February 2020 and 18 January 2021 who received medical care recorded on the electronic medical records systems used by the sports and exercise medicine physicians of the UK Sports Institutes of England, Northern Ireland, Scotland and Wales. The cases are from the population of approximately 2500 athletes who were competing in Olympic, Paralympic or Commonwealth Games sports at a senior international level for their home nation, or Great Britain and Northern Ireland. The study period was split into two waves for analysis to align with the first and second waves of the UK epidemic: the 6 months prior to August 2020 and the subsequent 6 months through January 2021.

Data collection

Athlete demographics, sporting discipline and relevant medical comorbidity data were obtained. The COVID-19 case medical record of all athletes was reviewed by a sports and exercise medicine physician until the end of the study follow-up period (11 March 2021) and the following key variables collected were:

COVID-19 diagnostic criteria; including clinical features and when available, diagnostic test results, that is, PCR from upper airway swabs, or SARS-CoV-2 antibody testing.

Nature and severity of initial symptoms experienced.

Time from symptom onset to resolution (symptom duration).

Time loss was the number of days from symptom onset to full training and competition participation. This included days when athletes were either completely unavailable, or had training modified due to illness.

Investigations, treatment and hospital care required for illness.

All data were anonymised in accordance with the privacy notices associated with the Sports Institutes’ electronic medical records systems, whereby prior informed consent was obtained from all athletes.

COVID-19 case and symptom definitions

Athletes were classified as having either (1) confirmed COVID-19 based on the presence of consistent clinical features and a positive SARS-CoV-2 PCR test or antibody test, or (2) probable COVID-19 based on consistent clinical features alone and diagnosed at a time of heightened community exposure risk in line with Public Health England guidance at this time 1 ( figure 1 ). Notably, SARS-CoV-2 antigen or antibody testing was not available in the UK for non-hospitalised individuals during the UK epidemic first wave.

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Athlete numbers with COVID-19, with UK new case data overlaid from the UK government’s coronavirus dashboard (downloaded on 25 February 2021). 22

Symptomatic presentation was classified into five clinical phenotypic groups, based on the predominant anatomical focus:

UR: sore throat±change in smell or taste or sinus problems reported±a cough±fever.

Lower respiratory (LR) illness: presence of dyspnoea±chest pain±cough±fever±other LR tract symptoms (eg, wheeze).

Cough only: cough as the predominant symptom recorded and in the absence of coexisting dyspnoea and without other UR symptoms.

Gastrointestinal (GI): with predominant symptoms being diarrhoea±nausea±abdominal pain.

Non-specific: main clinical feature was fever, fatigue±headache±myalgia but a lack of any prominent respiratory or GI symptoms.

The COVID-19 symptom and time loss duration was grouped as short (≤28 days) or prolonged (>28 days) in a similar manner to Sudre and colleagues. 3

A historical acute respiratory illness comparator dataset was obtained from the English Institute of Sport (EIS) Performance Data Management System from 1 January 2016 to 31 December 2019. This dataset consisted of all cases with the diagnostic code of ‘respiratory tract infection’ and was the same electronic medical records and health surveillance system that was used to identify the COVID-19 diagnoses.

Data and statistical analysis

Data are reported as mean (SD) or median (IQR or range). Symptom duration and time loss were not normally distributed and were compared using the non-parametric Mann-Whitney U test. Χ 2 tests, or Fisher’s exact test when expected cell counts were below five, were used to compare subgroups of the population to see whether they shared the same proportion of probable versus confirmed cases, prolonged symptom duration or time loss. Χ 2 tests and risk ratio calculations were performed using a series of 2×2 tables splitting the data into presence/absence of the feature being tested. A Haldane-Anscombe correction of 0.5 was automatically applied to any tables that contained a zero-cell count. All CIs are at 95%. For all analyses, a p value of <0.05 was considered significant. Analyses were performed using Python V.3.8 with Pandas (V.1.0.5), statsmodels (V.0.11.1) and SciPy (V.1.5) packages. Graphics were produced using Python V.3.8 with Matplotlib (V.3.2.2) and Seaborn (V.0.11.1) packages.

Athlete characteristics

A total of 147 athletes (92 male; 63%) were diagnosed with COVID-19, with a similar proportion of confirmed (n=71; 58 antigen confirmed, 13 antibody confirmed) and probable (n=76) cases ( table 1 ). A similar number of athletes developed COVID-19 during the first and second waves of the UK epidemic, at 80 and 67, respectively ( figure 1 ); and characteristics of athletes with confirmed and probable cases were similar ( online supplemental table 1 ).

Supplemental material

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Athlete characteristics and COVID-19 symptom patterns

The majority of athletes were preparing for summer sports (93%) and in able-bodied sport (83%), with the overall general demographic characteristics (ie, age and gender distribution) of athletes with COVID-19 considered representative of the UK Sports Institutes’ athlete pool (data not presented). The majority of athletes (77%) had no medical comorbidities, although, when present, asthma was the most common condition reported (18%).

COVID-19 symptom pattern and clinical phenotypes

A broad range of symptoms were reported ( table 2 ) at presentation with fatigue, cough and headache being most prevalent, in 57%, 50% and 46% of athletes, respectively. Dyspnoea was reported in 18% of athletes. GI symptomology was the least prevalent presentation, apparent in only three athletes (2%). The presence of multiple symptoms (ie, ≥3) was apparent in 38% of athletes and 18% reported five or more symptoms at presentation. The most prevalent clinical phenotype was UR, classified in 37% of athletes. Symptom and phenotype pattern was comparable between male and female athletes and between confirmed and probable cases ( online supplemental table 1 ).

The majority of athletes reported mild symptoms (n=140, 95%), that did not limit their ability to perform activities of daily living (eg, self-care). No athletes required hospital care or specific COVID-19 treatment (eg, oxygen or dexamethasone).

COVID-19 symptom duration and time loss

The median (IQR, range) between symptom onset and resolution was 10 days (6–17 days, 0–148 days) ( figure 2 ) with female athletes having a slightly longer median symptom duration than male athletes at 12 days (8–18 days, 3–138 days) vs 9 days (5–16 days, 0–148 days), respectively (p=0.006). Of the total cohort, 21 athletes (14%) had symptoms >28 days and 5 (3% of total) had symptoms lasting >90 days. Symptom duration was similar between able-bodied and Paralympic athletes (p=0.46) and in those with and without asthma (p=0.95).

COVID-19 symptom duration.

Symptom duration was shorter in those presenting with a UR versus LR phenotype, at 10 (IQR 7–15, 2–148) and 18 (IQR 10–33, 4–121) days, respectively (p=0.01) ( figure 3 ).

(A) Symptom duration based on COVID-19 clinical phenotype, and (B) time loss based on COVID-19 clinical phenotype.

The median (IQR, range) time loss was 18 (12–30 days, 0–275 days) ( figure 4 ). Of the total cohort, 75 (51%) athletes had more than 17 days of time loss, of whom 40 (27%) athletes were still not fully available >28 days and 9 (6%) >90 days. Seventy-one per cent of athletes with >28-day symptoms also had >28-day time loss.

Time loss from (A) COVID-19 (B) historical data for acute respiratory illness in the UK Sports Institute system.

Characteristics of athletes with prolonged (>28 days) time loss

The presence of chest pain at presentation was associated with a higher likelihood of prolonged time loss (>28 days), with no other single symptom indicative of prolonged return to full sport participation ( table 2 and figure 5 ). The presence of five or more symptoms was also not associated with prolonged time loss (p=1.0).

Risk ratio of (A) >28-day symptom duration versus individual symptoms at presentation and (B) >28-day time loss versus individual symptoms at presentation.

Athletes with LR symptoms were 2.1 (CI 1.2 to 3.5) times more likely to have a prolonged time loss (>28 days). The sensitivity of LR to detect this was 0.30 (CI 0.17 to 0.47) and the specificity was 0.88 (CI 0.80 to 0.93). Thus, in this cohort, the negative predictive value of LR (probability of not having prolonged time loss without LR phenotype) was 77% (CI 73% to 81%), whereas the positive predictive value (probability of having prolonged time loss given LR phenotype) was 48% (CI 32% to 65%). There were no other predictive factors ( tables 2 and 3 , figure 3 ).

Association of athlete characteristics and symptom patterns with symptom duration

Athlete characteristics and symptom patterns associated with prolonged time loss (>28 days)

Comparison of time loss for historical EIS acute respiratory illness data

Our review of historical illness surveillance data revealed a shorter duration time loss period for acute respiratory illness with a median of 6 days (IQR 0–7 days, 0–224) (p<0.001) ( figure 4 ). The prevalence of a prolonged time loss was also lower at 4% for acute respiratory illness vs 27% for COVID-19 (p<0.001).

The primary aim of this study was to report the clinical characteristics, disease course and impact of COVID-19 on full sport participation, in a cohort of very closely monitored and supported international athletes, many of whom were in the preparatory phase for the 2020 Tokyo Olympic and Paralympic Games. Our analysis included athletes who developed COVID-19 in both the first and second UK epidemic waves, representing approximately 6% of the UK Sports Institutes’ athlete pool. Respiratory tract-focused symptomatology was the most common presentation; with fatigue, cough and headache being the most prevalent symptoms; GI issues were uncommon.

In keeping with the findings reported in an age-matched demographic of the general population with COVID-19, 3 in the vast majority of cases, COVID-19 was a self-limiting illness, with symptoms lasting a median of 10 days and with no cases requiring specific targeted treatment (eg, oxygen or dexamethasone) or acute hospital care. Further, COVID-19 illness did not appear to be associated with protracted symptoms in the majority of athletes; that is, at 1 month following the onset of symptoms, only approximately 1 in 10 athletes remained symptomatic, again broadly aligning with the general population findings.

In contrast, however, COVID-19 does appear to have a more pronounced impact on full athletic recovery with over a quarter of athletes in this cohort not returned to full sport participation at 1 month following their initial infection date. Moreover, 6% of athletes were still limited at 3 months. This delayed return to full sport participation has profound implications for competition preparation, particularly given the close proximity to the Tokyo Olympic and Paralympic Games. It also compares unfavourably with our historical data, monitoring the impact of respiratory tract ‘infection’ time loss in this population of internationally competitive athletes. In the vast majority of our historical case series, an infective pathogen was not identified, and thus it is not possible to reliably compare the impact of SARS-CoV-2 infection with other specific viral pathogens.

It is important to note that, at the time of study, UK Sports Institute COVID-19 RTP guidance 7 recommended a minimum of 7 days of graded return with training modification and thus this and a conservative approach to RTP in the context of this novel pathogen may have influenced the calculation of short-term (ie, <1 month) time loss.

An associated aim of this evaluation was thus to determine if there were factors that could help clinicians when trying to assess and predict the development of protracted COVID-19 recovery. Historically, the ‘neck check’ rule has been used to aid RTP in athletic individuals with respiratory symptoms. 13 Specifically, it has been proposed that if respiratory symptoms localise to the UR tract (eg, sore throat and/or coryzal symptoms), then these are unlikely to impact training and it would be feasible to allow an athlete to continue with some form of exercise; whereas for those with symptoms below the neck, a period of full exercise cessation is recommended. This approach has, however, never been robustly evaluated in a prospective randomised trial and thus although widely used, remains contentious. Data from the recent AWARE-1 Study challenge this approach and indeed promoted the value of identifying a ‘symptom cluster’ that was associated with prolonged RTP, in symptomatic athletes with acute respiratory illness (including COVID-19). In addition, that study revealed that excessive fatigue was a key symptom associated with protracted RTP, with 70% of athletes with this symptom demonstrating an RTP greater than 40 days following infection, 12 a finding that aligns with data from a general population symptom-tracker study in the UK from Sudre and colleagues 3 who reported that fatigue at presentation was associated with an almost threefold likelihood of an individual developing long COVID-19.

In the current study, reporting data from an elite athlete cohort, we found that the presence of an LR pattern (ie, including features such as dyspnoea, chest pain and cough) was most indicative of a prolonged return to full training and was associated with almost three times the likelihood of a prolonged time loss (>28 days). This was a relatively arbitrary division, based on the presence of clinical features alone, and thus without confirmatory radiological or laboratory investigations, but may be indicative of likely low-grade pulmonary inflammation and potentially a more pronounced systemic response.

However, even based on clinical report, we found that a presentation confined to the UR tract was associated with a shorter duration of illness (median symptom duration of 10 days for the UR phenotype compared with 18 days for the LR phenotype) and a shorter return to full sport participation (median time loss of 17 days for the UR phenotype compared with 27 days for the LR phenotype). The reason this differs from the AWARE-1 findings may relate to differences in the study population (ie, elite vs broader athletic capability) and methodology (ie, medical records vs self-reported questionnaire data). Regardless, an approach that identifies the pattern of symptom localisation may be helpful in managing expectations regarding symptom duration and full sporting participation in elite athletes and now needs to be assessed and further validated in a broad range of athletic cohorts.

Several guidelines have now been published regarding protocols for RTP for athletes recovering from mild-moderate COVID-19 illness. 7 14 The most widely used guidance, that appeared early in the first wave of the global pandemic, recommended at least 10 days between symptom onset and the start of graduated exercise progression over a further 7 days. This 17-day minimum graduated RTP (GRTP) was advocated to mitigate any risk of vigorous exercise early in the illness heightening susceptibility to more serious complications (eg, pneumonia or cardiac inflammation). Data since that time indicate a very low overall incidence of these types of complications 15 and thus on the basis of a risk analysis a recommendation for shorter duration of exercise cessation may be appropriate, certainly in athletic individuals with relatively short-lived symptoms that are confined to the UR tract. It is noteworthy that data from two recent studies, enrolling a significant number of elite athletes, reveal cardiac inflammatory sequelae from COVID-19 in only a small proportion of athletes (approximately 0.6%). 16 17

The reason why an athlete may suffer from protracted symptoms and a delayed return to sport has not been systematically evaluated or presented in this report. Several mechanisms have been proposed (eg, autonomic dysfunction) and several are potentially relevant in the context of a delayed return to full sport participation. 18 19 Indeed, while ongoing detailed clinical evaluations are being conducted to establish relevant factors in Home Nation Sports Institutes (HSNI) athletes with protracted illness, this was not an aim of the current work, and we did not continue to prospectively track the intensity of persisting symptoms and limited exercise tolerance. This work is clearly needed in studies evaluating the pathophysiological mechanisms (including cardiac involvement) underpinning protracted COVID-19 recovery in both the general and athletic population.

Methodological considerations

Several methodological limitations are worthy of consideration. In the UK first wave, there was no community-based access to SARS-CoV-2 antigen testing. In this work, we therefore had to characterise the cohort, based on a classification as either a probable or confirmed diagnosis. It is therefore possible that some of the cases could have been classified incorrectly. Our comparison of these groups however shows similar clinical characteristics ( online supplemental file 1 ) and we used the Public Health England diagnostic guidance at that time to evaluate cases in at time with very heightened background infection rate and avoidance strategies in place in the UK. 1 While dyspnoea was more prevalent in the probable versus confirmed cases, dyspnoea alone was not independently associated with a longer time loss. Notably, the prevalence of chest pain which was associated with longer time loss was similar between probable and confirmed cases. Additionally, in contrast with general population, this cohort of individuals are closely monitored from a health point of view and have regular and detailed contact with Sport and Exercise Medicine (SEM) professionals. Overall, it therefore seems likely that these cases do represent true SARS CoV-2 infection.

In this respect, it is also noteworthy that, when compared with the background case rate in the UK, there appears to be a reduced prevalence or potential ‘infection rate’ during the second wave ( figure 1 ). This pattern may reflect the paucity of community-based tests in the first wave in the UK, or indeed the fact that more robust infection avoidance strategies were in place for the second wave. Certainly, within the HSNI, COVID-19 risk mitigation and testing systems improved considerably between the first and second waves. It is likely that illness behaviour will continue to be dramatically altered by global vaccination strategies, when they are widely available in athletic populations. 20

Ideally, we would have wished to use a prospective design to track athlete symptoms and to use a validated scoring system to record and characterise disease severity. However, the data collection system used at that time did not permit this type of analysis. Our definition of ‘time loss’ is one employed in the UK Sports Institutes and thus allowed direct comparison with our historical surveillance database. This is based on clinicians’ assessment of whether athletes are fully available to train and compete, and given the same systems were used for both historical monitoring and during the COVID-19 pandemic, provides methodological rigour. However, whether return to being ‘available’ is actually indicative of a full athletic recovery is likely to be more accurately determined by detailed physiological and psychological assessment. It is also possible that heightened clinical scrutiny, quarantine and GRTP requirements, in the context of this novel pathogen and an evolving understanding of COVID-19, may have influenced athlete symptom reporting or indeed prompted caution with respect to the acute RTP advice afforded to an athlete. Although this is likely to be relevant in some cases, it is worth noting that this cohort of athletes were highly motivated to continue uninterrupted training, given uncertainty regarding the timeline for the Tokyo 2020 Olympic Games and other international selection events. Overall, therefore, we feel that it is unlikely that a conservative approach to RTP significantly influenced the data reported of time loss at 28 days following the onset of infection.

A final limitation is that this study may suffer from sparse data bias 21 due to the low occurrences of various combinations of case characteristics (eg, summer vs winter sports, or clinical symptoms such as chest pain) as can be seen in tables 2 and 3 . As such, the risk ratio estimates and CIs may be biased upwards if above 1, or downwards if below 1, and this should be considered in the interpretation and potential application of the data presented.

In a cohort of elite athletes, COVID-19 was associated with a mild, self-limiting illness, lasting on average 10 days, but causing prolonged impact on full sport participation, longer than a month, in a quarter of athletes. Delayed RTP was associated with LR tract symptoms, specifically chest pain, at presentation and therefore consideration might be given to expediting RTP in athletes presenting with mild, short-lived COVD-19 symptoms confined to the UR tract. Further work is needed to determine the mechanisms associated with prolonged time loss following COVID-19 illness.

What are the findings?

In a cohort of elite athletes, preparing for international competition, COVID-19 illness largely resulted in a mild, self-limiting illness, not requiring hospital care.

The pattern and duration of COVID-19-related symptoms was similar to that reported in the UK general population; however, approximately a quarter of athletes had not returned to full sport participation at 28 days after symptom onset.

The presence of clinical features implicating lower respiratory tract involvement was associated with prolonged illness and delayed return to full sport participation.

How might it impact on clinical practice in the future?

Insight regarding the clinical course and time loss following COVID-19 illness in elite athletes informs recovery management and athlete counselling.

Consideration could be given to expediting return to full sporting participation for those who present with symptoms primarily confined to the upper respiratory tract.

Further work is needed to determine the factors underpinning a delayed return to full sport participation following COVID-19 in some athletes.

Ethics statements

Patient consent for publication.

Not required.

Ethics approval

This study was then approved by a UK Sports Institutes medical group, as a clinical audit, and therefore not requiring ethical approval.

Acknowledgments

The authors would like to thank Faye Hodson for administrative assistance.

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Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

• Data supplement 1

Twitter @Breathe_to_win, @neilSportDoc, @EmilWalsted, @dundeesportsmed, @craig_ranson

Contributors JHH and CR designed and developed the protocol, assisted with data analysis, and drafted, edited and approved the manuscript. MW performed all data analyses and acts as the guarantor for data. ESW provided statistical analysis and review of the manuscript. MM, NH, RM, AB, ML and NE contributed to the methods and data collection, and assisted production of the manuscript.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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• Open access
• Published: 06 June 2024

The impact of inactivity during the COVID-19 pandemic on the physical performance of high school athletes

• Selim Asan 1 ,
• Süleyman Ulupınar 1 ,
• Serhat Özbay 1 ,
• Sevinç Namlı 1 ,
• Cebrail Gençoğlu 1 ,
• Ferhat Canyurt 1 ,
• Yunus Emre Çingöz 2 &
• Abdullah Bora Özkara 3   na1  

BMC Sports Science, Medicine and Rehabilitation volume  16 , Article number:  126 ( 2024 ) Cite this article

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Background/Objective

This study was conducted during the 2019–2020 academic year to evaluate the impact of participation in school sports on students’ Body Mass Index (BMI) and Assessing Levels of Physical Activity (ALPHA) test scores. Interrupted by the COVID-19 pandemic, which led to a suspension of in-person education, the study resumed in September 2021, refocusing on the effects of pandemic-induced inactivity on the physical fitness levels of the same cohort.

The study included twenty-nine male high school students (age: 17,24 ± 0,73 years), divided into thirteen athletes (participating in sports such as football, basketball, and track) and sixteen non-athletic counterparts. They underwent reassessment using the ALPHA test battery, evaluating cardiorespiratory, musculoskeletal, and motor skills fitness. Data were analyzed using independent and paired samples t-tests and a two-way repeated measures ANOVA to assess changes over time and between groups. Discriminant function analysis evaluated the ALPHA test’s ability to classify students based on their athletic status pre- and post-pandemic.

Initially, athlete students exhibited significantly better BMI, 20 m shuttle run, and 4 × 10 m speed run scores compared to their non-athlete peers. After the pandemic, only the 20 m shuttle run scores remained significantly higher for athletes, with diminished distinctions in other fitness areas. The classification accuracy of the ALPHA test battery decreased from 89.7 to 75.9% post-pandemic.

The enforced sedentary lifestyle due to the COVID-19 pandemic adversely affected all students, particularly diminishing health-related fitness parameters such as body composition, cardiorespiratory and musculoskeletal strength, and motor skills. Students previously engaged in regular physical activity, notably school athletes, experienced significant fitness declines. This highlights the urgent need for targeted interventions to encourage active lifestyles among youth in the post-pandemic phase, aiming to avert long-term adverse health outcomes.

Peer Review reports

In the contemporary era, the limitations imposed by time and space have increasingly influenced the lifestyles and activity levels of children and adolescents [ 1 , 2 ]. Schools have traditionally played a pivotal role in fostering physical activity among young people, acting not only as educational institutions but also as environments conducive to health and physical well-being [ 3 , 4 ]. However, the emergence of the COVID-19 pandemic has significantly disrupted conventional schooling methods, leading to a marked rise in sedentary behavior among the youth due to the widespread suspension of face-to-face educational activities [ 5 , 6 ]. This interruption of routine school activities, especially physical education and sports, has resulted in a loss of critical opportunities for engaging in physical activity, thereby fostering a sedentary lifestyle that detrimentally impacts both physical and mental health [ 4 , 7 , 8 ].

Conversely, for those who had already adopted a sedentary lifestyle prior to the pandemic’s outbreak, the changes brought about by COVID-19 may not seem markedly significant [ 8 , 9 , 10 ]. This group, already habituated to a lifestyle with minimal physical activity, might not view the pandemic-induced restrictions and home confinement as a drastic deviation from their typical routines. On the contrary, individuals who led active lifestyles before the pandemic, particularly students involved in school sports and physical activities, have experienced significant disruptions [ 8 , 11 ]. Accustomed to regular exercise, competitions, and the sociability of team sports, these students have faced abrupt cessation of their usual physical and social activities. The transition from active engagement to enforced sedentary living due to lockdown measures has posed a substantial challenge, likely resulting in pronounced declines in their physical fitness, mental well-being, and overall health [ 8 , 12 ].

The differential impact of the pandemic on physical activity levels thus highlights a divergence: while individuals with previously sedentary lifestyles may have observed little change, those who were actively engaged, especially in school sports, have encountered significant obstacles [ 8 , 11 ]. This divergence underlines the critical need for specialized strategies to counteract the varied effects of the pandemic across different population segments. For students formerly active in sports, reengagement in physical activities and reestablishment of their former participation levels are essential for their comprehensive post-pandemic recovery. Consequently, assessing how the pandemic has differently impacted students involved in school sports and their non-athletic counterparts is vital. This evaluation serves as a crucial foundation for the development of specific interventions designed to alleviate the adverse effects associated with extended periods of inactivity. Therefore, the primary goal of this research is to investigate the disparate impacts of the COVID-19 pandemic on the physical activity levels and health-related fitness parameters between high school students who were actively involved in school sports prior to the pandemic and those who maintained a sedentary lifestyle.

Research design

The present study employed a mixed-method approach to examine the differential impacts of the COVID-19 pandemic on high school students, distinguishing between those actively participating in sports and their sedentary peers. Utilizing a longitudinal framework, we conducted assessments before and after the pandemic’s onset, facilitating a detailed comparison of temporal changes in physical fitness levels. Our primary tool for evaluation was the ALPHA test battery, which allowed us to quantitatively measure vital health-related physical fitness parameters, including cardiorespiratory fitness, musculoskeletal strength, and motor skills [ 13 , 14 ]. This design enabled a nuanced analysis of how the pandemic has affected the physical health of these two distinct student groups.

Participants

This research was conducted with a group of 29 male high school students, each aged between 16 and 18 years old. These students had progressed to secondary education prior to the COVID-19 pandemic and remained enrolled through September 2021. Initial measurements were taken between October and November 2019, with the final assessments completed in September 2021. Originally, the purpose of these initial measurements was distinct and not primarily focused on the pandemic’s impact. However, the onset of COVID-19 significantly shifted our research focus, allowing us to utilize these pre-existing data points to investigate the pandemic’s effects on the physical fitness of these students over the specified period. Initially, the research commenced with 68 students prior to the pandemic, but post-pandemic conditions resulted in only 29 students completing the study. Participants were divided into two groups: 13 students actively involved in at least one school sports team (four in football, three in basketball, four in volleyball, two in table tennis) and 16 students not engaged in any sports activities. The selection of participants was based on voluntariness, ensuring both groups were homogeneous in terms of age, gender, and educational level.

Before the pandemic, these participants engaged in training sessions 3 to 5 times per week, with each session lasting between 90 and 120 min. The majority of these sessions consisted of aerobic exercises, but they also included sport-specific training such as plyometrics, sprints, agility drills, and calisthenic strength development exercises. Prior to participating in the study, all participants and their parents signed informed consent forms, which detailed the purpose, procedures, potential benefits, and risks of the study. Participants were also required to attend a structured trial session before the tests, during which they were fully informed about the study’s procedures and tests. Inclusion criteria were defined as being enrolled in secondary education during the study period and being actively involved in school sports teams before the pandemic or not participating in any sports activities. Exclusion criteria included students who did not regularly attend school during the study period, were unable to participate in the tests due to health problems, or did not sign the informed consent form.

Data collection

Height and body mass measurements were conducted with precision using standardized equipment. Heights were measured to the nearest 0.1 cm using a stadiometer (Holtain Ltd., Crosswell, Crymych, Dyfed, United Kingdom). Body weights were assessed to the nearest 0.1 kg on a validated digital scale, ensuring reliable data for Body Mass Index (BMI) calculations and other health-related assessments.

The ALPHA test battery was utilized to evaluate a range of physical fitness metrics. The 20-meter shuttle run test was conducted to estimate maximal oxygen uptake (VO 2max ), an essential measure of cardiorespiratory endurance. This test involves participants running between two lines 20 m apart, keeping pace with audio beeps that increase in speed at set intervals. The VO 2max estimation utilized the formula: VO 2max  = 0.301 × (shuttle run score) − 0.9 × (age) − 6.642 × (gender) − 0.173 × (body weight in kg) + 63.168, where gender is assigned values (1 for males, 0 for females), providing a significant assessment of cardiorespiratory health [ 13 ]. Musculoskeletal fitness was assessed using the standing long jump test for lower body strength and the handgrip strength test for upper body strength (Takei A5001 Hand Grip Dynamometer). The participants’ agility and motor coordination were assessed through the 4 × 10-meter shuttle run, requiring swift direction changes and speed. Performance times were accurately recorded using a photoelectric cell system, ensuring exact measurement of each participant’s agility (Smart Speed electronic system, Fusion Sport, Cooper Plains, Australia).

Statistical analyses

Data analysis was performed using IBM SPSS Statistics for Windows, Version 25.0 (IBM Corp, Chicago, IL, USA). All data were reported as mean ± standard deviation, with a significance level set at p  ≤ 0.05. Initial differences between groups were analyzed using independent samples t-tests, while within-group changes were evaluated using paired samples t-tests, with effect sizes presented. Effect sizes were calculated using Cohen’s d formula [ 15 , 16 ] and classified according to Hopkins [ 16 , 17 ], aiding in the assessment of the practical significance of the study’s findings. To examine the interactions between time and group, a two-way (group×time) repeated measures ANOVA was utilized. This statistical approach allowed for the examination of changes over time within each group and the differences between groups over the same period. To address the challenges posed by our study’s small sample size and enhance the reliability of our findings, we employed bootstrap methods in conducting the discriminant function analysis. Specifically, we utilized the bootstrap technique with 1000 samples, coupled with Bias Corrected and Accelerated (BCa) confidence intervals, to robustly estimate the classification accuracy of the model. This approach allowed us to more accurately predict group membership based on the independent variables of the ALPHA test battery, while also mitigating potential biases and improving the precision of our estimates.

In the athlete group, excluding handgrip strength, all parameters showed a significant decrease in performance post-pandemic compared to pre-pandemic levels (Table  1 ). BMI, 20 m shuttle run, and Standing Broad Jump variables exhibited a moderate effect size, indicating a significant reduction in these fitness measures due to the pandemic. The 4 × 10-meter shuttle run variable demonstrated a large effect size, highlighting a more pronounced decrease in agility performance within the athlete group after the pandemic. The sedentary group displayed a significant decrease only in the 20 m shuttle run post-pandemic, with a moderate effect size.

Pre-pandemic, the athlete group significantly outperformed the sedentary group in Body Mass Index, 20 m shuttle run, and 4 × 10-meter shuttle run parameters, indicating higher fitness levels among the athletes. However, post-pandemic, only the 20 m shuttle run parameter remained significantly higher in the athlete group compared to the sedentary group, suggesting a retained but diminished advantage in cardiorespiratory fitness. Furthermore, a significant group*time interaction was observed in the Standing Broad Jump parameter. This finding indicates that the decline in performance due to the pandemic’s impact was greater in the athlete group than in the sedentary group, highlighting the more substantial effect of reduced physical activity and altered training conditions on students previously engaged in regular athletic activities.

Discriminant function analysis was employed to classify the participants into either the athlete or sedentary group based on their pre-pandemic physical fitness measures (Table  2 ). The analysis accurately classified 89.7% of the students into their correct groups, demonstrating the efficacy of the physical fitness measures in distinguishing between the two lifestyles. Specifically, for the athlete group, consisting of 13 members, 92.3% (12 students) were correctly classified into the athlete group, while 7.7% (1 student) was mistakenly classified into the sedentary group. On the other hand, in the sedentary group, which comprised 16 members, 81.2% (13 students) were correctly identified as part of the sedentary group, and 18.8% (3 students) were incorrectly classified as belonging to the athlete group.

Utilizing discriminant function analysis to classify participants based on their post-pandemic physical fitness measures yielded an overall correct classification rate of 75.9% (Table  3 ). Among the athlete group, which consisted of 13 individuals, 69.2% (9 students) were accurately classified back into the athlete group, whereas 30.8% (4 students) were mistakenly classified as part of the sedentary group. This misclassification indicates a notable impact of the pandemic on the physical fitness levels of students previously identified as athletes, affecting their classification based on post-pandemic physical fitness measures. In the sedentary group, comprising 16 individuals, 81.2% (13 students) were correctly identified as sedentary, while 18.8% (3 students) were inaccurately classified as belonging to the athlete group. This classification accuracy demonstrates a relative stability in the physical fitness measures of the sedentary group when compared to the pre-pandemic period.

The discriminant function analysis conducted for pre-pandemic and post-pandemic physical fitness measures utilized Box’s M statistic to assess the equality of covariance matrices across groups. For the pre-pandemic analysis, Box’s M value was 20.305, with an associated F value of approximately 1.074 (df 1  = 15, df 2  = 2649.3), resulting in a significance level of 0.375. In the post-pandemic analysis, Box’s M value increased to 26.474, with an F value of approximately 1.401 (df 1  = 15, df 2  = 2649.3), and a significance level of 0.138. The significance levels in both analyses (0.375 pre-pandemic and 0.138 post-pandemic) suggest that the assumption of equal covariance matrices across groups was not violated, indicating that the discriminant function analysis was appropriately applied to the data. Furthermore, the analysis confirmed the absence of multicollinearity among the ALPHA test variables, with the highest correlation coefficient (r) observed being 0.62. This indicates that the variables within the ALPHA test battery were sufficiently independent, ensuring the validity of the discriminant function analysis results.

The COVID-19 pandemic has significantly disrupted the daily lives and routines of individuals worldwide, with particularly profound effects on the physical activity and fitness levels of adolescents [ 2 , 6 , 18 ]. This study provides an in-depth analysis of these impacts, highlighting the varied experiences of high school students engaged in athletic programs compared to their sedentary peers. Our findings indicate a broad decline in physical fitness across most parameters for the athlete group, an observation that starkly contrasts with the relatively stable metrics, apart from the 20 m shuttle run, in the sedentary group. This disparity underscores the extensive disruption experienced by students typically involved in structured physical activities, emphasizing the far-reaching consequences of the pandemic on established fitness routines.

In light of global trends, comprehensive research utilizing Argus app data demonstrates a significant worldwide reduction in physical activity, as reflected by decreased daily step counts following pandemic-induced restrictions [ 18 ]. This global phenomenon provides a background for our findings, reinforcing the dramatic declines in specific fitness parameters among high school athletes we observed. The universal challenge posed by social distancing measures and lockdowns is further exemplified by the nuanced perspectives our study offers. The differential impacts we observed—substantial declines in endurance and agility for athletes versus minimal changes for the sedentary—echo the broader disruptions documented globally. Additionally, another study details an international online survey initiated seven languages to illuminate the behavioral and lifestyle consequences of COVID-19 restrictions [ 10 ]. This report presents critical results on physical activity and nutrition behaviors, indicating a negative effect on all intensities of physical activity with an increase in daily sitting time from 5 to 8 h per day. These findings suggest that while isolation is a necessary measure to protect public health, it alters physical activity and eating behaviors in a direction that could compromise health. This broader context supports our specific observations of dramatic declines in fitness parameters among high school athletes, providing a deeper understanding of the pandemic’s impact on young individuals engaged in regular sports activities.

The findings of our study align with the longitudinal research conducted in China in several aspects, indicating broad impacts of the COVID-19 pandemic on adolescent physical fitness [ 8 ]. However, a notable divergence is observed in the realm of muscular strength. While Zhou et al. (2022) reported an improvement in this area among adolescents during the lockdown, reflected through enhanced performance in exercises like pull-ups, our study did not observe similar trends. Specifically, handgrip strength among our participants remained unchanged, underscoring a distinct contrast in the outcomes related to muscular strength. This difference may underscore the variation in the effectiveness of different types of home-based physical activities undertaken during lockdown conditions [ 19 , 20 ]. It suggests that pandemic impacts on physical fitness components vary, with the nature and type of activities available during lockdowns significantly influencing specific fitness outcomes. This observation emphasizes the complex nature of physical fitness adaptations under pandemic-induced restrictions, highlighting the need for diverse and adaptable physical activity strategies [ 21 , 22 ].

The notable decrease in physical fitness among adolescents with higher baseline fitness levels, a trend consistent with both our findings and the previously mentioned studies [ 8 , 10 , 12 ], underscores the uneven impact of the pandemic across different demographic groups. The pandemic has not only disrupted regular physical activity but also led to significant lifestyle shifts, including dietary changes, as individuals, including athletes, navigate the constraints of lockdowns and social distancing [ 1 , 9 , 23 , 24 ]. The increase in sedentary behaviors and the shift towards unhealthy dietary patterns, exacerbated by the pandemic as highlighted by previous research, have contributed to the declining physical fitness levels observed [ 24 , 25 ]. This shift is concerning and suggests a compounded effect of reduced physical activity and poor nutrition on overall adolescent health and well-being.

The necessity of regular exercise, emphasized by existing studies, becomes particularly pertinent in light of our findings. Despite pandemic-related challenges, the significance of engaging in home-based exercises such as yoga, pilates, and aerobics cannot be overstated in countering the effects of prolonged inactivity [ 21 , 26 , 27 ]. The observed post-pandemic decrease in physical activity rates, coupled with our research outcomes, underscores the urgent need for specialized interventions that foster physical activity and nutritional well-being during periods marked by significant restrictions [ 19 , 23 , 25 ]. In conclusion, our study contributes valuable insights into the specific effects of the COVID-19 pandemic on the physical fitness of adolescents, highlighting the critical need for strategies to support youth health during times of global crisis. By documenting the decline in physical fitness among athletes and noting the relative stability among sedentary peers, we underscore the pandemic’s broad impact and the importance of maintaining an active lifestyle and healthy diet, even under challenging conditions. Moving forward, it is imperative to develop and implement comprehensive public health strategies that can effectively address the multifaceted challenges presented by the pandemic, ensuring the physical and mental well-being of adolescents in these unprecedented times.

Limitations of the study and recommendations for Future Research

While our study offers significant insights into the impacts of the COVID-19 pandemic on adolescent physical fitness, several limitations must be acknowledged to better interpret and generalize the findings. First, the sample size and demographic scope of our study, primarily focusing on male high school students from a single geographical region, may limit the generalizability of our findings to broader populations. Additionally, as the study involved only one type of educational setting, future studies should aim to include a more diverse cohort encompassing different age groups, genders, and socio-economic backgrounds. This expansion would provide a more comprehensive understanding of the pandemic’s impact on physical fitness across various demographics. Moreover, our study assessed conventional fitness metrics such as cardiorespiratory fitness, musculoskeletal strength, and motor skills, without delving into psychological or behavioral changes that might accompany altered physical fitness levels. Acknowledging the interrelation between physical and psychological health, future research should consider these aspects to provide a holistic view of adolescents’ well-being during and after the pandemic. The longitudinal design of our study was also constrained by the unique circumstances of the pandemic, which limited our ability to conduct follow-up assessments under normal conditions. As such, long-term studies extending beyond the pandemic would offer valuable insights into the recovery process and the efficacy of different intervention strategies in restoring physical fitness levels. These studies should also explore the long-term psychological impacts and behavioral adaptations resulting from extended periods of physical inactivity. Lastly, while our findings underscore the need for targeted interventions to mitigate the negative effects of pandemic-related disruptions on adolescent physical fitness, specific recommendations for intervention programs or policy measures were not sufficiently detailed in our initial analysis. Future studies should explore the effectiveness of various physical activity programs and policies in promoting physical fitness during times of social restrictions. Such research could inform public health strategies and educational policies aimed at maintaining and enhancing physical fitness among adolescents in the face of future public health crises.

In conclusion, our study provides a detailed examination of the significant impacts of the COVID-19 pandemic on the physical fitness of high school students, distinguishing between those engaged in regular athletic activities and their sedentary counterparts. The findings underscore a notable decline in physical fitness levels, particularly among athletes, highlighting the profound effects of pandemic-induced disruptions on structured physical activities and training routines. Moreover, the diminished discriminative power of the ALPHA test battery post-pandemic signals a need for continuous monitoring and assessment of physical fitness measures to better understand and address the evolving challenges faced by youth in maintaining physical health. Future research should expand upon our findings by incorporating diverse populations, employing objective measures of physical activity, and exploring the interrelations between physical, psychological, and behavioral health aspects. This holistic approach will enable a more comprehensive understanding of the pandemic’s multifaceted impact on youth and inform the development of effective, evidence-based interventions. Ultimately, our study calls for an integrated effort among educators, policymakers, and health professionals to prioritize and promote physical activity as a crucial component of youth development and public health, particularly in the face of challenges posed by the COVID-19 pandemic and potential future public health emergencies.

Data availability

The datasets generated and analyzed during the current study consist of numerical data related to physical fitness measurements. These data are available upon reasonable request. Requests for access to these data should be directed to Dr. S.U. ([email protected]). Data are provided under specific conditions which will be detailed upon request. The numerical data are primarily in Excel format. Supplementary documentation, including a data dictionary explaining the measurements and a methodology guide detailing the data collection and analysis procedures, is also available to facilitate understanding and use of the dataset.

Abbreviations

Body Mass Index

Coronavirus Disease 2019

Assessing Levels of Physical Activity

Maximum Oxygen Uptake

Standard Deviation

Analysis of Variance

Statistical Package for the Social Sciences

Probability Value

Student’s t-Test

F Statistic

Pearson Correlation Coefficient

Degrees of Freedom

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This study was submitted in the form of an abstract to the 7th International Congress on Academic Sports Studies.

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Selim Asan, Süleyman Ulupınar, Serhat Özbay, Sevinç Namlı, Cebrail Gençoğlu & Ferhat Canyurt

Faculty of Sport Sciences, Bayburt University, Bayburt, Turkey

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Conception and design of the study: S.A., S.U., S.Ö., and C.G. Data acquisition, analysis, or interpretation of data: S.A., S.U., F.C., Y.E.C., and A.B.Ö. Drafting the manuscript: S.A., S.U., S.N., and A.B.Ö. All authors critically reviewed the manuscript for important intellectual content. Senior authorship: A.B.Ö. All authors approved the final version of the manuscript.

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Asan, S., Ulupınar, S., Özbay, S. et al. The impact of inactivity during the COVID-19 pandemic on the physical performance of high school athletes. BMC Sports Sci Med Rehabil 16 , 126 (2024). https://doi.org/10.1186/s13102-024-00916-3

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COVID's impact on college athletes' mental health and performance

College athletes spoke about disappointments amid COVID.

Student athletes are used to having routines and game schedules. But that regimen was taken away as of March 2020, as lockdowns and restrictions were put in place throughout the country to combat COVID-19.

Some college athletes and experts shared with ABC News the toll they said the pandemic has taken on student athletes' mental well-being as well as their progress in their sport.

MORE: Study shows less than 1% of pro athletes infected by COVID-19 also developed inflammatory heart disease

"The pandemic was awful for me in the sense that I felt like I lost everything in an instant," Baylee Tkaczuk, a gymnast who attended the University of Wisconsin Oshkosh from 2016 to 2020, told ABC News.

Tkaczuk, who graduated in May 2020, spoke about disappointments amid COVID.

"One day my team and I were conference champs for the first time in 24 years and we were ready to go to nationals," she said. "The next day we learned we wouldn't be going. It was awful for the seniors last year because it was so abrupt and we never got to compete in our last competitions."

“For many student-athletes, their sport is a big part of their identity, their community on campus and their daily routine,” Dr. Sarah Lipson, an assistant professor in the department of health law policy and management at the Boston University School of Public Health told ABC News.

While athletes fear getting COVID-19 just like everyone else, there's the added sense of loss from restrictions put on their practice sessions and competitions which can affect their progression in their sport, said Dr. Shekhar Saxena, professor of the practice of global mental health at the Harvard T. H. Chan School of Public Health.

"The time window that athletes have in their career to do their best is very narrow and for some, one year lost could be a career lost. For others, the time lost breaks their routine and the chance to win a medal or to set a record -- that can result in anxiety and depression," Saxena told ABC News.

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A junior when the pandemic hit, Noa Covell, now a senior on the women's rowing team at Ithaca College, had a hard time processing that school and sports were becoming remote activities.

"Our whole team was told that we had to go home right after returning back to campus from our spring training trip in Georgia," Covell said. "Working out alone for the first couple of months made me feel extremely isolated and unmotivated."

Covell said she knew many of her teammates felt the same, so she found a way to keep her team connected even though they were all miles apart.

"We decided to try to make a schedule to do workouts over Zoom together. Having Zoom open during the workout and seeing the faces of my teammates made a huge difference," Covell said.

Even athletes participating in socially distanced games and practices feel the effects of the pandemic.

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Original research article, psychological impact of the covid-19 pandemic on athletes.

• 1 Youth Sports Club, Akoka Study Centre, Lagos, Nigeria
• 2 Human Kinetics and Health Education, University of Lagos, Lagos, Nigeria

This study explored the influence of athletic identity and sports participation on the psychological well-being of athletes during a pandemic. The objective of the study was to understand the psychological impact of the coronavirus lockdown measure on athletes who were not able to carry out their normal daily routine. Athletes from nine different sports completed an online survey during the sixth week of the total lockdown in Nigeria. The online survey consists of an athletic identity scale and the Kessler Psychological Distress Scale (K10). Data collected were analyzed using Multiple regression and the Mann-Whitney test at 0.05 level of significance. The result of the findings revealed that category of sports (individual and team) ( M = 0.73, β = −6.116) and athletic identity ( M = 59.16, β = −0.166) predicts psychological distress to some degree. Few individual sports athletes and athletes with low athletic identity are prone to higher levels of psychological distress than team sports athletes and athletes with high athletic identity during the coronavirus pandemic lockdown. Individual sports athletes reported elevated levels of psychological distress compared to team sports athletes ( z = −2.186, p = 0.03, r = 0.27). In conclusion, the results have confirmed that some athletes competing in individual sports experience elevated levels of psychological distress during the coronavirus pandemic, therefore they need the support of a sports psychologist during such periods to help in maintaining their psychological well-being.

Introduction

Pandemics have been around for more than a century, and they continue to impact humanity negatively. There have been pandemics such as the H1N1 in Mexico, which rapidly spread to the whole world ( Cowling et al., 2010 ), the MERS-COV, Ebola, and SARS which came later. These pandemics cause enormous negative economic, social, and security impacts on the global community ( Qiu et al., 2017 ), but their psychological influence is hardly recognized. Recently, the world started to experience another pandemic caused by the novel coronavirus-19 that originated in Wuhan, China ( Toresdahl and Asif, 2020 ). The coronavirus has a similar mode of transmission to SARS and MERS ( Dong and Bouey, 2020 ), but it has spread so fast to many other countries, including Nigeria.

With the large-scale spread of this coronavirus and the knowledge of its transmission, most governments introduced heightened measures to control its spread ( Taylor et al., 2008 ; Dong and Bouey, 2020 ). These measures include the use of protective equipment and the introduction of non-pharmaceutical protocols such as social distancing, hygiene guidelines, and, in more severe cases, a total lockdown ( Cowling et al., 2010 ; Schinke et al., 2018 ). The consequence of these measures implied that gatherings of people were not welcome ( Dong and Bouey, 2020 ), and as a result, many sports events earlier scheduled were cancelled or suspended due to the high risk of spreading the virus. The major events postponed include the Olympics slated to be held in Tokyo, UEFA Euro Cup, UEFA Champions League, and CAF Nations Cup qualifiers ( Samuel et al., 2020 ). Most football leagues and competitions were also affected by safety measures. In Nigeria, the National Sports Festival was postponed indefinitely, pending advice from the Nigeria Centre for Disease Control ( Okpara, 2020 ). As expected, the postponement of these competitions came with a lot of economic hardships on host cities and sports event organizers. Sports fans also had their fair share. These postponements also have a significant psychological influence on the athletes who are to participate in these competitions.

Most studies have focused on the psychological implication of pandemics on the general population ( McAlonan et al., 2007 ; Taylor et al., 2008 ), with very few paying attention to special populations like athletes in recent times ( Turbeville et al., 2006 ; Pillay et al., 2020 ). Recent research on home confinements as a result of the coronavirus have shown that athletes experience negative psychological effects ( Dong and Bouey, 2020 ; Toresdahl and Asif, 2020 ). In fact, some studies have revealed that athletes experience mental health challenges just like the general population and are therefore not immune ( Gouttebarge and Kerkhoffs, 2018 ; Schinke et al., 2018 ; Pillay et al., 2020 ). On the other hand, other studies have stated that sports provide a protective effect that prevents psychological disturbances. For example, a study was carried out to compare general health in athlete and non-athlete women ( Alamdarloo et al., 2019 ). The study found out that athletes differed from non-athletes in anxiety and severe depression, with the mean scores for these two variables lower in athletes compared to non-athletes. Similarly, another study suggested that physical activity in the right quantity has the potential to reduce symptoms of anxiety and depression ( Siefken et al., 2019 ). It seems that there is no agreement as to the existence of mental health problems among sports athletes due to the belief that sports prevent ill mental health. However, recent studies on mental health in sports among elite athletes have revealed that, compared to the general population, athletes are under-diagnosed, and the culture of mental toughness promotes this situation ( Schinke et al., 2018 ). Many athletes who exhibit these ill mental health symptoms, such as distress, burnout, depression, or sleep disturbance, adverse feelings or thoughts, and drug abuse ( Gouttebarge and Kerkhoffs, 2018 ), hide it from their teammates and coaches due to the mental toughness culture that pervades the atmosphere.

Furthermore, athletes who suffer from these conditions may not inform their coach or teammates for fear of losing their playing position. If they compete in individual sports, they may not want to be deprived of competing against an opponent. Studies have shown that individual sports athletes are at a greater risk of psychological distress than team sports athletes ( Tasiemski and Brewer, 2011 ; Purcell et al., 2019 ). Mental health challenges have been suggested to be more prevalent in individual sports athletes compared to team sport athletes ( Pluhar et al., 2019 ), owing to the nature of individual sports. Specifically, individual sports athletes have to deal with both success and failure on their own, while team sports athletes enjoy a shared responsibility ( Mladenović, 2019 ). Furthermore, team sports provide more social opportunities compared to individual sports in which there is no peer support. This situation may be tougher for athletes who are much younger and inexperienced ( Nicholls et al., 2016 ). For instance, studies have emphasized the high risk which college athletes are exposed to, including the inability of college athletes in dealing with the challenges that they encounter. In fact, youth athletes who are unable to deal with perceived failure prefer to drop out of sports participation ( Crane and Temple, 2015 ), hence experiencing a depletion in their athletic identity. Similarly, a study on collegiate athletes' reaction to loss revealed that unsatisfied athletes tended to decrease their athletic identity compared to athletes who were satisfied by their performance ( Brewer et al., 1999 ). Athletes reduced their self-identification with their athletic role as a response to poor performance.

Athletic identity refers to the degree to which an individual attributes or identifies with the athletic role. Although it is developed through social interaction and validation, it is accompanied by both negative and positive outcomes ( Verkooijen et al., 2012 ; Reifsteck, 2013 ). This identity with the athlete's role is confirmed by others and motivates the individual involved to be more committed to training and sports goal achievement. Athletes who are high in athletic identity exhibit behaviors such as going regularly to the gym and sports field and even buying mostly athletic gears and equipment. However, an overemphasis on athletic identity may lead to negative outcomes as stated earlier. Studies have stated that a reduction in the opportunity to participate in sports harms the mental health of athletes and their athletic identity levels ( Masten et al., 2006 ; Miller and Hoffman, 2009 ). Consequently, when an athlete is not regularly allowed to express himself/herself, there is a high tendency for that athlete to experience a reduced athletic identity ( Fraser-Thomas et al., 2008 ; Altintaş and Kelecek, 2017 ). This phenomenon is expected more in youth athletes, who may drop out of sports ( Nicholls and Polman, 2007 ; Hall et al., 2017 ; Lewis et al., 2017 ), than in elite professional athletes who may cope with such a situation. In addition, it has also been revealed in other studies that when athletes, especially those high in athletic identity, are unable to engage in their daily routine as a result of injury ( Mittly and Nemeth, 2016 ), they start to resent their identification as athletes ( Hadiyan and Sheikh, 2015 ). This makes athletic identity a critical factor that should be considered especially in athletes as they go through the period of home confinement during the coronavirus pandemic.

Although recent studies are beginning to investigate the psychological well-being of athletes during the coronavirus pandemic ( Costa et al., 2020 ; Mehrsafar et al., 2020 ; Pillay et al., 2020 ), most of these studies are from Europe and the USA. More studies are required to better understand athletes' experience from other climes like Africa and, specifically, Nigeria. There is limited knowledge about the influence of athletic identity and sports participation on the psychological well-being of athletes, especially during a pandemic. A recent study explored the differences in gender, type of sport, and competitive level in athletic identity during the coronavirus lockdown and found out that elite athletes and team sports athletes showed higher athletic identity ( Costa et al., 2020 ). However, this study did not investigate the influence of extrinsic rewards on psychological well-being and how athletic identity interacts with well-being in athletes during the coronavirus lockdown. Based on this, our study aims to investigate differences by competitive level, extrinsic rewards, and category of sports participation in athletes and understand how athletic identity, age, category of sport participation, and the number of years participating in sports interact with the psychological well-being of athletes during the coronavirus lockdown.

Methodology

Participants and procedure.

The sample comprised 64 athletes from nine different sports: two team sports (football and basketball) and seven individual sports (athletics, cycling, taekwondo, tennis, gymnastics, badminton, and table tennis). The participants were classified as professional athletes ( n = 20), which included athletes who compete in national and regional tournaments, and non-professional athletes ( n = 44) who compete in state tournaments. The authors contacted coaches known to them through voice calls and WhatsApp messages to help in reaching their athletes about the possibility of taking part in the study. This was done during the home confinement period of the total lockdown which started at the end of March 2020. A weblink to the consent form and online survey was made available to coaches and some athletes via WhatsApp from May 5, 2020, during the height of the pandemic lockdown in Nigeria. The online survey was open for 4 weeks from the May 5, 2020 to June 2, 2020. Due to the circumstances at that period, the authors could not determine which sports athletes could take part in the study. Hence, those who responded to the survey by completing it were regarded as study participants, and the participation was anonymous. Since we were interested in athletes all over the country, we did not request their location. The ethical approval board of the Department of Human Kinetics and Health Education was contacted by email, and they approved the study.

The full survey comprised 26 questions covering a range of subject areas; those reported here include demographic information: gender, age category, type of sport, and level in sport. In addition, the respondents were asked about their years of sports participation as well as earnings from sports.

Anxiety and Depression During the Viral Pandemic

To measure psychological distress during the pandemic, the 10 items from the Kessler Psychological Distress Scale (K10) were employed ( Andrews and Slade, 2001 ; Kessler et al., 2002 ; Sampasa-Kanyinga et al., 2018 ). The K-10 was developed and validated as a screening tool for assessing the likelihood of common mental disorders in the general population and clinical samples ( Kessler et al., 2002 ; Slade et al., 2011 ; Sunderland et al., 2012 ). The K-10 demonstrates strong psychometric properties ( Pereira et al., 2019 ) and has been used across different populations and cultures ( Chan and Fung, 2014 ; Sampasa-Kanyinga et al., 2018 ). The K10 is a 10-item scale that asks respondents how often they have experienced certain symptoms during the preceding 4 weeks. The participants responded on a five-point scale depending on how frequently they experienced each symptom. The five-point scale ranges from none of the time (1) to all of the time (5). The K10 has items such as item 1 (In the past 4 weeks, about how often did you feel tired out for no good reason?) and item 5 (In the past 4 weeks, about how often did you feel restless or fidgety?). Past research has shown that K10 has satisfactory psychometric properties ( Taylor et al., 2008 ; Sampasa-Kanyinga et al., 2018 ). In this study, the internal consistency was satisfactory (α = 0.86).

Athletic Identity

To measure athletic identity, the original 10-item scale for athletic identity measurement was used ( Brewer et al., 1993 ; Hadiyan and Sheikh, 2015 ; Tunçkol, 2015 ). This test was chosen because of its ability to measure levels of athletic identity and its high internal consistency index test–retest reliability. The Athletic Identity Measurement Scale is supported as a unidimensional and multidimensional instrument ( Brewer and Cornelius, 2001 ). The evaluation of the unidimensional scale can be performed by using the total score to produce a single self-evaluation score that represents the athletic identity, with higher scores indicating a strong athletic identity. The multidimensional scale contains four scales: self-identity, social identity, exclusivity, and negative affectivity ( Brewer et al., 1993 ). Self-identity items capture reports that are self-referenced. Social identity items express the degree to which individuals view themselves as occupying the athletic role. Exclusivity measures the self-worth of an individual established through participation in the athletic role. Negative affectivity is the degree to which individuals experience negative emotions from undesirable sporting outcomes such as injury or retirement. The participants were asked to indicate their agreement with each item by responding on a seven-point scale from “strongly agree” to “strongly disagree.” The scale comprised 10 items measuring self-identity (e.g., “I have many goals related to sport”), social identity (e.g., “Most of my friends are athletes”), negative affectivity (e.g., “I feel bad about myself when I do poorly in sport”), and exclusivity (e.g., “Sport is the most important part of my life”). The internal consistency of this questionnaire was satisfactory (α = 0.93).

Data Analysis

The characteristics of the participants were described using frequency distribution, while group differences were subjected to Mann–Whitney tests since the data collected did not meet the assumptions of parametric tests such as small samples and normality of data. To understand whether one group experiences psychological distress more than the other during the coronavirus lockdown, the Mann–Whitney test was conducted to test the difference between professional and non-professional athletes, team and individual sports athletes, and athletes who earned financial rewards from sports participation and athletes who do not earn from sports participation. Multiple regression analysis was performed in order to determine the possible effect of the interaction among athletic identity, years participating in sports, age, and psychological distress scores (criterion variable). We used STATA version 14 for all statistical analysis. All statistical tests were performed at 0.05 level of significance.

Sample characteristics are displayed in Tables 1 and 2 . Results from the Mann–Whitney tests are shown in Table 3 . Analysis by competitive level (non-professional and professional) did not yield any significant difference on psychological well-being between professional and non-professional athletes ( z = 0.63, p = 0.53, r = 0.08). Specifically, professional athletes were not different from non-professional athletes based on psychological distress. There was a significant difference between individual sports athletes and team sports athletes ( z = −2.19, p = 0.03, r = 0.27), but with a small effect size. Financial opportunities did not reveal any significant difference. Athletes who earned from their participation in sports did not differ significantly in psychological distress from those who did not earn from sports participation ( z = 0.46, p = 0.65), and the effect size of the analysis was small ( r = 0.06).

Table 1 . Sample description.

Table 2 . Prevalence of psychological distress by sample characteristics.

Table 3 . Mann-Whitney tests for psychological distress.

Results from the multiple regression with psychological distress as the dependent variable and athletic identity, age, sport type, and years participating in sports as predictor variables are displayed in Table 4 . The results show that the categories of sport participation ( b = −6.116, SE = 2.610, p = 0.023) and athletic identity ( b = −0.166, SE = 0.075, p = 0.03) have significant but negative relationships with psychological distress. The other variables had no significant relationship with psychological distress.

Table 4 . Regression result for psychological distress.

This study sought to investigate the influence of athletic identity on the psychological well-being of athletes during the COVID-19 pandemic. In this study, we were interested in finding out the differences in psychological distress between professional and non-professional athletes, between individual and team sports athletes, and between athletes who earned from sports participation and those who do not earn from sports participation during the COVID-19 pandemic lockdown. There were two significant findings of this study. The first is that individual athletes differed significantly from team sports athletes in their psychological response to the COVID-19 pandemic lockdown. Secondly, we found out that athletic identity has a significant relationship with psychological distress.

Our study revealed that individual sports athletes experienced high psychological distress compared to team sports athletes who experienced low psychological distress. However, our result should be interpreted with caution, owing to the number of individual athletes who participated in the study. Individual sports athletes are at a higher risk of experiencing psychological distress due to the pandemic lockdown that prevents participation in regular sporting activities. Studies have shown that individual sports athletes are at a greater risk of psychological distress than team sports athletes ( Tasiemski and Brewer, 2011 ; Purcell et al., 2019 ). Furthermore, other studies have suggested that individual sports provide little or no social opportunities and a lot of personal responsibility for both success and failure, hence making individual athletes more prone to psychological distress compared to team sports athletes ( Dias et al., 2010 ; Mladenović, 2019 ; Pluhar et al., 2019 ). For instance, individual sports athletes attribute failure to themselves more than athletes in team sports where there is a diffusion of responsibility, and this situation makes them more prone to psychological distress when compared to team sports athletes ( Nixdorf et al., 2016 ).

Based on the result from the multiple regression analysis, our study showed that the age of athletes and the number of years spent participating in sports did not predict psychological distress. However, athletic identity and category of sport participation were able to predict psychological distress to some degree. Athletes who competed in individual sports experienced higher psychological distress compared to those who competed in team sports. This finding is supported by a number of studies ( Dias et al., 2010 ; Pluhar et al., 2019 ). The circumstances surrounding the nature of individual sports make the athletes who take part in individual sports prone to psychological distress than team sports athletes ( Nixdorf et al., 2016 ; Purcell et al., 2019 ). Furthermore, athletes who reported higher athletic identity experienced lower psychological distress compared to those who reported lower athletic identity. Although there are no studies that have directly reported this finding, our findings are similar to a previous study which showed that an increase in self-identity decreases anxiety levels ( Masten et al., 2006 ). The abrupt end to sports events and activities brought about by the COVID-19 lockdown is associated with a loss of aspects that contribute to one's sense of self, which can negatively affect self-identity and lead to depressive symptoms ( Tasiemski and Brewer, 2011 ).

We found out that both professional and non-professional athletes do not differ in the symptoms of psychological distress that they reported. This result has been confirmed in a study that sought to investigate the effect of soccer on mental health ( Heun and Pringle, 2018 ). It was concluded that participants in football are not different from the general population in mental health problems. Specifically, there are general risk indicators such as negative life events in which both athletes and the general population experience comparable psychological distress ( Rice et al., 2016 ; Purcell et al., 2019 ).

With regards to financial compensation, there was no significant difference in psychological distress between athletes who earned from sports participation and other athletes who did earn from their participation in sports. Previous studies have highlighted the importance of non-monetary rewards to athletes over monetary rewards ( Podlog et al., 2015 ; Maier et al., 2016 ). Hence, our study suggests that the absence of extrinsic rewards from sports during the COVID-19 pandemic lockdown did not influence the psychological reaction of athletes who usually received financial reinforcement.

The findings of this study have implications for coaches and athletes who compete at state, regional, and national sports tournaments in Nigeria. Nigerian athletes, especially individual sports athletes who depend largely on their sport as a means of achieving their goals, may suffer the consequences of this over-dependence during the COVID-19 lockdown. Sports psychologists are not usually present as part of the support staff to athletes in most sports federations. For this reason, local sports coaches work with athletes based on their experience alone, without any knowledge of mental health, thereby increasing the chances of mental health problems in athletes. Nigeria sports federations should engage the services of sports psychologists as part of the support staff to athletes, include courses that emphasize psychological education in the training programs of coaches, and organize online mental health seminars as part of athlete education during and beyond the lockdown period.

Limitations

The main limitation of this study was the size of the sample, which is relatively low and had more respondents from one sport (football). In addition, most of our samples were from team sports. Hence, the data cannot be easily generalized. More studies with larger samples are needed to be able to generalize the findings. Our study was not able to compare gender differences due to the low number of female athletes responding; more studies are required in this regard. Furthermore, the study included a self-report psychological distress scale which was not validated for the intended population. Hence, we cannot draw any causal conclusion based on the current findings.

In conclusion, the results of this study indicate that individual sports athletes experienced high psychological distress as a result of the COVID-19 pandemic lockdown. The number of individual sports participants in the study were fewer compared to team sports participants, and this may have contributed to this result. Hence, this result should be interpreted with caution. Furthermore, this result should inform practitioners to pay closer attention to athletes who compete in individual sports. For example, the COVID-19 pandemic lockdown is a peculiar situation in which athletes had to be in isolation, away from their sport without any certainty of resumption or any form of real social support from relatives and friends. It might have led to feelings of sadness and hopelessness in some individual sports athletes. For this reason, coaches and the other staff who work with individual sports athletes should regularly keep in touch with the athletes using online interventions during the pandemic lockdown to help them have a sense of belonging. Further research should focus on determining, by comparing different sports, the highest prevalence of psychological distress.

Our data showed that athletic identity and category of sports participation predict, to a certain extent, the level of psychological distress athletes experience during the COVID-19 pandemic lockdown. These findings may have important implications for practitioners, coaches, and athletes. A number of studies have suggested that individual sports athletes experience anxiety and psychological distress more than team sports athletes ( Pluhar et al., 2019 ). With regards to athletic identity, it is important to note that athletes may reduce their connection with the athletic role as a means of protecting their self-image ( Brewer et al., 2010 ). When some athletes begin to divest or reduce their athletic identity during a pandemic, it may be a sign that they are experiencing psychological distress. However, this might not be the case for other athletes. Nevertheless, it demands some level of awareness from coaches and sports psychologists. Hence, athletic identity should be considered not as the cause of psychological distress but as a potential predictor of psychological distress during pandemic lockdowns. Sports federations in Nigeria should employ sports psychologists who can support athletes in readjusting their goals and adapting to changing circumstances like the coronavirus pandemic lockdown, using accessible online interventions. More research is needed to understand the interaction between athletic identity and psychological distress.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics Statement

The studies involving human participants were reviewed and approved by Department of Human Kinetics and Health Education. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

CU and CA wrote the Introduction, discussion and conlusions. Data collection and analysis was mainly done by CU. The authors approved the submitted version.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Keywords: psychological distress, viral pandemic, athletes, athletic identity, age

Citation: Uroh CC and Adewunmi CM (2021) Psychological Impact of the COVID-19 Pandemic on Athletes. Front. Sports Act. Living 3:603415. doi: 10.3389/fspor.2021.603415

Received: 06 September 2020; Accepted: 09 March 2021; Published: 21 April 2021.

Reviewed by:

Copyright © 2021 Uroh and Adewunmi. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Clifford C. Uroh, cliffordchisom@gmail.com

This article is part of the Research Topic

The Effects of the Covid-19 Pandemic on Sport: Mental Health Implications on Athletes, Coaches and Support Staff

The impact of the COVID-19 pandemic on Antidepressant Prescribing with a focus on people with learning disability and autism

COVID-19 lockdowns led to increased reports of depressive symptoms in the general population and impacted the health and social care services of people with learning disability and autism. We explored whether the COVID-19 pandemic had an impact on antidepressant prescribing trends within these and the general population.

Paper information

• Christine Cunningham,
• Orla Macdonald ,
• Andrea Schaffer ,
• Andrew Brown ,
• Milan Wiedemann ,
• Rose Higgins ,
• Chris Bates,
• John Parry,
• Louis Fisher ,
• Helen Curtis ,
• Amir Mehrkar ,
• Liam Hart ,
• Seb Bacon ,
• Will Hulme ,
• Vicky Speed ,
• Richard Croker ,
• Chris Wood ,
• Alex Walker ,
• Colm Andrews ,
• Ben Butler-Cole ,
• Dave Evans ,
• Peter Inglesby ,
• Iain Dillingham ,
• Simon Davy ,
• Lucy Bridges ,
• Tom O'Dwyer ,
• Steve Maude ,
• Becky Smith ,
• Ben Goldacre ,
• Brian MacKenna

With the approval of NHS England, we used >24 million patients’ primary care data from the OpenSAFELY-TPP platform. We identified patients with learning disability or autism and used an interrupted time series analysis to quantify trends in those prescribed and newly prescribed an antidepressant across key demographic and clinical subgroups, comparing pre-COVID-19 (January 2018-February 2020), COVID-19 lockdown (March 2020-February 2021) and the recovery period (March 2021-December 2022).

Prior to COVID-19 lockdown, antidepressant prescribing was increasing at 0.3% (95% CI 0.2% to 0.3%) patients per month, in the general population and in those with learning disability, and 0.3% (95% CI 0.2% to 0.4%) in those with autism. We did not find evidence that the pandemic was associated with a change in trend of antidepressant prescribing in the general population (RR 1.00 (95% CI 0.97 to 1.02)), in those with autism (RR 0.99 (95% CI 0.97 to 1.01)), or in those with learning disability (RR 0.98 (95% CI 0.96 to 1.00)).

New prescribing post lockdown was 13% and 12% below expected if COVID-19 had not happened in both the general population and those with autism (RR 0.87 (95% CI 0.83 to 0.93), RR 0.88 (95% CI 0.83 to 0.92))), but not learning disability (RR 0.96 (95% CI 0.87 to 1.05)).

Conclusions and Implications

Pre-COVID-19, antidepressant prescribing was increasing at 0.3% per month. While we did not see an impact of COVID-19 on overall prescribing in the general population, prescriptions to those aged 0-19, 20-29, and new prescriptions were lower than pre-COVID-19 trends would have predicted, but tricyclics and new prescriptions in care homes were higher than expected.

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N.C.A.A. Athletes’ Pay Deal Raises Questions About Future of College Sports

The landmark settlement made many wonder what the reality — and impact — of revenue-sharing plans with college athletes would look like.

By David W. Chen ,  Jacey Fortin and Anna Betts

Brent Jacquette knows a thing or two about college sports. A former collegiate soccer player and coach in Pennsylvania who is now an executive at a consulting firm for athletic recruiting, he’s well aware of issues surrounding pay for college athletes.

But even for an industry veteran like Mr. Jacquette, the news of the N.C.A.A.’s staggering settlement in a class-action antitrust lawsuit on Thursday came as a surprise, with more than a little anxiety. The first words that came to mind, he said, were “trepidation” and “confusion.”

And he was not alone in feeling unsettled. Interviews, statements and social media posts mere hours after the settlement was announced showed that many were uncertain and concerned about what the future of collegiate sports holds.

“These are unprecedented times, and these decisions will have a seismic effect on the permanent landscape of collegiate athletics,” Phil DiStefano, chancellor of the University of Colorado Boulder, and Rick George, the school’s athletic director, said in a statement .

If the $2.8 billion settlement is approved by a judge, it would allow for a revenue-sharing plan through which Division I athletes can be paid directly by their schools for playing sports — a first in the nearly 120-year history of the N.C.A.A. Division 1 schools would be allowed to use about $20 million a year to pay their athletes as soon as the 2025 football season.

Mr. Jacquette thought of the word “trepidation” because of the impact that the settlement, shaped by the biggest and wealthiest universities with robust football programs, could have on coaches and athletes at smaller institutions and in low-profile sports.

And “confusion," because families of college athletes might soon be overwhelmed by all the possible ways for a student to get paid. In past years, the only form of compensation that students could get was athletic scholarships. But now, with the possibility of a revenue-sharing plan and pay arrangements involving students’ name, image and likeness , they have a lot more to consider when planning their collegiate sports careers.

“As this makes big news, people see this pot of gold at the end of the tunnel,” Mr. Jacquette said.

Many questioned what the financial burdens stemming from a revenue-sharing plan would look like.

Smaller conferences, such as the Big East — which includes Georgetown, Villanova and the University of Connecticut — have voiced “strong objections ” to the settlement, worried about shouldering an unfair burden of costs involved in revenue sharing. They said schools that have higher-profile sports teams and are part of bigger conferences, which often have TV contracts and much higher revenues, should be responsible for covering more of the costs.

Even coaches at powerful athletic programs, such as the University of Florida, which is part of the Southeastern Conference, had qualms. Tim Walton, the school’s softball coach, wondered in an interview with The Associated Press what this would mean for smaller sports programs on campus, and how the university would handle sharing revenues with athletes.

Another concern from critics of the settlement was whether female athletes would be compensated fairly. The settlement did not address how they would be paid compared to men, but Title IX prohibits sex-based discrimination in educational settings.

“Oftentimes, we put all of our eggs in the revenue-generating sports, which is comprised of mostly male sports,” said Jasher Cox, athletic director of Allen University, a historically Black and Division II school in South Carolina.

But many still questioned how the settlement would pan out in practice. Terry Connor, the athletic director at Thomas More University in Kentucky, said in an interview that the reality of revenue sharing felt somewhat distant. Although his school is Division II and would not necessarily be part of a revenue-sharing plan, Mr. Connor said that this still affects college sports as a whole.

The settlement is only the latest in a series of big changes at the N.C.A.A. in recent years, Mr. Connor said, and “how we’ll have to adapt to that is going to be the big question.”

Mr. Jacquette cautioned that it was still “premature” to assess the full impact of the settlement, since the details had not been released. And Sam C. Ehrlich, a professor at Boise State University who has written extensively about college athletes, said that while the settlement was a milestone, it should not be seen as the be-all and end-all of college sports.

Pointing to the Supreme Court’s unanimous ruling in 2021 that the N.C.A.A. could not bar payments to college athletes, Mr. Ehrlich said the college sports landscape has been ever-changing. That decision paved the way for N.I.L. arrangements, or payments based on an athlete’s name, image and likeness. He also cited Johnson v. N.C.A.A. , a pending case over whether college athletes should be classified as employees, which could have profound labor and tax implications.

“This is a big moment, for sure, but it’s not like we have reached the finish line,” Mr. Ehrlich said. “I wouldn’t even necessarily go as far to say, ‘this is the climax here.’ This is still going to be ongoing for several years.”

Billy Witz contributed reporting.

David W. Chen reports on state legislatures, state level policymaking and the political forces behind them. More about David W. Chen

Jacey Fortin covers a wide range of subjects for the National desk of The Times, including extreme weather, court cases and state politics all across the country. More about Jacey Fortin

Anna Betts reports on national events, including politics, education, and natural or man-made disasters, among other things. More about Anna Betts

Inside the World of Sports

Dive deeper into the people, issues and trends shaping professional, collegiate and amateur athletics..

The Latest in Sports Downsizing: Professional leagues are embracing smaller markets  in their search for newer stadiums and arenas and the potential for more devoted fan bases.

The History of Black Baseball Players: As the number of African American players in M.L.B. dwindles, a new exhibit at the Hall of Fame  traces 150 years of Black baseball feats, stars and obstacles.

The Dangers for Female Climbers: Women are increasingly reporting sexual harassment and abuse in the sport , including accusations against the renowned climber Nirmal Purja.

A Cricket Stadium’s Brief Life: Built in 100 days for the Cricket World Cup, a stadium on Long Island  will host nine matches before it is dismantled.

Another Fight Looms for Women: Despite gains, women still lag far behind men in the little-regulated industry of college sports. A proposed revenue-sharing deal  could create new clashes over equality.

COVID & Schools: How England Is Researching the Pandemic’s Deep Impact on Kids

This essay was originally published as part of the Center on Reinventing Public Education’s 2023 “State of the American Student” report . As part of the effort, CRPE asked 14 experts from various sectors to offer up examples of innovations, solutions or possible paths forward as education leaders navigate the current crisis. ( See all the perspectives ) 

The impacts of the Covid-19 pandemic are likely to be profound and long-lasting. We have already seen substantial short-term effects on young people’s educational experiences, particularly for those from less advantaged backgrounds. It is vital that we fully understand these impacts, including the burden on ethnic minorities and those from lower socioeconomic backgrounds.

Amid the pandemic, a team across UCL and the Sutton Trust (a think tank with 25 years’ experience researching social mobility), established the COVID Social Mobility and Opportunities study (COSMO for short) to play this vital role for England. Our aim is to build the evidence base to understand the pandemic’s long-term effects on educational and career trajectories.

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The study focuses on the experiences of a cohort of young people (those aged 14–15 at the onset of the Covid-19 pandemic) for whom the disruption had a particularly acute impact at a crucial moment in their educations—with minimal time for catch-up before graduating from secondary school. In addition, this group’s national age-16 examinations (known as GCSEs) were replaced with purely teacher-assessed grades, throwing their usual post-16 transition into further uncertainty.

COVID & Schools: How England Is Researching the Pandemic’s Deep Impact on Kids

COSMO has recruited a representative sample of over 13,000 young people in 500 schools across England, over-sampling disadvantaged and ethnic minority groups and targeting other hard-to-reach groups. Young person and parent questionnaires—enhanced with educational administrative data—have collected rich data on young people’s experiences of education and well-being in the aftermath of the pandemic, along with information on their post-16 education transitions. Key findings include:

Young people’s educational experiences during Covid-19 lockdowns varied considerably.

To take one example, we looked at live online lessons, perhaps emblematic of schooling during this period—but certainly not experienced universally. In the early pandemic, the most dramatic differences were between the state and private sectors. State schools with more advantaged students caught up with the amount of live online lessons provided by private schools in the early 2021 lockdown. But schools with poorer students continued to lag, likely because they were tackling important welfare needs.

Young people from less advantaged homes were more likely to report barriers to learning at home.

They were less likely to have a quiet space to focus on learning and more likely to use a mobile device or to share devices to carry out online activities. We also confirmed that those affected by these issues did indeed report spending less time on schoolwork during lockdowns.

The impacts on learning are widespread—and recognized.

Four in five young people told us that their educational progress suffered due to the pandemic. Almost half said that they had not caught up with the learning they lost. Over a third felt they had fallen behind their classmates. This rises to almost half for those who attended schools with the most disadvantaged students.

Efforts to help students catch up have not reached as many as we might hope.

This is perhaps unsurprising given that England’s catch-up spending plans were estimated to be worth around £310 per pupil, vs. £1,830 in the United States. Almost half of young people in the cohort reported that they had received no specific catch-up learning at all. Despite the efforts of the government’s National Tutoring Programme, which aimed to put one-on-one and small group tutoring at the heart of catch-up plans, only 27% of the sample reported receiving this type of assistance.

On a more positive note, there is encouraging evidence that those who did receive small group tutoring were more likely to be from less advantaged backgrounds.

Those who took up tutoring also performed better in their teacher-assessed age-16 examinations, compared to similar individuals who were offered tutoring but did not take it.

We are not the only study across the world aiming to track the long-term implications of the Covid-19 pandemic for young people’s life chances. For example, Generations, led by the Australian National University, is taking a similar approach to ours, tailored to their own context. Other researchers likely are working with similar aims, again with variations depending upon differences in their national contexts and education systems.

Hopefully, we are only at the start of the journey for COSMO. We plan to follow young people as they continue their transition into adult lives, checking in every couple of years or so. This builds on the UK’s existing cohort studies, some of which are now following their members into retirement. About half of our cohort will make this transition via university, starting in autumn 2023. We will seek to learn about their academic preparation for higher education and how they are managing financially against a difficult economic backdrop, among other priorities. Our longer-term follow-ups will focus on experiences in the labor market, family formation, and all other aspects of adult life. Crucially, our research will allow us to understand how these experiences differ depending upon their experiences of the pandemic—and how this has mediated preexisting inequalities.

See more from the Center on Reinventing Public Education and its 2023 “State of the American Student” report .

Moderna’s path to vaccine innovation: A talk with CEO Stéphane Bancel

This interview is part of COVID-19 vaccines: The road to recovery and beyond , a series that includes a broad array of voices leading the historic global effort to develop, distribute, and provide equitable access to COVID-19 vaccines, including the Africa CDC ; CEPI ; Gavi, the Vaccine Alliance ; Moderna ; and Pfizer .

The COVID-19 pandemic has resulted in devastating public-health and economic outcomes. It also spurred one of the most promising scientific feats in the last century—the development of several highly effective vaccines authorized for emergency use by the US Food and Drug Administration (FDA) in less than one year.

About this series: COVID-19 vaccines: The road to recovery and beyond

This interview is part of the series COVID-19 vaccines: The road to recovery and beyond . By drawing on the experience of private- and public-sector experts across a wide range of perspectives—from vaccine innovation to manufacturing, distribution, and accessibility—we aim to help leaders navigate recovery efforts for the COVID-19 pandemic and share some of the lessons they’ve learned to combat the pandemic and support the future of vaccines. Articles in the series include interviews with the heads of top global health organizations, government agencies, and vaccine manufacturers. For example:

• Africa CDC: Africa’s plan for a continent-wide pandemic recovery
• Accelerating pandemic response efforts: An interview with CEPI’s Richard Hatchett
• Gavi, the Vaccine Alliance: Finding solidarity in an effort to vaccinate the world
• Moderna’s path to vaccine innovation: A talk with CEO Stéphane Bancel
• Pfizer’s mix of science and grit alters the course of its COVID-19 response

Along with public-health authorities, we recognize that vaccination is critical to combating infectious diseases, and we are committed to the urgent effort of bringing an end to the COVID-19 pandemic and transforming the future of immunization.

This achievement required unprecedented mobilization and the cooperation of a broad set of global stakeholders in both the public and private sectors, including governments, vaccine developers, and public-health organizations. Building on deep scientific knowledge gained from years of experience working with viruses, such as MERS, SARS, influenza, HIV, and Hepatitis C, the medical industry’s private sector has made immense progress in advancing potential treatments and vaccines to help address COVID-19. 1 “The bold mission of America’s biopharmaceutical companies is to bring an end to the burdens of disease, in all its forms,” Our commitment, America’s Biopharmaceutical Companies, 2018, innovation.org. Looking ahead, the breakthroughs stemming from COVID-19 hold vast potential for the broader vaccines industry with the emergence of ground-breaking innovation, more public engagement, and increased focus from health officials.

Making inroads in the fight against COVID-19 is Massachusetts-based biotech company Moderna, which has been looking to innovate approaches to vaccine development since the company’s start in 2010. Before COVID-19, Moderna already had a new class of vaccines in the works that use messenger ribonucleic acid, or mRNA, 2 Messenger ribonucleic acid, or mRNA, is a single-stranded molecule that carries genetic code from DNA in a cell’s nucleus to ribosomes, the cell’s protein-making machinery. “The science and fundamentals of mRNA technology,” Moderna, 2021, modernatx.com. which instructs a patient’s own cells to produce the proteins needed to activate the immune system to prevent illness. “The potential implications of using mRNA as a drug are significant and far-reaching and could meaningfully improve how medicines are discovered, developed, and manufactured,” says Moderna’s CEO Stéphane Bancel.

Bancel spoke with McKinsey’s Olivier Leclerc about why he believes his company was well positioned to respond to the COVID-19 crisis, how scientific breakthroughs with mRNA led to an effective COVID-19 vaccine, and what it takes to lead his company for long-term impact during the crisis. Below is an edited excerpt of Bancel’s remarks.

Responding to COVID-19

McKinsey: Vaccine development is a long, complex process. How did Moderna step up when the pandemic was declared?

Stéphane Bancel: By March 2020, the World Health Organization [WHO] declared COVID-19 a pandemic, and we were racing against the virus every day while we still had almost 20 non-COVID-19 programs that needed to keep moving. We raised the cadence of our executive-committee meetings from once a month to once or twice a week to have a clock speed that was adapted to the situation. We also used a decentralized model, which gave the distinct teams the independence to move quickly. The pace was unprecedented, fueled by the need to respond to a pandemic situation. To deliver on our goal of 100 million doses of COVID-19 vaccines within 12 months 3 Reuters staff, “Moderna says shipped 100 million COVID-19 vaccine doses to United States,” March 29, 2021, reuters.com. and a billion doses by the end of 2021, the team worked seven days a week and, at times, pulled all-nighters. If it weren’t for the extraordinary people I work with—who are selfless, mission-driven, and committed to building the best version of Moderna possible—we would not be where we are today.

McKinsey: Considering the intense pressure to develop an effective vaccine, how was interaction with the US government managed?

Stéphane Bancel: It came down to the collaboration between the pharmaceutical industry and the US federal government. The US government picked three different technologies to invest in for a diversified risk profile and then chose two pharmaceutical companies per technology. In the end, they were betting on six different companies. It was a brilliant move. The conditions of the contract included a base business of 100 million doses, with options to increase depending on the clinical data and the efficacy at the time of launch. This allowed us to take on a lot of business risk at a time when every single day mattered.

The other key part of this equation is that the FDA worked relentlessly to authorize the Moderna COVID-19 vaccine, and others, with an emergency use authorization [EUA]. Usually, you submit a question to the FDA, and they have a defined timeline for responding and engaging with clinical-trial sponsors. But they adapted to the crisis situation. During the pandemic, we could reach out to them any time—including weekends.

McKinsey: What were some difficult decisions you faced while developing the COVID-19 vaccine?

Stéphane Bancel: One tough spot we were in was deciding whether to slow down our Phase 3 clinical study. The study began on July 27, 2020, and the first few weeks were fantastic. However, we weren’t enrolling enough people from diverse backgrounds into the study, especially those disproportionally affected by COVID-19, such as African Americans. We felt we were failing society if we didn’t include communities most impacted by the virus. After many discussions, we decided to slow down the study, which made a big impact on our timeline. But at the end of the day, when you step back and look at the big picture, you can see that the tough decisions are well worth it.

We are now one of the first biotech companies to publish the demographic data of our clinical trials. In our Phase 3 study, we had 9.7 percent African American or Black participants, 4.7 percent Asian, 0.8 percent American Indian or Alaska Native, and 20.0 percent Hispanic participants, which reflects a greater diversity among participants than many other previous drug trials. 4 Meera Jagannathan, “Vaccine trials have underrepresented people of color for the past decade—and many failed to even report demographic data,” MarketWatch, February 19, 2021, marketwatch.com.

Delivering innovative solutions

McKinsey: What is mRNA technology? And why is it so effective against COVID-19?

Stéphane Bancel: Simply put, messenger RNA [mRNA] vaccines are a new type of medicine that trigger an immune response to protect against infectious diseases. Many other vaccines put a weakened or inactivated virus into the body to trigger that response. Instead, mRNA vaccines teach our bodies how to make a protein, or a piece of a protein, to get the same result.

Moderna’s COVID-19 mRNA vaccine tells your cells to make a harmless viral protein called a spike. This stimulates your immune system to make antibodies and immune cells that counterattack the spike when they come across it. When scientists published the genetic code for the COVID-19 virus in January of 2020, we realized that the spike protein of the Middle East Respiratory Syndrome [MERS], and SARS-CoV-2 5 The scientific name of the new strain of coronavirus is SARS-CoV-2. In people, the disease caused by the virus is called coronavirus disease 2019, also known as COVID-19. Because we are addressing the virus itself in the context of animal health, we refer to it as SARS-CoV-2 (“Basics of COVID-19,” Centers for Disease Control and Prevention, last updated May 24, 2021, cdc.gov). were very similar. In our previous work on the MERS virus with Dr. Anthony Fauci’s team at the National Institute of Allergy and Infectious Diseases [NIAID], we determined that the best vaccine using Moderna immunotechnology was a full-length spike protein. Based on that work, and all the work we had done on vaccines before, we were hopeful that we were off to a great start.

McKinsey: How can Moderna’s mRNA platform respond to new variants of coronavirus and their potential to evade the immune system?

Stéphane Bancel: Some mutations of the COVID-19 virus will likely have no impact on our vaccine’s efficacy, while others might. With several mutations, there is more and more “drift” from the original SARS-CoV-2 that was sequenced. Our mRNA platform lets us create new versions of the vaccine to attach to that variant in a matter of weeks. In January 2020, it took us just 42 days to go from a sequence of the SARS-CoV-2 virus to shipping the first product for human clinical trial to the federal government. The mRNA platform also allows for multiple variant sequences to be included in one vial, which lets us respond to new mutations faster than ever.

Our team, like most scientists around the world, has been following new variants, and we continue to have clinical trials under way. One of the benefits of mRNA is the flexibility and speed to development. We have been closely monitoring how our authorized COVID-19 vaccine protects against emerging variants, and in parallel, we are advancing our booster strategy.

McKinsey: Now that mRNA technology has been proven to work for COVID-19, what role do you expect it to play in the future of medicine and healthcare?

Stéphane Bancel: At Moderna, our mission is to deliver on the promise of mRNA science to create a new generation of transformative medicines for patients. Since mRNA is an information-based platform, it works similar to a computer’s operating system, letting researchers insert new genetic code from a virus—like adding an app—to create a new vaccine quickly. When COVID-19 struck, we already had nine vaccines in clinical trials using mRNA technology. The COVID-19 vaccine was our tenth. Because we had invested in building our mRNA platform, it was basically a copy and paste—inserting the new genetic code into our preexisting platform. It’s this type of technology that helped Moderna develop a COVID-19 vaccine in only 11 months. 6 A Phase 3 randomized, placebo-controlled, observer-blind clinical trial to evaluate the efficacy, safety, and immunogenicity of the Moderna COVID-19 Vaccine in participants 18 years of age and older is ongoing in the United States (NCT04470427). Randomization was stratified by age and health risk: 18 to under 65 years of age without comorbidities (not at risk for progression to severe COVID-19); 18 to under 65 years of age with comorbidities (at risk for progression to severe COVID-19); and 65 years of age and older with or without comorbidities. “Clinical trial data,” Moderna, 2021, modernatx.com.

Since mRNA is an information-based platform, it works similar to a computer’s operating system, letting researchers insert new genetic code from a virus—like adding an app—to create a new vaccine quickly.

We are now in a world where mRNA as a platform has been derisked for use in vaccines and can be authorized for emergency use. Moving forward, using genetic information—either human genes or the genome of a virus—gives us more opportunities for new mRNA programs. Moderna was always built to scale up, and we plan to conduct larger trials and accelerate our clinical programs. We are studying the use of our mRNA platform to develop medicines for infections of the lung and many other organ systems where we hope mRNA may help patients.

Looking ahead at the opportunities for faster product innovation and delivery—combined with a world where the general public, healthcare professionals, and governments are more conscious of the spread of viruses and willing to invest in treatment—I think there is an opportunity with mRNA to transform infectious diseases in the next five years.

Creating impact for the long haul

McKinsey: What has helped Moderna deliver impact—not just over the past year, but also over the past ten years?

Stéphane Bancel: I’m obsessed with digitalization. At past companies, I was extremely frustrated about the time we wasted as a business not serving the customer and not pushing the envelope because we didn’t have data or the data were incorrect. I remember a moment that shifted my thinking for the rest of my career. It was the year 2000, and I was fresh out of business school and working for a big pharma company. I spent a week chasing down a manufacturing lot. The internet was booming, yet I was still sending emails trying to locate a lot—information that should have been available to me from any device or computer system. Now at Moderna, we challenge ourselves daily to digitize the company better.

The process starts by being very thoughtful about technology, building our own apps, adding the right people, and then giving all employees access to that technology. The last step is very important. Everyone at the company has access to our systems from anywhere via their company mobile device—whether they are approving an invoice or designing a drug. This digital experience is completely ingrained in our DNA.

One of the biggest challenges over the next three years for both the HR team and the digital team is to incorporate more artificial intelligence as part of our process. With all of the structured data we’ve gathered—through preclinical trials, research, and experiments—we’ve been able to build better algorithms. These algorithms are enabling us to employ machine learning and make faster decisions. For instance, we can get predictions in the clinical space that humans wouldn’t be able to make in a reasonable amount of time.

Coronavirus vaccines progress: What’s next?

McKinsey: Managing for the long haul can be hard under normal circumstances. Did you have to adjust your leadership style in response to the crisis?

Stéphane Bancel: One of the hardest things to deal with in this type of crisis is being able to go the distance. Many of us end up working more hours under stress when we are in crisis mode, which tends to come at the expense of our health and well-being. It’s important to make the right lifestyle choices to avoid possible burnout. I’ve learned over the years that engaging in sports and getting good sleep is critical for me in managing my stress. Everyone needs to find what works best for them to maintain that type of pace, or else it’s just not possible to sustain.

I also learned that fighting COVID-19 has to be a team effort. When we’re juggling many decisions, it’s the team that has to keep all the pieces in the air at the same time. And subsets of the team need to be able to accomplish a task or get aligned even if I’m not in the room. To do so, the team needs to be informed and have enough pieces of the puzzle to be effective and avoid any disconnects. It also takes being even clearer than usual on our goals, articulating those goals clearly, and passing the ball when needed. Our whole team needs to be moving in the same direction.

This content is provided “as is” solely for informational purposes. It is not legal, health, or safety advice. Organizations should engage their own experts to ensure any adopted measures are compliant with applicable laws and standards in their jurisdictions. The opinions expressed by individuals or organizations are their own and do not reflect the views or opinions of McKinsey & Company. References to specific products or organizations do not constitute any endorsement or recommendation by McKinsey.

Stéphane Bancel is Moderna’s CEO and a biochemical engineer. Olivier Leclerc is a senior partner in McKinsey’s Los Angeles office.

The authors wish to thank Jennifer Heller, Adam Sabow, Jeff Smith, and Ramesh Srinivasan for their contributions to this article.

This article was edited by Astrid Sandoval, an executive editor in the London office.

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