Counseling for Physical Activity in Adults during the COVID-19 Pandemic: A Scope Review

Objective: The aim of this scope review was to map the available scientific evidence on physical activity counseling for adults during the COVID-19 pandemic. Methods: The search was performed in PubMed, Web of Science, Scopus, SPORTDiscus, LILACS, SciELO, and CINAHL databases. Studies that described the population of adults over 18 years of age that used physical activity counseling during the COVID-19 pandemic context were selected. Data extracted were author, study location, sample, age group, sex, population characteristics, design, means used for intervention, time of intervention, professionals involved, and intervention or counseling strategy. Results: Physical activity counseling interventions were aimed at participants with insufficient levels of physical activity or with comorbidities; counseling was carried out in the online format; by health professionals, in the highest proportion of coaches, physicians, researchers, and nutritionists; through educational contents regarding the practice of physical activity; and using the transtheoretical model of behavior change as a reference method. Conclusions: The results of this review can provide tools for health professionals to assist in the process of coping with physical inactivity.


Introduction
Physical activity is broadly defined as any bodily activity that improves or maintains general health and fitness [1,2]. Scientific evidence has reported that regular physical activity significantly reduces the risk of all-cause mortality [3,4], chronic noncommunicable diseases [5], and types of cancers [5][6][7]. In the context of the COVID-19 pandemic, encouraging physical activity has become a global public health priority because increasing physical activity levels during this period resulted in reduced harm to physical health and improved immune function [8][9][10] and reduced risk of systemic inflammation, which resulted in lower chances of mortality from COVID-19 [10]. In addition, increased physical activity levels during the COVID-19 pandemic improve mental health [11]. A study showed that satisfactory levels of physical activity were associated with greater well-being, quality of life, and lower depressive symptoms such as anxiety and stress, regardless of age, during the first year of the COVID-19 pandemic [11].
Countries have presented alarming data on physical inactivity, with prevalence increasing with age, and it is higher among females when compared to males [12][13][14]. In addition, during the pandemic caused by the SARS-CoV-2 virus (severe acute respiratory syndrome-coronavirus), physical activity levels have declined [15,16] due to COVID-19 restrictions such as lockdowns, quarantine measures, and social distancing. Because of this, meeting physical activity guidelines posed a significant challenge [17][18][19]. Studies on the impact of physical inactivity caused by COVID-19 are still being explored; however, they have identified that reduced levels of physical activity may lead to greater chances of negative outcomes related to physical and mental health [20]. Other studies identified that adults infected with COVID-19 who did not meet the physical activity guidelines were more likely to be hospitalized and died when compared to those who met the physical activity guidelines [10]. In this period, it was found that fragile populations, which had multiple comorbidities such as diabetes, hypertension, and cardiovascular diseases, are more exposed to the severe clinical condition of SARS-CoV-2 [21]. This way, maintenance of physical activity during the pandemic context has been recommended [22], as it presents better control over these comorbidities [21], immunological benefits [9], and other health-related positive effects [15].
Physical activity counseling can be defined as advice and discussions about the practice of physical activity between health professionals and patients [23]; way of acting that involves listening, understanding people, and supporting them to plan and make more favorable decisions [24]; and general and structured guidelines aimed at encouraging the practice of physical activity in different domains [25]. Counseling interventions can include goal setting, self-monitoring, feedback, incentives, and problem solving [26]. Many studies have shown that counseling interventions can be effective strategies for promoting physical activity, have low costs [27], are replicable, and sustain physical activity for more than 12 months [23]. However, interventions that help individuals to engage in healthrelated beneficial behaviors, including physical activity, during the pandemic context are limited [22].
Thus, knowing evidence about the characteristics of counseling interventions that help reduce physical inactivity in adults, potentiated by the COVID-19 pandemic, is necessary. To our knowledge, currently no review presented this information. Thus, the aim of this study was to map the scientific evidence on physical activity counseling for adults during the COVID-19 pandemic.

Methods
This is a scope review whose guiding question was: What is the scientific evidence on physical activity counseling for adults during the COVID-19 pandemic? The research protocol was registered in the Open Science Framework (https://osf.io/e7jtv/, accessed on 6 December 2021), with writing of the text according to recommendations of the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews guide (PRISMA-ScR) [28] and the Joanna Briggs Institute (JBI) method [29]. This review followed six steps: identification of the research question; identification of relevant studies; selection of studies; data analysis; grouping, data synthesis, and presentation; and quality assessment of the risk of bias [29].

Study Eligibility Criteria
Inclusion criteria were: (a) original quantitative or qualitative articles with crosssectional, longitudinal design, case-controls, cohort studies, interventions, or randomized clinical trials; (b) technical and governmental documents; (c) publications in English, Spanish, and Portuguese; and (d) all studies published until 3 December 2021. Exclusion criteria were: (a) narrative and integrative reviews, theoretical essays, conference abstracts; (b) articles not available in full in databases, and that all possibilities of accessing the texts have been exhausted, such as sending an email to the authors; and (c) articles that did not present data classifying population, concept, and context.

Selection of Evidence Sources
Two reviewers (LG and MSM) independently examined each database for potential articles. After extracting articles from databases, duplicate articles were excluded and then articles were excluded after reading titles and abstracts. Subsequently, the texts of selected articles were read in full for the selection of studies. Disagreements between the two reviewers were resolved by consensus meeting. If disagreements were not resolved, the opinion of a third reviewer (DASS) was consulted. The Rayyan software (Intelligent Systematic Review) was used to manage the studies found, whose functions allow the identification and exclusion of duplicate studies and division and organization of the results of each database, simultaneously and in a blind system. Selected articles underwent a final screening, after being read in full, and those that met the inclusion criteria were exported to the Zotero ® bibliographic manager version 5.0 (Roy Rosenzweig Center for History and New Media, Fairfax, VA, USA).

Search Strategies
Considering the inclusion criteria, a search strategy was developed for groups of descriptors inserted in the Medical Subject Headings ( (7) Cumulative Index to Nursing and Allied Health Literature (CINAHL) via EBSCOhost. Descriptor groups were: (1) population (adults); (2) concept (physical activity counseling); and (3) context (COVID-19 pandemic). As additional resource, manual searches were performed in the references of selected articles. More details are described in Supplementary Document S1.

Risk of Bias Assessment
The risk of bias of included studies was independently assessed by two researchers (LG and MSM). For cases of disagreement between researchers, a third researcher was consulted through a consensus meeting (DASS). To assess the risk of bias, the tool proposed by the National Heart, Lung, and Blood Institute (NIH) [30] was used according to the type of study. For intervention studies with control group, the Quality Assessment Tool for Controlled Intervention studies tool was used and for intervention studies without control group, the Before-After (Pre-Post) Quality Assessment Tool was used. For each criterion evaluated, "no", "yes", "not reported", and "not applicable" were assigned. The total score was obtained by adding the score of each question answered as "yes" (+1), while "no" and "not reported" were negatively counted (zero) and the criterion "not applicable" was excluded from the calculation [30].

Results
A total of 1641 records, removing duplicates, were identified in this scope review. After reading titles and abstracts, 44 studies (2.7%) were considered eligible for full reading. Of this total, 31 were excluded because they did not meet the eligibility criteria, totaling 11 articles in the review (0.67%) via search in databases. No records were added after reading references (citation search); therefore, 11 articles were included for descriptive synthesis ( Figure 1).

Characteristics of Records
All selected records were original articles (n = 11; 100%). Studies were conducted in seven countries (United States of America, United Kingdom, Netherlands, Spain, China, Taiwan, and Australia). The United States of America was the country with the highest number of records (n = 5; 45.4%).

General Sample and Population Characteristics
The sample size ranged from 7 [31] to 137 participants [32]. In addition to representing a majority in all samples, three articles were conducted specifically with female samples [14,33,34]. Heterogeneity was identified in relation to the sample characteristics, highlighting four samples composed of participants with insufficient levels of physical activity at the baseline [14,16,22,35], two samples with cancer survivors [32,34], and two with type II diabetes patients [36,37]. Regarding the objectives of the studies, six articles directed interventions to physical activity [31][32][33][34][35]38], two studies were focused on behavioral change [36,37], two studies investigated a whole lifestyle [16,22], and one study directed actions towards physical activity and behavioral change [14]. Regarding the research design, the selected studies were classified as randomized controlled trials (n = 4), intervention studies (n = 4), non-randomized controlled trials (n = 1), longitudinal (n = 1), and quasi-experimental (n = 1). Regarding the data analysis used, the studies were designated as quantitative (n = 8) or qualitative (n = 3) ( Table 1).

Characteristics of Records
All selected records were original articles (n = 11; 100%). Studies were conducted in seven countries (United States of America, United Kingdom, Netherlands, Spain, China, Taiwan, and Australia). The United States of America was the country with the highest number of records (n = 5; 45.4%).
The results identified after the counseling intervention indicated that six studies increased the participants' physical activity levels (i.e., indicators of physical activity and/or exercise) [14,16,22,33,35,36], and one study reported that there was no increase in physical activity levels [32]. None of the studies have identified that the intervention decreased the physical activity levels (or in the indicators of exercise and/or sport) of the participants. For four studies [31,34,37,38], it was not possible to identify the effect of the intervention on physical activity levels or other variables because they proposed to analyze the participants' feedback on the interventions performed. Results were based on feedback from participants regarding physical activity orientation, type of physical activity, intensity, educational sections, and others. Thus, it was not possible to identify an effect on the increase in physical activity levels. Control group: received a printed leaflet with guidelines and possible benefits of physical activity after cancer treatment. It also introduced physical activity guidelines and provided information on monitoring and intensity of physical activity; Online group: received access to the Online Physical Activity Support Program (IPAS), structured according to the transtheoretical model, using aspects of the theory of planned behavior and social cognitive theory. Participants were separated into stages of behavior change and, according to each stage, received information, images, and interactive attributions and videos of physical activity; Blended group: Received access to IPAS and phone calls for physical activity counseling. Subjects were asked to exercise on a stationary bike or treadmill and to establish goals and targets for intended behavior change.
The intervention showed no significant association with moderate and vigorous physical activity between the online group and the control group (p = 0.39), and between the blended care group and the control group (p = 0.75). Additionally, of the 1242 invited patients, 137 participated in the study (participation rate: 11.0%).  The results were based on feedback from participants, demonstrating that the content of the intervention was acceptable and relevant to meet needs related to healthy living.

Risk of Bias Assessment
The risk of bias/methodological quality was analyzed considering the general score of studies included in the review (11 articles) ( Table 3). Among controlled intervention studies and pre-and post-intervention studies with a control group and without a control group, the study by Mcdonough et al. (2021) obtained the highest score, while the study by Jiwani et al. (2021) obtained the lowest score (Table 3).
Total score * 1.0 0.5 0.5 0.9 0.7 0.3  * To determine the total score, the equation was considered: total positive responses/total number of questions considered in the study); £ : Questions for each study type are available at https://www.nhlbi.nih.gov/healthtopics/study-quality-assessment-tools (accessed on 1 January 2022).

Discussion
The main findings of this review were: (1) most physical activity counseling interventions during the COVID-19 pandemic were performed for participants with insufficient levels of physical activity or comorbidities; (2) most records on physical activity counseling interventions were provided by researchers, in the online format; (3) physical activity counseling interventions were performed by health professionals; (4) the instruments most used in counseling interventions were educational contents regarding the practice of physical activity; (5) most records used the transtheoretical model of behavior change as reference method; and (6) physical activity counseling interventions increased participants' physical activity levels.
Included records showed that most participants who received physical activity counseling intervention had insufficient levels of physical activity or comorbidities. The physical activity counseling carried out during the COVID-19 pandemic represents an opportunity to address the issue and support the change in behavior and healthy habits, given that physical inactivity can bring negative health outcomes, associated with noncommunicable chronic diseases recognized as factors contributing to compromising clinical conditions and deaths in the pandemic scenario [40]. Additionally, physical activity counseling received by people with insufficient levels of physical activity or those with comorbidities supposedly has a positive effect, demonstrating that professionals recognize evidence of physical activity as a relevant factor in the treatment of these conditions [27]. However, counseling should also include individuals without comorbidities, regardless of sex or age [27], given that, in addition to the benefits of the practice of physical activity [41], it can also contribute to mental health related to the pandemic scenario [42].
The results of the present study indicated that physical activity counseling interventions for adults during the COVID-19 pandemic were carried out in the online format [14,16,22,[32][33][34][35]37,38]. A possible justification would be the fact that the protective measures imposed by the pandemic to prevent the spread of the virus (for example, social distancing, isolation, and the closing of establishments) caused most participants to stay at home [31]. Thus, this may have led to increased accessibility and greater relevance in the use of digital platforms by various population groups, making them viable in the conduct of health interventions [43]. In addition, with the use of digital platforms, direct contact with other individuals is avoided, contributing to the containment of the COVID-19 pandemic [44], also presenting the following advantages: information and interactions in real time without the need or displacement of professionals or participants and low cost [43]. Thus, digital platforms are viable and strategic means to engage participants in physical activity and support health-related behavior change [45]. However, it should be considered that the adoption of these technologies can be fragmented [46], especially in low and middle-income countries, since individuals do not have equitable access to digital technologies, either due to lack of adequate devices or internet access [47,48].
Physical activity counseling interventions were carried out by health professionals, mostly coaches, physicians, researchers, and nutritionists. Other review studies with similar themes have identified different results, reporting that physicians had higher proportion of counseling interventions [24,27]. However, the findings in the present review suggest expanding the scope of action and practice of health professionals, since counseling interventions are not the responsibility of a single professional category but of a multidisciplinary team [49]. Additionally, any professional should be able to implement educational and counseling actions, adding experiences for the development of techniques that synthesize better information in different fields of activity [50].
The present study pointed out that the instruments most used in counseling interventions were educational contents regarding the practice of physical activity, including recommendations for physical activity or exercises [16,22,32,35], benefits of PA practice [32], and PA guidelines [31,35]; negative effects or reduction of sedentary behavior [14,22,35]; and general practices of healthy behaviors [33,34]. The findings suggest that since the lack of standardization of contents covered and the knowledge about physical activity guidance and advice as education strategy are still scarce [51], receiving common information (for example, benefits of physical activity and harmful effects of sedentary behavior) can raise awareness and influence most participants to engage in physical activities [52]. However, when considering the barriers imposed during the pandemic period, it is necessary to verify which content will be implemented according to the reality and needs of participants [52]. Therefore, the use of health education strategies can enable changes in professional practices and encourage the search for healthy behaviors [51].
The records included indicated that the most discussed reference method for counseling was the transtheoretical model (behavioral change) [22,31,32,36,37]. These findings can be explained by the fact that such behavior change model is a structured and widely recognized approach to counseling to facilitate healthy behaviors [53]. Additionally, changes are gradually observed through a cyclical process of stages [31], causing participants to set goals, face barriers, and build interrelationships with professionals, expanding possibilities to initiate or increase levels of physical activity [53]. Furthermore, it allows researchers to perform a quantifiable assessment of the behavior change stage in which the individual is in [53]. However, it should be explored during the pandemic period, integrating effective, viable, and acceptable solutions (e.g., performing physical activity safely, reflective exercises), especially for economically-disadvantaged participants.
The results identified in the present review showed that most counseling interventions increased participants' physical activity levels [14,16,22,33,35,36]. In agreement with the results of the present study, other non-pandemic review studies identified that physical activity counseling interventions showed promising results in increasing physical activity levels in the short term [54,55], but evidence on the effectiveness of long-term interventions has not yet been explored. In this way, the findings of the present study give the direction that counseling interventions for physical activity in the pandemic period can be good strategies for people with insufficient physical activity levels [56], because it can help in the systematic performance of physical activity and reduce health problems [40,57]. In addition, increasing physical activity levels can help reduce the worsening of clinical conditions caused by COVID-19 [5,17,[58][59][60][61]. Regarding the feasibility and acceptability of interventions, four studies [22,34,37,38] investigated this issue and reported that interventions were feasible, acceptable, and effective for improving functional fitness, preventing some of the consequences of physical inactivity and social isolation associated with the pandemic, increasing knowledge of health behaviors, and meeting important needs related to healthy living.
The risk of bias/methodological quality was analyzed considering the overall scores of included studies. Some of the items included by the analysis instrument [30], evaluated in this review, contributed to the reduction of scores attributed to controlled intervention studies such as blinding for intervention evaluation and adherence to intervention protocols for each treatment group and the design of pre-and post-intervention studies without control group, sufficient sample size, and loss to follow-up accounted for in the analysis. Considering that the results of counseling interventions can impact both the reduction of physical inactivity [27] as well as the service provided to the population, a better analysis of the design and conduction of studies is justified, so that the evaluated outcomes are not submitted to comparison bias, providing knowledge of the scope and effectiveness of interventions.
This scope review mapped scientific evidence on physical activity counseling for adults during the COVID-19 pandemic. Common axes regarding types, methods, and means of carrying out interventions during the COVID-19 pandemic were reported. As study limitation, the search in the gray literature may not have been sufficient to cover the related content on the subject, especially because theses or dissertations were not included. However, eight databases were searched, in addition to the reading of references to increase sensitivity in the search for articles. Another limitation of this review was the selection of studies to obtain the information of interest. This is because we included studies in which the objective was to increase physical activity levels due to pandemic-related effects and studies which presented interventions carried out during the COVID-19 pandemic. However, it is noteworthy that all the selected articles had deleterious effects related to the pandemic context in the conduct of interventions or in the results, making them relevant for the purpose of this review. Although most of the studies identified in the present review showed a positive association with the investigated outcome, further reviews should be explored, providing secure evidence regarding the efficacy, feasibility, and acceptability of physical activity counseling interventions during the COVID-19 pandemic.
Among practical implications, it could be mentioned that technological resources (online platforms, telephone contact, and applications) are strong allies to promote physical activity counseling interventions during the COVID-19 pandemic. In addition, physical activity counseling interventions are necessary for healthy subjects, or for those with comorbidities, regardless of sex or age, since physical activity can be beneficial to most participants, both for physical and mental health, especially during the pandemic period. It is important to highlight that counseling should be feasible and implemented through safe, viable, and effective strategies, considering the reality and needs of participants.

Conclusions
According to the findings of this review, interventions on physical activity counseling during the COVID-19 pandemic were provided by health professionals through technological resources, based on educational contents and behavioral strategies, and resulted in increases in participants' physical activity levels. The importance of new records on the subject, capable of intervening during pandemic restrictions, is highlighted. The results of this review allow health professionals to assist in the process of coping with physical inactivity through interventions, educational practices, and informational materials, contributing to the physical and mental health of participants. Furthermore, the results found in this review showed that despite the different intervention methods used, most interventions on physical activity counseling resulted in increased physical activity levels and this can be considered support for decision-making and health interventions. Future reviews should explore the feasibility and applicability of different physical activity counseling interventions in different contexts.
Author Contributions: All authors contributed equally to the conception and design of the study, acquisition of data, or analysis and interpretation of data, drafting the article or revising it critically for important intellectual content, and final approval of the version to be submitted. All authors have read and agreed to the published version of the manuscript.