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Nowhere to hide: The significant impact of coronavirus disease 2019 (COVID-19) measures on elite and semi-elite South African athletes

      Abstract

      Objectives

      To describe the perceptions of South African elite and semi-elite athletes on return to sport (RTS); maintenance of physical conditioning and other activities; sleep; nutrition; mental health; healthcare access; and knowledge of coronavirus disease 2019 (COVID-19).

      Design

      Cross- sectional study.

      Methods

      A Google Forms survey was distributed to athletes from 15 sports in the final phase (last week of April 2020) of the level 5 lockdown period. Descriptive statistics were used to describe player demographic data. Chi-squared tests investigated significance (p < 0.05) between observed and expected values and explored sex differences. Post hoc tests with a Bonferroni adjustment were included where applicable.

      Results

      67% of the 692 respondents were males. The majority (56%) expected RTS after 1–6 months. Most athletes trained alone (61%; p < 0.0001), daily (61%; p < 0.0001) at moderate intensity (58%; p < 0.0001) and for 30–60 min (72%). During leisure time athletes preferred sedentary above active behaviour (p < 0.0001). Sleep patterns changed significantly (79%; p < 0.0001). A significant number of athletes consumed excessive amounts of carbohydrates (76%; p < 0.0001; males 73%; females 80%). Many athletes felt depressed (52%), and required motivation to keep active (55%). Most had access to healthcare during lockdown (80%) and knew proceedings when suspecting COVID-19 (92%).

      Conclusions

      COVID-19 had physical, nutritional and psychological consequences that may impact on the safe RTS and general health of athletes. Lost opportunities and uncertain financial and sporting futures may have significant effects on athletes and the sports industry. Government and sporting federations must support athletes and develop and implement guidelines to reduce the risk in a COVID-19 environment.

      Keywords

      Practical implications

      • 1.
        Implement a culture of education for athletes and support staff regarding hygiene, wearing masks, social distancing measures and self-isolation to improve health literacy and promote required behaviours.
      • 2.
        Consider health, nutritional and psychological support and education during the remainder of the lockdown period.
      • 3.
        Reduce the injury risk by implementing a progressive training load and allowing for maximum adaptation before competition is re-introduced.
      • 4.
        Sleep hygiene and its effects on performance should become an imperative part of athletic education.
      • 5.
        Athletes returning to sport should require thorough medical assessment including nutrition assessment prior to resumption of high intensity sporting activity.
      • 6.
        Mental health aspects form an important part of athlete performance and should be recognised and acted on timeously through life/performance coaches or psychologists.
      • 7.
        Stimulate athletes to become saving and investment-wise, and plan their future in time for a career/business/life after sport.

      1. Introduction

      The coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) resulted in a global pandemic with unprecedented consequences. Many scientific articles (peer-reviewed and non-peer reviewed) have been published regarding epidemiology,
      • Zhou P.
      • Yang X.-L.
      • Wang X.-G.
      • et al.
      A pneumonia outbreak associated with a new coronavirus of probable bat origin.
      pathogenesis,
      • Rothan H.A.
      • Byrareddy S.N.
      The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak.
      complications
      • Jiang F.
      • Deng L.
      • Zhang L.
      • et al.
      Review of the clinical characteristics of coronavirus disease 2019 (COVID-19).
      and treatment.
      • Richards G.
      • Mer M.
      • Schleicher G.
      • et al.
      COVID-19 and the rationale for pharmacotherapy: a South African perspective.
      The COVID-19 pandemic forced governments to implement unparalleled measures to curb the rapid spread of the disease including strict lockdown, banning of all organised and social gatherings (including sports events) and restricting non-essential travel, with a significant effect on the sports industry and athletes. In South Africa, level 5 lockdown measures were enforced from 26 March to 30 April (5 weeks). Only essential services, travel and shopping were allowed and exercise outside individual property boundaries was not allowed,

      President Cyril Ramaphosa: South Africa's response to Coronavirus COVID-19 pandemic. South Africa: South Africa Government Newsroom Speeches; 2020. Available at: https://www.gov.za/speeches/president-cyril-ramaphosa-south-africas-response-coronavirus-covid-19-pandemic-23-apr-2020.

      likely having a psychological impact on all, including athletes.
      • Qiu J.
      • Shen B.
      • Zhao M.
      • et al.
      A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: implications and policy recommendations.
      Our current understanding of these lockdown measures on training, nutrition and mental health of athletes are limited. This study aims to investigate the perceptions of South African elite and semi-elite athletes on (1) return to sport (RTS); (2) maintenance of physical conditioning and other activities; (3) sleep; (4) nutrition; (5) mental health; (6) healthcare access; and (7) knowledge of the COVID-19 disease.

      2. Methods

      A cross-sectional study was designed, based on input from researchers and clinicians looking after athletes, regarding the challenges they experienced during the lockdown period. Survey questions were adapted from validated questionnaires on maintenance of activity,
      • Thomas S.
      • Reading J.
      • Shephard R.J.
      Revision of the physical activity readiness questionnaire (PAR-Q).
      nutrition
      • Segal-Isaacson C.
      • Wylie- Rosett J.
      • Gans K.M.
      Validation of a short dietary assessment questionnaire: the Rapid Eating and Activity Assessment for Participants short version (REAP-S).
      and mental state.
      • Krueger R.F.
      • Derringer J.
      • Markon K.E.
      • et al.
      Initial construction of a maladaptive personality trait model and inventory for DSM-5.
      The survey was piloted by 20 healthcare workers including sports physicians, physiotherapists and biokineticists. Following ethics approval from the Ethical Committee of the University of Pretoria (REC 274/2020), a link to the online Google Form survey was distributed to a convenience sample of athletes via WhatsApp. Athletes were asked to read the description and need for the study and click on the link to proceed after giving consent. Participants from 15 sports (soccer, hockey, rugby, cricket, athletics, netball, basketball, endurance running, cycling, track and field, swimming, squash, golf, tennis, karate) were recruited through the databases of the researchers, sports medicine healthcare professionals and administrators affiliated with the research team. The inclusion criteria was (1) elite and semi-elite athletes based in South Africa, (2) >18 years of age. Recreational athletes were excluded. The survey was live for 72 h during the level 5 lockdown period, from 28 April to 30 April 2020 and took 10–15 min to complete. Data were collected from Google Forms and exported to a csv file for data analysis. The data consisted of categorical feedback, hence the descriptive statistics consisted of frequencies and percentages which described the feedback received. We used the Chi-square goodness of fit test to investigate if a significant difference, tested at a 5% level of significance, existed between the observed and expected values. The Chi-square test of independence was used to explore sex specific associations. Post hoc analyses were included with a Bonferroni adjustment where applicable. As questions were single or multiple choice options. It should be noted that proportions do not add up to 100% for the questions with multiple responses. Multiple choice options on risk reduction behaviour were listed as per the World Health Organization (WHO)

      World Health Organization. Coronavirus. Available at: https://www.who.int/health-topics/coronavirus#tab=tab_3.

      and National Institute for Communicable Diseases (NICD)

      Guidelines for case-finding, diagnosis, management and public health response in South Africa, Centre for Respiratory Diseases and Meningitis and Outbreak Response, National Institute for Communicable Diseases (NICD) of the National Health Laboratory Services (NHLS) and the National Department of Health, South African Government, South Africa, 2020. Available at: https://www.nicd.ac.za/wp-content/uploads/2020/03/NICD_DoH-COVID-19-Guidelines-10March2020_final.pdf.

      documents regarding the most important aspects.

      3. Results

      From a total of 1080 distributed surveys, 692 athletes responded. The response rate was 64% and respondents consisted of 67% males (Table 1). Some (presumably university level semi-elite athletes, n = 55; 8%) reported participation in two or more sports. Four respondents preferred not to reveal their sex.
      Table 1Athlete demographics: sex and sport involvement.
      Type of sport involvementTotal surveys distributed n = 1080Female n = 225 (33%)Male n = 463 (67%)Responses n = 769

      (Respondents n = 692)
      Response rate within each sport
      n%%%%
      Soccer2505372672
      Hockey15019141674
      Rugby1304171369
      Cricket1104161277
      Athletics1001581072
      Netball80311086
      Basketball80176981
      Endurance running50104678
      Cycling2042390
      Track and field3031243
      Swimming3031237
      Squash1501140
      Golf1501133
      Tennis1010.530
      Karate1010.320
      Respondents n = 692: completed responses received back.
      Responses n = 769: athletes reported participation in two or more sports.
      Most respondents were from soccer (26%), followed by hockey (16%) and rugby (13%). Most males participated in soccer (37%), while most females played netball (31%).
      Regarding return to competitive sport, 35% athletes expected to RTS within 1–3 months whilst 31% felt unsure, and no sex difference was observed (p = 0.0740). Only 50% athletes were comfortable with RTS when allowed by authorities, and results are comparable between males and females (p = 0.6901). The athletes are willing to compete behind closed doors (p < 0.0001), while male athletes are more willing than females (p < 0.0001) (Table 2).
      Table 2Athlete responses to return to competitive sport during the lockdown period.
      Return to competitive sport during lockdown
      When do you think you will be competing again?Female n=225Male n=463PNTS n=4Total n=692p- value
      %%%%
      1 montha81110<0.0001
      Significant difference p<0.05.
      1–3 monthsb303835
      3–6 monthsc24195021
      >6 monthsd433
      Unsureb34295031
      As you are aware, the SARS-CoV-2 virus will not simply “disappear” and maybe around for some time. Should regulations and authorities allow return to sport, would you be comfortable to return to your sport?Female n=225Male n=463PNTS n=4Total n=692p- value
      Yesa48512550<0.0001
      Significant difference p<0.05.
      Nob16145015
      Maybec36352535
      If you answered “No” or “Maybe”, please say what would make you comfortable to return to sport
      MaybeFemale n=82Male n=160PNTS n=1Total n=430 (% of 243)p- value
      I am assured that protocols have been put in place to significantly reduce my chances at contracting the virus595354<0.0001
      Significant difference p<0.05.
      Risks must be reduced by 100%403910040
      My sporting federation and government must be happy with guidelines to protect athletes443638
      The international sporting world must be moving in the same direction243229
      I am enabled financially or equipment-wise by my federation to take the precautionary measures implemented91312
      NoFemale n=35Male n=65PNTS n=2Total n=174

      (% of 102)
      p- value
      Risks must be reduced 100%546210060<0.0001
      Significant difference p<0.05.
      I am enabled financially or equipment-wise by my federation to take the precautionary measures implemented11943
      The international sporting world must be moving in the same direction173427
      My sporting federation and government must be happy with guidelines to protect athletes232926
      I am assured that protocols have been put in place to significantly reduce my chances at contracting the virus49405010
      Would you compete behind closed doors but televised?Female n=225Male n=463PNTS n=4Total n=692p- value
      Yes72865082<0.0001
      Significant difference p<0.05.
      No28145018
      PNTS: Prefer not to say.
      ab When significance tests indicated that differences existed between the counts within each question, the superscripts indicate which options reported similar results. These represent the post hoc results.
      * Significant difference p< 0.05.
      For exercise maintenance and other activities, more athletes trained alone (p < 0.0001), compared to those training alone but digitally directed by a trainer, or a medical person or using technology like Zoom together with other athletes. More males used Zoom to train with other athletes than females (p < 0.0001). Most athletes trained daily vs alternative days or ≤3× a week (p = 0.0001). More males trained daily compared to females (p = 0.0059). Sessions consisted mainly of own body weight (males 73%) and cardio exercises (females 70%). Athletes could train outside without breaking the law (p < 0.0001) (male vs female p = 0.3779), at a reduced training intensity (p < 0.0001) (male vs female p = 0.6972) and sessions lasted mostly 30–60 min (males vs females p = 0.6351). Sports specific equipment is used significantly more (p < 0.0001) than treadmills, steppers, stationary bikes, swimming. Males and females had comparable results (p = 0.0899). Sedentary behaviour above active behaviour was preferred during leisure time (p < 0.0001). Sedentary behaviour largely favoured watching television, and males significantly favoured electronic gaming compared to females (p < 0.0001) (Table 3).
      Table 3Athlete responses to exercise maintenance and other activities during the lockdown period.
      Exercise maintenance during lockdown
      How are you maintaining activity during lockdown?
      Questions were open to select more than one option i.e. percentages may add up to >100.
      Female n=225Male n=463PNTS n=4Total n=897 (% of 692)p- value
      %%%%
      Alonea57637561<0.0001
      Significant difference p<0.05.
      Directed digitally by a Fitness or Personal trainerb31232525
      Directed digitally by a medical person (Physiotherapist/Biokineticist/Sports Scientist)b30202524
      Using technology like Zoom etc. with other athletesb102420
      How often do you train in a week?Female n=225Male n=463PNTS n=4Total n=692p- value
      Dailya53657561<0.0001
      Significant difference p<0.05.
      Every alternate dayb27232524
      3× or less a weekc201215
      What do your sessions consist of?
      Questions were open to select more than one option i.e. percentages may add up to >100.
      % of Female% of Male% of PNTSTotal n=2031

      (% of 692)
      p- value
      Own body weight strengtha66735071<0.0001
      Significant difference p<0.05.
      Cardio (running/stepper/cycle/treadmill) a70652567
      Sport specific exercises that are functionalb62485052
      Resisted strength work (use of elastics and/or weights)b43522549
      Flexibilityc31302531
      Proprioception (balance)c24242524
      Are you able to exercise outside without breaking the law? (e.g. in your backyard)Female n=225Male n=463PNTS n=4Total n=692p- value
      Yes85822583<0.0001
      Significant difference p<0.05.
      No15187517
      Have you reduced your training load and intensity during this lockdown period?Female n=225Male n=463PNTS n=4Total n=692p- value
      Yes76747575<0.0001
      Significant difference p<0.05.
      No24262525
      At what intensity do you exercise?Female n=225Male n=463PNTS n=4Total n=692p- value
      Higha36362536<0.0001
      Significant difference p<0.05.
      Moderateb57587557
      Lowc767
      When you do exercise, how long are your sessions?Female n=225Male n=463PNTS n=4Total n=692p- value
      <30 mina11125011<0.0001
      Significant difference p<0.05.
      30–45 minb35312533
      45–60 minb403939
      >60 minc14182517
      Do you have any of the following equipment you use at home to assist you with exercise?
      Questions were open to select more than one option i.e. percentages may add up to >100.
      % of Female% of Male% of PNTSTotal n=1609

      (% of 692)
      p- value
      Sports specific equipment (soccer ball/rugby ball/tennis ball, etc.)a56677563<0.0001
      Significant difference p<0.05.
      Resistance bandsab53527552
      Free weightsb41485046
      Swimming poolc312829
      Stationary bike (or any equipment to allow for indoor cycling)c282023
      Stepperd8112510
      Treadmilld10910
      Other activities during lockdown
      Aside from exercise, what else do you do to keep busy during the lockdown?
      Questions were open to select more than one option i.e. percentages may add up to >100.
      % of Female% of Male% of PNTSTotal n=2693

      (% of 692)
      p- value
      Active<0.0001
      Significant difference p<0.05.
      Fix things at home or spring cleana58495052
      Games outdoors (playing with kids, etc.) b21282525
      Sedentary
      Watch televisiona72717572
      Social mediaa61577558
      Read a bookbc50417544
      Electronic gaming (play station etc.) bcde11517538
      Cell phone gamingcde29402536
      Work remotely on your other business venturesde372730
      Board gamese243129
      Drink alcoholf354
      PNTS: Prefer not to say.
      ab When significance tests indicated that differences existed between the counts within each question, the superscripts indicate which options reported similar results. These represent the post hoc results.
      # Questions were open to select more than one option i.e. percentages may add up to >100.
      * Significant difference p< 0.05.
      More athletes reported changes in sleep-wake times during the lockdown period (p < 0.0001), but they still experienced restful sleep (p < 0.0001) and did not experience constant fatigue (p < 0.0001). There were no sex differences in sleep-wake times (p = 0.6045) and restful sleep (p = 0.2455), however, a significantly larger proportion of females felt more fatigued than males (p = 0.0213) (Table 4).
      Table 4Athlete responses to sleep, nutrition and mental state during the lockdown period.
      Sleep during lockdown
      Have you been sleeping and waking up at your normal times as before the lockdown?Female n=225Male n=463PNTS n=4Total n=692p- value
      %%%%
      Yes202221<0.0001
      Significant difference p<0.05.
      No807810079
      Is your sleep restful?Female n=225Male n=463PNTS n=4Total n=692p- value
      Yes70752573<0.0001
      Significant difference p<0.05.
      No30257527
      Are you feeling constantly fatigued during the lockdown?Female n=225Male n=463PNTS n=4Total n=692p- value
      Yes483810042<0.0001
      Significant difference p<0.05.
      No526258
      Nutrition during lockdown
      Has your diet worsened or improved during the lockdown?Female n=225Male n=463PNTS n=4Total n=692p- value
      Improved365325470.1486
      Worsened64477553
      If your diet has worsened, in what way?
      Questions were open to select more than one option i.e. percentages may add up to >100.
      Female n=143Male n=219PNTS n=3Total n=686 (% of 365)p- value
      Excessive carbohydrates (includes sweets/chocolates/rice/bread etc.)a807310076<0.0001
      Significant difference p<0.05.
      Fizzy drinksb24416734
      Poor hydration during exercise and after exerciseb34336734
      Excessive processed foodsc16223320
      Excessive red meatcd10176715
      Alcohold1283310
      Are you using any supplements to assist in boosting your immune system?Female n=225Male n=463PNTS n=4Total n=692p- value
      Yes363032<0.0001
      Significant difference p<0.05.
      No647010068
      If yes to the above question, what supplements?
      Questions were open to select more than one option i.e. percentages may add up to >100.
      Female n=82Male n=173PNTS n=0Total n=219p- value
      Multivitamina392736<0.0001
      Significant difference p<0.05.
      Vitamin Cb462336
      Otherab241723
      Proteinb101415
      No information suppliedc165
      Zincc524
      Mental state during lockdown
      Do you feel depressed?Female n=225Male n=463PNTS n=4Total n=692p- value
      Yes604875520.3230
      Yes, all of the time423
      Yes, on very few occasions292727
      Yes, sometimes27197522
      No40522548
      No40522548
      Do you feel you have a loss of “energy” daily?Female n=225Male n=463PNTS n=4Total n=692p- value
      Yes5342100460.0275
      Significant difference p<0.05.
      No475854
      Do you struggle to keep yourself motivated to exercise?Female n=225Male n=463PNTS n=4Total n=692p- value
      Yes605275550.0150
      Significant difference p<0.05.
      No40482545
      Have you re-adapted to developing a new routine daily with lockdown?Female n=225Male n=463PNTS n=4Total n=692p- value
      Yes62695066<0.0001
      Significant difference p<0.05.
      No38315034
      Has your libido (sexual appetite)...during lockdownFemale n=225Male n=463PNTS n=4Total n=692p- value
      Decreaseda14132513<0.0001
      Significant difference p<0.05.
      Increasedb13382530
      Stay the samec73495057
      Are you aware of several psychological and mental health programmes available online and via skype should you need it?Female n=225Male n=463PNTS n=4Total n=692p- value
      Yes604750510.6483
      No40535049
      Have you been sleeping and waking up at your normal times as before the lockdown?Female n=225Male n=463PNTS n=4Total n=692p- value
      %%%%
      Yes202221<0.0001
      Significant difference p<0.05.
      No8078100.0079
      Is your sleep restful?Female n=225Male n=463PNTS n=4Totalp- value
      Yes70752573<0.0001
      Significant difference p<0.05.
      No30257527
      Are you feeling constantly fatigued during the lockdown?Female n=225Male n=463PNTS n=4Totalp- value
      Yes483810042<0.0001
      Significant difference p<0.05.
      No526258
      PNTS: Prefer not to say.
      ab When significance tests indicated that differences existed between the counts within each question, the superscripts indicate which options reported similar results. These represent the post hoc results.
      # Questions were open to select more than one option i.e. percentages may add up to >100.
      * Significant difference p< 0.05.
      Even though not statistically significant, more than half of the athletes admitted to the worsening of their diet (p = 0.1486), with females significantly more than males (p < 0.0001). Excessive carbohydrate consumption was significantly more (p < 0.0001) than excessive fizzy drinks, poor hydration during and after exercise, processed foods, and red meat (Table 4).
      Observing mental state, 52% of the athletes felt depressed at some time (p = 0.3230), and females reported a significantly (p < 0.0001) higher rate. While 54% of all athletes did not report energy loss, and 55% struggled to keep motivated; female athletes reported higher energy loss (p = 0.0084) and lack of motivation (p = 0.0358) compared to males. Most felt they adapted to the new routine (males vs females p = 0.0765). Libido stayed the same for most respondents, but significantly more males reported increased libido compared to females (p < 0.0001). Many athletes were not aware of online psychological and mental health programmes, however, females are significantly more mindful (p = 0.0020) (Table 4).
      A significant number of athletes had access to healthcare (p < 0.0001; males vs females p = 0.5934). Both males and females accessed telehealth opposed to physical consultations (p < 0.0001), via WhatsApp (65% males vs 52% females) or telephone (60% males vs 56% female). More athletes had access to general practitioners and physiotherapists for medical assistance compared to other healthcare professionals (p < 0.0001). Males and females differed significantly towards choice of health access (p < 0.0001) (Table 5).
      Table 5Athlete responses to healthcare and knowledge on COVID-19 during lockdown.
      Questions on healthcare during lockdown
      Do you have easy access to your healthcare professionals?Female n=225Male n=463PNTS n=4Total n=692p- value
      %%%%
      Yes81.3379.2775.0079.91<0.0001
      Significant difference p<0.05.
      No18.6720.7325.0020.09
      Is your access via
      Questions were open to select more than one option i.e. percentages may add up to >100.
      % of Female% of Male% of PNTSTotal n=1246

      (% of 692)
      p- value
      Telehealth<0.0001
      Significant difference p<0.05.
      Whatsappa52655061
      Telephonea56602559
      Social mediab151917
      Other electronic meansb13132513
      Physical
      Physical consultations40252530
      Which professionals do you have access to?
      Questions were open to select more than one option i.e. percentages may add up to >100.
      % of Female% of Male% of PNTSTotal n=1168

      (% of 692)
      p- value
      General Practitionera52445047<0.0001
      Significant difference p<0.05.
      Physiotherapista30462541
      Otherb392328
      Biokineticistb27285028
      Sports Physicianb163026
      Knowledge on COVID-19 during lockdown
      Where do you gain your knowledge from regard COVID-19?
      Questions were open to select more than one option i.e. percentages may add up to >100.
      % of Female% of Male% of PNTSTotal n=2265

      (% of 692)
      p- value
      Television newsb73742573<0.0001
      Significant difference p<0.05.
      News websitesab726810070
      Social mediabc59582558
      Official government websites and social media sitesc60487552
      Radiod272425
      A friendefg15142515
      My doctorefg91614
      Community forumsfg1392510
      My physiog2129
      My bankerb122
      What are the most important aspects in reducing risk at contracting the coronavirus?
      Questions were open to select more than one option i.e. percentages may add up to >100.
      % of Female% of Male% of PNTSTotal n=4181

      (% of 692)
      p- value
      Social distancing of 2 md61575058<0.0001
      Significant difference p<0.05.
      Handwashing with soap and watera898310085
      Coughing/sneezing into a flexed elbowcd727010071
      Not rubbing eyes/nose/mouthbc807510077
      Cloth masksij202523
      Hand sanitising with alcohol content 70ab848410084
      Sneezing/coughing into a handkerchiefefh38405040
      Wearing glovesefg43435043
      Social distancing of 1 mfgh33415039
      Surgical masksfgh383939
      FFP1/FFP2/N95 masksghi31305031
      Disposing of clothes when returning from shops etc.j17152516
      What are the main symptoms of the coronavirus that should prompt you to get a medical opinion?
      Questions were open to select more than one option i.e. percentages may add up to >100.
      % of Female% of Male% of PNTSTotal n=1980

      (% of 692)
      p- value
      Fevera797910079<0.0001
      Significant difference p<0.05.
      Dry Coughb616510064
      Shortness of breathc788510083
      Sore throatb56637561
      Should you think you have coronavirus symptoms do you know how to proceed?Female n=225Male n=463PNTS n=4Total n=692p- value
      Yes929210092
      No888
      If your answer is yes to the above question how would you proceed?
      Questions were open to select more than one option i.e. percentages may add up to >100.
      % of Female% of Male% of PNTSTotal n=1190

      (% of 692)
      p- value
      Contact a doctora71747573<0.0001
      Significant difference p<0.05.
      Phone the toll-free NICD numberb52505051
      Go to a lab and ask them for testing for COVID-19c242424
      Search on google or social mediad7109
      Just arrive at a doctors rooms for a consultatione122
      Speak to your pharmaciste022
      Do you have easy access to your healthcare professionals?Female n=225Male n=463PNTS n=4Total n=692p- value
      Yes81.3379.2775.0079.91<0.0001
      Significant difference p<0.05.
      No18.6720.7325.0020.09
      Is your access via
      Questions were open to select more than one option i.e. percentages may add up to >100.
      % of Female% of Male% of PNTSTotal n=1246

      (% of 692)
      p- value
      Telehealth<0.0001
      Significant difference p<0.05.
      Whatsappa52655061
      Telephonea56602559
      Social mediab151917
      Other electronic meansb13132513
      Physical
      Physical consultations40252530
      Which professionals do you have access to?
      Questions were open to select more than one option i.e. percentages may add up to >100.
      % of Female% of Male% of PNTSTotal n=1168

      (% of 692)
      p- value
      General Practitionera52445047<0.0001
      Significant difference p<0.05.
      Physiotherapista30462541
      Otherb392328
      Biokineticistb27285028
      Sports Physicianb163026
      PNTS: Prefer not to say.
      ab When significance tests indicated that differences existed between the counts within each question, the superscripts indicate which options reported similar results. These represent the post hoc results.
      # Questions were open to select more than one option i.e. percentages may add up to >100.
      * Significant difference p< 0.05.
      Television news, news websites, social media and government sites were the sources of knowledge on COVID-19 used as opposed to radio, friends, doctors, community forums, physiotherapists and bankers (p < 0.0001) and no sex difference was observed. Handwashing with soap and water and hand sanitising with >70% alcohol content were rated as the most important (p < 0.0001; males vs females p = 0.8127). Most athletes were aware that shortness of breath, fever, dry cough and sore throat were the main symptoms of COVID-19 (p < 0.0001; males vs females p = 0.8402). Shortness of breath was identified by 85% male vs 78% female athletes as the main symptom of COVID-19. Most athletes knew how to proceed on symptom development (p < 0.0001; males vs females p = 1.000). On suspicion of COVID-19 symptoms, a significant difference existed in accessing healthcare via contacting their doctors, or opting for contacting the National Institute of Communicable Diseases (NICD) hotline, as opposed to going to a laboratory for testing, searching the web or social media or going to the doctor's rooms (p < 0.0001). Both males and females knew proceedings (p = 1.000), and would contact a doctor (Table 5).

      4. Discussion

      The COVID-19 pandemic lockdown measures significantly impacted elite and semi-elite athletes in South Africa. One of our key findings is that despite high levels of uncertainty regarding RTS guidelines, most athletes are continuing to train daily. Two out of three athletes trained alone with only a minority of athletes using digital guidance by a professional. There are certain risks to unsupervised training,
      • Myer G.D.
      • Faigenbaum A.D.
      • Cherny C.E.
      • et al.
      Did the NFL lockout expose the Achilles heel of competitive sports?.
      including an inadvertent lapse into poor technique and posture, which may predispose athletes to injuries.
      • Aicale R.
      • Tarantino D.
      • Maffulli N.
      Overuse injuries in sport: a comprehensive overview.
      Solo training and a lack of sport- specific training may also be challenging for athletes who participate in team and very technical (e.g. pole vault) sports. More than half of the athletes were training at a moderate exercise intensity for 30–60 min per day, at a lower training load than normal. Moderate training loads allow for recovery
      • Maupin D.
      • Schram B.
      • Canetti E.
      • et al.
      The relationship between acute: chronic workload ratios and injury risk in sports: a systematic review.
      and this is important during the COVID-19 pandemic to avoid blunting of the immune system.
      • Matthews C.E.
      • Ockene I.S.
      • Freedson P.S.
      • et al.
      Moderate to vigorous physical activity and risk of upper-respiratory tract infection.
      • Soligard T.
      • Steffen K.
      • Palmer D.
      • et al.
      Sports injury and illness incidence in the Rio de Janeiro 2016 Olympic Summer Games: a prospective study of 11,274 athletes from 207 countries.
      • Schwellnus M.
      • Soligard T.
      • Alonso J.-M.
      • et al.
      How much is too much? (Part 2) International Olympic Committee consensus statement on load in sport and risk of illness.
      Even though the additional recovery time came at an opportune time (e.g. Olympics was 4 months away), deconditioning is bound to occur, posing challenges in reconditioning and safe RTS.
      • Myer G.D.
      • Faigenbaum A.D.
      • Cherny C.E.
      • et al.
      Did the NFL lockout expose the Achilles heel of competitive sports?.
      The majority of athletes engaged in own bodyweight strength training, cardio workouts, and functional sport-specific training, resembling appropriate active rest phase modalities.
      • de Oliveira Neto L.
      • Elsangedy H.M.
      • de Oliveira Tavares V.D.
      • et al.
      Training in home – home-based training during COVID-19 (SARS-COV2) pandemic: physical exercise and behavior-based approach.
      Only a small number of athletes included proprioception in their programmes. Good proprioception plays an important role in accurate movement patterns and can prevent injuries and recurrence of injuries.
      • Ogard W.K.
      Proprioception in sports medicine and athletic conditioning.
      Such exercises are easy to do indoors and even in confined spaces, and should be recommended. Athletes had considerable access to equipment, including sports specific equipment, treadmills, steppers, free weights, swimming pools and stationary bikes, providing good opportunities for cross-training, which we also recommend to assist with whole-body maintenance and to add variety.
      • Jukic I.
      • Calleja-González J.
      • Cos F.
      • et al.
      Strategies and solutions for team sports athletes in isolation due to COVID-19.
      Leisure time activities with possible lifestyle changes during lockdown were of concern. The majority chose sedentary behaviour, especially watching television. Males engaged more in electronic and cell-phone gaming, possibly contributing to sleep alteration and feelings of fatigue. Few partook in alcohol-related activities during this period. The detrimental effects of sedentary behaviour on both physical and mental health is beyond dispute.
      • Farren G.L.
      • Zhang T.
      • Gu X.
      • et al.
      Sedentary behavior and physical activity predicting depressive symptoms in adolescents beyond attributes of health-related physical fitness.
      • de Oliveira R.G
      • Guedes D.P.
      Physical activity, sedentary behavior, cardiorespiratory fitness and metabolic syndrome in adolescents: systematic review and meta-analysis of observational evidence.
      Realistic changes to decrease sedentary behaviour during the lockdown needs to be advocated by health care professionals. Athletes are also exposed to the negative psychological consequences of COVID-19 like anxiety and stress reported across the wider society, where people are overwhelmed by the constantly changing alerts and media reports about the virus spread. Home confinement not only affect the physiological status of athletes,
      • COVID-19 and Sporting Activity
      AIS framework for rebooting sport.
      • Sarto F.
      • Impellizzeri F.
      • Spörri J.
      • et al.
      Impact of potential physiological changes due to COVID-19 home confinement on athlete health protection in elite sports: a call for awareness in sports programming.
      but the inability to compete may also influence athlete mental health.
      • Reardon C.L.
      • Hainline B.
      • Aron C.M.
      • et al.
      Mental health in elite athletes: International Olympic Committee consensus statement (2019).
      We found that one in two athletes was depressed, with energy loss and lack of motivation to train. Females are more affected in all these spheres, with potentially profound adverse effects on their mental health.
      • Trojian T.
      Depression is under-recognised in the sport setting: time for primary care sports medicine to be proactive and screen widely for depression symptoms.
      • Tolentino J.C.
      • Schmidt S.L.
      DSM-5 criteria and depression severity: implications for clinical practice.
      A recent consensus document on athlete mental health stressed the importance of mental wellbeing for optimal performance.
      • Reardon C.L.
      • Hainline B.
      • Aron C.M.
      • et al.
      Mental health in elite athletes: International Olympic Committee consensus statement (2019).
      Access to psychological support to maintain their mental health during and after lockdown is paramount. A significant proportion of athletes reported a change in sleep routine, even though still restful. Nevertheless, almost half of the respondents reported feeling chronically fatigued. Quality and quantity of sleep have a significant impact on injury incidence and recovery post-exercise.
      • Nédélec M.
      Recovery strategies in elite sport: focus on both quantity and quality of sleep.
      Sleep allows for the immune system to regenerate and recuperate.
      • Haspel J.A.
      • Anafi R.
      • Brown M.K.
      • et al.
      Perfect timing: circadian rhythms, sleep, and immunity – an NIH workshop summary.
      Compromised immunity increases the risk of viral illness (including COVID-19), this is particularly important given the imminent winter of the southern hemisphere. Social isolation, exercise reduction, sedentary behaviour, and changes in nutrition have a psychological consequence and can impact sleep and fatigue. Athletes need to be educated regarding the psychological impact on sleep and fatigue
      • Jukic I.
      • Calleja-González J.
      • Cos F.
      • et al.
      Strategies and solutions for team sports athletes in isolation due to COVID-19.
      and re-adjust their sleeping patterns on RTS.
      More than half of the athletes reported deterioration in eating habits, especially a significant increase in carbohydrate ingestion. Impaired nutrition may result in a myriad of issues upon RTS including deteriorated performance, lifestyle-related concerns and affecting weight category sport.
      • Thomas D.T.
      • Erdman K.A.
      • Burke L.M.
      Nutrition and athletic performance.
      Athletes are generally believed to consume substantial amounts of supplements,
      • Maughan R.J.
      • Depiesse F.
      • Geyer H.
      The use of dietary supplements by athletes.
      but a large percentage of athletes in our study did not consume supplements. Only one in three athletes used a combination of vitamin C, multivitamins, zinc, vitamin B, protein and other unclassifiable supplements. During the COVID-19 pandemic some authors have advised taking supplements including vitamin C, zinc and vitamin D for immune enhancement.
      • Richards G.
      • Mer M.
      • Schleicher G.
      • et al.
      COVID-19 and the rationale for pharmacotherapy: a South African perspective.
      • Jukic I.
      • Calleja-González J.
      • Cos F.
      • et al.
      Strategies and solutions for team sports athletes in isolation due to COVID-19.
      Most athletes can train outside without breaking regulations, exposing them to natural light to allow vitamin D synthesis.
      • Grant W.B.
      • Lahore H.
      • McDonnell S.L.
      • et al.
      Evidence that vitamin D supplementation could reduce risk of influenza and COVID-19 infections and deaths.
      Given the significant inadequacies in nutrition during the lockdown, it seems appropriate to implement nutritional guidance by a sports nutritionist, both during the lockdown and afterward.
      The majority of athletes had access to healthcare professionals, mostly through telehealth. With the implementation of the lockdown and dangers of COVID-19, the Health Professionals Council of South Africa relaxed its regulations on the use of telehealth, making it more accessible.
      • Kwinda M.A.
      Guidance on the application of telemedicine guidelines during the covid-19 pandemic.
      Only one in four had access to a sports physician, perhaps due to financial or travelling constraints. The athletes accessed traditional and social media to gain knowledge on COVID-19 demonstrating the ability of these platforms to reach wide audiences to deliver key public health messages. It appears that doctors or other evidence-based platforms were poorly utilised for this purpose possibly because healthcare professionals did not reach out to the athlete population. Nevertheless, athletes had good knowledge about COVID-19 preventative measures and presenting symptoms. They identified handwashing with soap and water or the use of alcohol-based hand sanitisers as a priority in reducing their risk of contracting the virus. Applying respiratory hygiene was rated high while only one in two athletes recognised social distancing of >2 m as important. Even though athletes were aware of how to mitigate the risk, they lacked awareness of the priorities of risk modification.

      World Health Organization. Coronavirus. Available at: https://www.who.int/health-topics/coronavirus#tab=tab_3.

      The timing of the survey may have contributed to athletes favouring the use of surgical and FFP1/FFP2/N95 masks (which should be reserved for healthcare professionals), instead of a cloth mask. Cloth masks have shown some potential to reduce the risk of viral transmission.
      • Greenhalgh T.
      • Schmid M.B.
      • Czypionka T.
      • et al.
      Face masks for the public during the covid-19 crisis.
      This information was shared by the government shortly before the start of the survey, which may have biased the responses.

      National Department of Health, COVID-19, online resource and news portal, South Africa, 2020. Available at: http://www.health.gov.za/index.php/component/phocadownload/category/631.

      The athletes also correctly recognised the most significant symptoms of COVID-19 as communicated by the World Health Organisation,

      World Health Organization. Coronavirus. Available at: https://www.who.int/health-topics/coronavirus#tab=tab_3.

      NICD

      Guidelines for case-finding, diagnosis, management and public health response in South Africa, Centre for Respiratory Diseases and Meningitis and Outbreak Response, National Institute for Communicable Diseases (NICD) of the National Health Laboratory Services (NHLS) and the National Department of Health, South African Government, South Africa, 2020. Available at: https://www.nicd.ac.za/wp-content/uploads/2020/03/NICD_DoH-COVID-19-Guidelines-10March2020_final.pdf.

      and National Department of Health,

      COVID-19 Corona Virus South African Resource Portal, 2020. Available at: https://sacoronavirus.co.za/.

      being shortness of breath, fever, dry cough and a sore throat. Almost all athletes knew how to proceed if they suspected having contracted the SARS-CoV-2 virus. Three out of four athletes know they should either contact their doctors, or the NICD toll- free number for guidance. These findings underline the vital role and efficacy of high quality messaging in traditional and social media in a pandemic.
      Athletes are keen to RTS, and the majority of athletes are even prepared to do so behind closed doors.
      • Lillicrap S.
      Behind closed doors: what impact can these coronavirus hit games have on players?.
      However, one in three athletes were unsure when to RTS, possibly owing to global uncertainty about the pandemic, lack of communication by national and international federations and sport governing bodies. One out of two athletes were comfortable to RTS when advised, the other half was unsure or would not return. Established protocols, risk mitigation strategies, guidance from sports federations and government following international trends, and financial support from federations and/or provision of protective equipment were some of the requirements identified by the athletes. Continuous athlete education to promote required behaviours, preparing the environment and health screening to evaluate COVID-19 status prior to RTS is needed.
      • Hughes D.
      • Saw R.
      • Perera N.K.P.
      • et al.
      The Australian Institute of sport framework for rebooting sport in a COVID-19 environment.
      Physiological readiness to RTS should include re-evaluating weight, blood pressure, liver function, glucose, glycated haemoglobin and lipid profiles.
      • Varaeva Y.R.
      • Livantsova E.N.
      • Polenova N.V.
      • et al.
      Characteristics of blood lipid profiles of professional athletes: a literature review.
      Then a stepwise and sport-specific return to training, synchronised with the expected gradual lifting of restrictions of movement and social distancing is advised.
      • Hughes D.
      • Saw R.
      • Perera N.K.P.
      • et al.
      The Australian Institute of sport framework for rebooting sport in a COVID-19 environment.
      High load, training load fluctuations that negatively impact acute:chronic load ratios are known injury risk factors.
      • Aicale R.
      • Tarantino D.
      • Maffulli N.
      Overuse injuries in sport: a comprehensive overview.
      • Maupin D.
      • Schram B.
      • Canetti E.
      • et al.
      The relationship between acute: chronic workload ratios and injury risk in sports: a systematic review.
      Accelerated RTS after the lockdown of NFL athletes in 2011, subsequently lead to high injury rates.
      • Myer G.D.
      • Faigenbaum A.D.
      • Cherny C.E.
      • et al.
      Did the NFL lockout expose the Achilles heel of competitive sports?.
      Ongoing monitoring of training loads, injury and illness upon RTS and addressing any deficits regarding the level of conditioning, strength, proprioception, neuromuscular activation and sport-specific conditioning following this period of lockdown, is recommended.
      • Soligard T.
      • Schwellnus M.
      • Alonso J.-M.
      • et al.
      How much is too much? (Part 1) International Olympic Committee consensus statement on load in sport and risk of injury.
      • Gabbett T.J.
      The training – injury prevention paradox: should athletes be training smarter and harder?.
      • Carmody S.
      • Borodina M.A.
      • Gouttebarge M.
      • et al.
      When can professional sport recommence safely during the COVID-19 pandemic? Risk assessment and factors to consider.
      Further, nutrition, sleep, mental and general health issues related to restriction of movement should be addressed
      • Soligard T.
      • Schwellnus M.
      • Alonso J.-M.
      • et al.
      How much is too much? (Part 1) International Olympic Committee consensus statement on load in sport and risk of injury.
      • Gabbett T.J.
      The training – injury prevention paradox: should athletes be training smarter and harder?.
      • Carmody S.
      • Borodina M.A.
      • Gouttebarge M.
      • et al.
      When can professional sport recommence safely during the COVID-19 pandemic? Risk assessment and factors to consider.
      and supported through the RTS process.

      AIS Whitepaper on load, Prescription of training load in relation to loading and unloading phases of training. Executive Summary, Version 1, 4 May 2015, 2020. Available at: http://runpure.com.au/wp- content/uploads/2016/02/AIS_White_paper_- _Loads_and_risks_following_troughs250615.pdf.

      It is also important to control the possible spreading of the virus during RTS, as well as managing the progress of the pandemic by early detection and management of new cases in the sports community to mitigate a second wave.
      • COVID-19 and Sporting Activity
      AIS framework for rebooting sport.
      • Hughes D.
      • Saw R.
      • Perera N.K.P.
      • et al.
      The Australian Institute of sport framework for rebooting sport in a COVID-19 environment.
      The majority of our study participants were males, with the sex distribution of our participants being representative of the current South African athlete population.

      Eminent Persons Group on Transformation in Sport (EPG), Sport transformation status report. A comparative & sport code specific assessment & introduction to school sport structure, Published by the Department of Sport & Recreation, South Africa, 2016/2017. Available at: https://www.srsa.gov.za/sites/default/files/Transformation %20Status%20Report%20-%202016-2017%20EPG%20-FINAL.pdf.

      Convenience sampling was used and team sports were overrepresented, thus the findings may not be generalisable to individual sports. We did not require athletes to report pre-lockdown sleep patterns, mental status or supplement use thus findings cannot be comparable to pre-lockdown habits. We did not specifically differentiate between guided or unguided training programmes, even though there was an option to indicate guidance by professionals. The study was open for only 72 h and may have limited the response rate. This short access period was necessary to allow timely data analyses and planning of implementation measures and advice before RTS. Additionally owing to availability of resources, we were unable to verify the level of evidence of websites, social media platforms or other sources of information used by athletes. We also did not specifically ask why athletes opted for advice from non-medical experts or how finances were affected.

      5. Conclusion

      COVID-19 has significant physical and mental effects on athletes including physical deconditioning, altered sleep patterns, worsening nutrition, uncertainty on RTS and feelings of depression. Athletes are well informed on the COVID-19 disease, however, the need remains to provide them with easy access to reliable evidence-based resources. Closer medical, nutritional and psychological support during and after the lockdown is recommended. Further, lost opportunities and uncertain financial and sporting futures may have long-lasting effects on both athletes and the sports industry. Re-adjustment to normal life and RTS will undoubtedly be challenging. Even though the international focus seems to be on RTS, this study shows that there are many other lifestyle challenges needing to be overcome prior to returning to a pre-COVID-19 normality. Governments and sporting federations should develop and implement regional and sport-specific evidence-based guidelines for safe RTS in a COVID-19 environment to minimise risk of community transmission and preserve public health.

      Funding

      No funding received.

      Authors’ contribution

      LP: responsible for the overall content as guarantor, study concept, study planning, data collection, content contribution, data interpretation, manuscript (first draft), manuscript editing. DCJvR: study planning, manuscript planning, content contribution, data interpretation, manuscript (first draft), manuscript editing. AJvR: manuscript planning, content contribution, data interpretation, manuscript (first draft), manuscript editing. DAR: data interpretation, manuscript (first draft), manuscript editing. LH: data interpretation, manuscript (first draft), manuscript editing. HPD: data interpretation, manuscript (first draft), manuscript editing. TC: manuscript planning, data analysis including statistical analysis, data interpretation, manuscript editing.

      Conflict of interest

      The authors report no conflict of interest pertaining to this manuscript.

      Data sharing statement

      No additional data are available.

      Acknowledgements

      The authors made available all contact numbers and data-free websites for the DOH, NICD as well as several pharmaceutical and private based companies providing telephonic support for depression.
      The authors would like to thank the following medical colleagues, athletes and sport administrators for distributing the survey: Dr Kevin Subbhan, Cheryl Roos, Zac van Heerden, Lance Stevens, Belinda Waghorn, Denise Polson, Calvin Shipley, Nick Brink, Josh Smith, Tim Vadachallam, Denis Riehbok, Kelvin Ndhlomo, John Williams, Warren Engelbrecht, Kutlwano Molefe, Christy Cronin, Neline Hoffman, Bernadette Costons, Rayno Rayepen, Dr Janesh Ganda, Fanie de Klerk, Dr Abdullah Moola, Elana Meyer, Nolene ConradJacques Durand, Steven Ball, Marianne Viljoen, Jason Fyfer, Setty Ndaba, Siphesihle Mthembu, Non Pongolo, Ryan Rickelton, Mangaliso Mosehle, Nolene Conrad, Rene Kalmer, Raisibe Ntokizane, Craig Cynkin, Shannon Naidoo, Granald Scott, Rooi Mahamutsa, Ludwe Mpakupaku.
      The authors would like to express their gratitude to Mrs Madeleen Scheepers for the upload of all publications to Endnote library.

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