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ORIGINAL RESEARCH
published: 09 April 2021
doi: 10.3389/fpubh.2021.643640
Frontiers in Public Health | www.frontiersin.org 1April 2021 | Volume 9 | Article 643640
Edited by:
Marcia G. Ory,
Texas A&M University, United States
Reviewed by:
Aya Yoshikawa,
Texas A&M University, United States
Andiara Schwingel,
University of Illinois at
Urbana–Champaign, United States
*Correspondence:
Monica R. Perracini
monica.perracini@unicid.edu.br
Specialty section:
This article was submitted to
Aging and Public Health,
a section of the journal
Frontiers in Public Health
Received: 18 December 2020
Accepted: 11 March 2021
Published: 09 April 2021
Citation:
Perracini MR, de Amorim JSC,
Lima CA, da Silva A,
Trombini-Souza F, Pereira DS,
Pelicioni PHS, Duim E, Batista PP, dos
Santos RB, de Lima MdCC and the
REMOBILIZE Research Network
(CANSORT-SCI) (2021) Impact of
COVID-19 Pandemic on Life-Space
Mobility of Older Adults Living in Brazil:
REMOBILIZE Study.
Front. Public Health 9:643640.
doi: 10.3389/fpubh.2021.643640
Impact of COVID-19 Pandemic on
Life-Space Mobility of Older Adults
Living in Brazil: REMOBILIZE Study
Monica R. Perracini 1,2
*, Juleimar Soares Coelho de Amorim 3, Camila Astolphi Lima 1,
Alexandre da Silva 4, Francis Trombini-Souza 5, Daniele Sirineu Pereira 6,
Paulo Henrique Silva Pelicioni 7, Etiene Duim 8, Patricia Parreira Batista 6,
Renato Barbosa dos Santos 1, Maria do Carmo Correia de Lima 2and
the REMOBILIZE Research Network (CANSORT-SCI)
1Master’s and Doctoral Program in Physical Therapy, Universidade Cidade de São Paulo, São Paulo, Brazil, 2Master’s and
Doctoral Programs in Gerontology, Faculty of Medical Sciences, Universidade Estadual de Campinas, Campinas, Brazil,
3Physiotherapy Undergraduate Program, Instituto Federal do Rio de Janeiro, Rio de Janeiro, Brazil, 4Department of Collective
Health, Faculdade de Medicina de Jundiaí, Jundiaí, Brazil, 5Master’s and Doctoral Program in Rehabilitation and Functional
Performance, Universidade de Pernambuco, Petrolina, Brazil, 6Department of Physical Therapy, Universidade Federal de
Minas Gerais, Belo Horizonte, Brazil, 7Division of Health Sciences, School of Physiotherapy, University of Otago, Dunedin,
New Zealand, 8Department of Diagnostic and Ambulatory Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
Background: The COVID-19 pandemic hit Brazil in a scenario of substantial
socioeconomic and health inequalities. It is unknown the immediate impact of social
restriction recommendations (i.e., lockdown, stay-at-home) on the life-space mobility of
older people.
Objective: To investigate the immediate impact of COVID-19 pandemic on
life-space mobility of community-dwelling Brazilian older adults and examine the social
determinants of health associated with change in life-space mobility.
Design: Baseline data from a prospective cohort study (REMOBILIZE Study).
Setting: Community.
Subject: A convenience snowball sample of participants aged 60 and older (n=1,482)
living in 22 states in Brazil.
Methods: We conducted an online and phone survey using an adapted version of the
Life-Space Assessment (LSA). Linear regression models were used to investigate social
determinants of health on the change in LSA score.
Results: Regardless of their gender and social determinants of health, participants
showed a significant reduction in life-space mobility since COVID-19 pandemic outbreak.
Life-space mobility reduction was higher among black individuals, those living alone and
aged between 70 and 79. Other variables associated with change in life-space mobility,
to a lesser extent, were sex, education and income.
Conclusion: Social restriction measures due to pandemic caused substantial reduction
in older adults’ life-space mobility in Brazil. Social inequalities strongly affected vulnerable
groups. Concerted actions should be put in place to overcome the deterioration
in life-pace mobility amongst these groups. Failure in minimizing health inequalities
amplified by the pandemic may jeopardize the desired achievements of the Decade of
Healthy Aging.
Keywords: participation, COVID-19, social distancing, health status disparities, well-being
Perracini et al. Impact of COVID-19 Pandemic on Life-Space Mobility
INTRODUCTION
Experts agree that older people are the group most affected
by the COVID-19 pandemic (1,2). Worldwide, more than
66% of adults aged 70 years and over have underlying
conditions and are at higher risk for severe disease, which
may result in hospitalization and death (3). Social restriction
recommendations (i.e., lockdowns, social distancing, stay-at-
home orders) have been set up as population-level measures to
suppress community transmission of COVID-19 (4). Although
these measures were adopted worldwide, how different groups
of older people adapted their life-space mobility to these new
circumstances (5) is still uncertain. Varying housing conditions,
social inequalities, and governments’ response policies may have
affected how older people moved around since the COVID-19
pandemic (6–8).
Life-space mobility is not a new concept (9); it corresponds
to how people engage in, maintain social relationships and
roles, and participate in meaningful activities within their
communities (10). It is recognized as a practical measure
to capture older people’s functional ability for moving
around in their environments in a specific period of time
(11). Restriction of life-space mobility occurs due to a
combination of losses in individuals’ intrinsic capacity,
limited personal resources, and difficulty dealing with
environmental challenges, resulting in potentially health
adverse outcomes (9).
Restrictions in life-space mobility (12,13) and in active
aging scores (12) were observed in community-dwelling older
people during the COVID-19 pandemic. Active aging was
evaluated using a novel scale that encompasses older people’s
striving for well-being through activities pertaining to their
goals, abilities, and opportunities (14). Declines in life-space
mobility and active aging unsurprisingly coincided, since social
restriction policies may have reduced opportunities for several
out-of-home activities (12).
Foreseen consequences of constriction in life-space mobility
observed in previous studies are decreased levels of physical
activity (15,16), higher prevalence of depressive symptoms (17),
cognitive decline (18,19), poor physical capacity (11), obesity
(6), and increased risk for developing frailty (9). Particularly,
inactivity related to deconditioning (20,21) increases the risk of
health deterioration associated with chronic non-communicable
diseases (21,22) and may accelerate the loss of muscle mass
and muscle strength, along with the accumulation of body fat.
Ultimately, inactivity results in poorer overall health (23).
Social inequalities may contribute to the negative impact
of social restriction recommendations on life-space mobility
since COVID-19 pandemic, particularly for older people
living in low-resource settings (24). Previous studies have
shown that lower life-space mobility scores were associated
with female sex, low educational level, insufficient income
(6,7,11), and poor physical and social environments (7).
Underlying inequalities of gender, race/ethnicity, income,
and residential segregation may expose vulnerable groups
of older people to negative consequences of the COVID-19
pandemic (25).
Our hypothesis is that levels of life-space mobility throughout
the pandemic will exhibit different trajectories according to
social determinants. Investigating how social factors influence
life-space mobility in this unique period can help to develop
interventions needed to deal with the deleterious effects of the
COVID-19 pandemic on health systems, individuals, and their
families (20,26,27). Therefore, this study (i) investigated the
immediate impacts of COVID-19 pandemic on the life-space
mobility of community-dwelling Brazilian older adults; and (ii)
examined the social determinants of health associated with
change in life-space mobility.
METHODS
Study Design, Setting, and Participants
We used baseline data from the REMOBILIZE study, which
involved a cohort survey to investigate life-space mobility
throughout the course of the COVID-19 pandemic and used a
task-force research network for a 12-month follow-up period.
We surveyed a convenience snowball sample of older adults aged
60 and older (n=1,482) living in 22 (82%) states in Brazil,
using the online platform SurveyMonkey R
. We used social
media (Facebook R
and Instagram R
) and WhatsApp R
to recruit
participants. A website was set up to reinforce the legitimacy
of the study and to provide a central address for respondents
to contact the research team. We contacted community leaders
and allied health professionals working in vulnerable regions to
include participants with different educational and income levels,
ethnicities, and genders. We excluded bedridden participants
and older adults living in long-term care facilities. Older adults
with cognitive decline or who were unable to answer interview
questions due to visual or other difficulties, such as digital
illiteracy, were helped by a proxy—either a family, friend,
or formal caregiver. We conducted data collection between
May 18th, 2020 and July 4th, 2020, and participants took
approximately 30 min to complete the survey.
The Ethical Research Committee of Universidade Cidade de
São Paulo approved all research procedures (protocol number
4.032.523). A consent form was included in the online survey
questionnaire as well as given in interviews conducted by
telephone. Participants consented or declined to participate in the
study by selecting an on-screen button.
Measures
Life-Space Mobility
Life-space mobility was assessed using a Brazilian Portuguese
version of the Life-Space Assessment (LSA; (28). The LSA
comprises five life-space levels: (1) rooms other than the
bedroom, (2) areas outside the house (i.e., porch, deck, yard,
hallway of an apartment building or garage), (3) neighborhood
other than own yard or apartment building, (4) outside the
neighborhood, but within town; and (5) places outside one’s
own town.
At the baseline, participants were asked about the places
they reached both before the COVID-19 pandemic and a week
before evaluation (since the pandemic period). For each level,
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Perracini et al. Impact of COVID-19 Pandemic on Life-Space Mobility
participants were asked how often within the week they attained
that level (less than once a week, one to three times a week,
four to six times a week, or daily) and whether they needed any
help to move to that level (without assistive device or assistance,
with an assistive device, or with personal assistance). In the
original instrument, displacement is evaluated in the previous 4
weeks, and the respondent is asked to appraise how many times
a week he/she attained that place. As most participants in our
study answered the questionnaire online without the assistance
of an interviewer, we chose to ask about the last week to avoid
misinterpretation. Life-space mobility questionnaires have been
applied in different timeframes according to specific populations
and circumstances (9,29).
A composite score is calculated by multiplying each life-space
level reached by the degree of independence and frequency (30).
Score range from 0 to 120 points; higher scores represent greater
mobility in space (11,28). The original instrument demonstrated
a reproducibility of 0.97 (95% CI 0.95–0.98). A moderate negative
correlation between LSA scores and accelerometry was observed
(−0.63, 95% CI −0.74–−0.40) (28).
Social Factors and Comorbidities
Independent variables were gender, age group (60–69, 70–79, and
≥80 years), self-report of skin color/race/ethnicity categorized
according to official Brazilian classification (white, black, pardo,
amarelo, or indigenous), marital status (single, married, divorced,
widowed), and education level (illiterate, 1–4 years, 5–8 years,
and ≥9 years of schooling), living alone (yes/no), income
level presented as the minimum wage per month guaranteed
by law in Brazil (<1, 2–3, 4–7, 8–10, and >10 minimum
wage salaries), employment (active, inactive, or unemployed),
receiving pension (yes/no), and reported comorbidities using
the Functional Comorbidity Index (FCI) questionnaire (31).
The FCI is composed of 18 comorbidities related mainly to
physical function. Comorbidities were summed up, and older
adults with two or more diseases were considered to have
multimorbidity (32).
Reported Social Restriction
Adherence to social restriction measures was captured using
a five-point Likert scale question: “Do you think you are
following the recommendations for social restriction measures?”
Possible responses were strongly agree, partially agree,
indifferent, partially disagree, and totally disagree. We also
asked participants, “What best describes you at this moment?”
Possible responses were “living a normal life, nothing has
changed in my daily routine;” “being careful, but going out for
work, visiting family members or other activities;” “going out
FIGURE 1 | Study flowchart.
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Perracini et al. Impact of COVID-19 Pandemic on Life-Space Mobility
TABLE 1 | Social determinants, multimorbidity and responses to social restriction
measures among community-dwelling older people between May and
July 2020 (33).
Characteristic N=1,482 (%)
Female Gender 1,096 (73.9)
Age groups (years)
60–69 831 (56.1)
70–79 420 (28.4)
80 and over 229 (15.5)
Ethnicity
White 915 (61.7)
Black 100 (6.8)
“Pardo” 439 (29.6)
“Amarelo” 23 (1.6)
Indigineous 5 (0.3)
Marital status
Single 152 (10.3)
Married 796 (53.7)
Divorced 184 (12.4)
Widowed 350 (23.6)
Living alone 256 (17.3)
Educational level (years of schooling)
Illiterate 117 (7.9)
1–4 282 (19.0)
5–8 181 (12.2)
9 or more 902 (60.9)
Income (minimum wage salary)a
<1 512 (34.5)
2–3 413 (27.9)
4–7 267 (18.1)
8–10 114 (7.7)
10 or more 176 (11.9)
Employment
Active 545 (36.8)
Inactive 836 (56.4)
Unemployed 101 (6.8)
Pension (yes) 1,215 (82.0)
Multimorbidity (two or more)b841 (56.8)
Following social restriction measures
Strongly and partially disagree 47 (3.2)
Partially agree 201 (13.6)
Totally agree 1,234 (83.3)
Social restriction behavior since pandemic
Living without any routine
change
42 (2.8)
Being careful, but leaving home
to work and visit relatives
169 (11.4)
Leaving home for unavoidable
matters (e.g., groceries,
pharmacy)
693 (46.8)
Restricted at home, but
receiving visits (relatives,
friends, deliveries)
132 (8.9)
Restricted at home and not
receiving visits
432 (29.1)
(Continued)
TABLE 1 | Continued
Characteristic N=1,482 (%)
Going out for a walk, as
exercise
8 (0.5)
missing data 6 (0.4)
aBrazilian minimum wage salary 1,045.00 BRL (corresponding to 189.3 USD; 1st May
2020) bMultimorbidity included stroke, Parkinson’s disease, arthritis, osteoporosis, urinary
and fecal incontinence, acute myocardial infarction, intestinal and depressive disease,
anxiety, visual and hearing impairment, spine, overweight, hypertension and dizziness.
only when it is inevitable, such as for food supplies, health-related
appointments, or to the drugstore;” “I have been receiving family
members, friends, and delivery services;” “completely isolated,
not going out at all;” “going out just for walking/jogging;”
and “other.”
Data Storage and Availability
The raw data from the baseline survey were exported from
the SurveyMonkey R
platform. During this stage, incomplete
questionnaires were identified and excluded. Two independent
researchers checked the complete submissions to search for
possible duplicates or inconsistent data, such as missing consent
or date of birth, bedridden status, and residents of long-term
care facilities. Searches for zip codes were also conducted. A final
anonymized data set was created with all eligible participants. We
used only cases for which the full information for all variables
of interest for the present study was available. The variables in
this dataset have not been recoded or imputed. The data and
codebook are available at: https://datadryad.org/stash/share/Rj8_
jEF6Tg40YBJolay_Hymqn_Azh3QedL1mPQX9kyg.
Statistical Analyses
Descriptive analyses were performed, both for the total sample
and based on the investigated outcomes, using proportions and
means (and standard deviation). LSA scores before and since
the COVID-19 pandemic were computed for each level (home,
outside home, neighborhood, town, and beyond town), and for
the composite score. The difference in total scores before and
since pandemic was presented as a delta (1LSA). We verified
whether the data set (LSA score and 1LSA) in each group
analyzed had a normal distribution using the Shapiro-Wilk test.
We used the non-parametric Wilcoxon test for paired data to
compare the composite score, the score for each level, and
the delta score. Univariate analysis of the associations between
independent variables and changes in LSA scores was evaluated
by Wilcoxon signed-rank (dichotomous variables) and Kruskal-
Wallis tests (categorical variables).
To examine whether social determinants were associated with
the 1LSA, we used crude and adjusted multiple linear regression
analyses. Social factors, comorbidities, and adherence to social
restriction were selected as multivariate adjusted model variables.
A backward stepwise method was used to obtain the final
model. The results of multiple linear regression are reported as
regression coefficients (β) and 95% confidence intervals (95% CI).
We evaluated the adequacy of the model by a set of statistics. The
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Perracini et al. Impact of COVID-19 Pandemic on Life-Space Mobility
statistics’ adjusted R2scores were used to verify the percentage
of variance related to the decrease in 1LSA explained by
the model. The Durbin-Watson statistic was used to verify the
assumption that the residuals were not correlated. We also tested
for multicollinearity in the final model, according to variance
inflation factors (VIF >1.10). To evaluate whether the residuals
had a normal distribution, the following graphs were performed:
standardized regression residuals by standardized regression-
predicted values, histogram of frequencies of standardized
regression residuals, and a quantiles-quantile graph (QQ plot).
Stata 14.0 (Stata Corporation LLC, College Station, TX) was
used for statistical analyses, and the level of statistical significance
was set at p<0.05.
RESULTS
After removing incomplete and duplicate questionnaires, 1,482
participants were included who provided all information
requested for the study (Figure 1). Seven hundred and ninety
nine respondents (53.9%) declared that they had answered the
questionnaire by themselves; 534 (36.0%) respondents had the
support of a family member, friend, or others to answer the
survey; and 149 (10.1%) respondents were proxies.
Mean age was 70.0 (SD 8.14) years old. Seventy three
point nine percentage were women, 53.7% were married, 61.7%
reported white ethnicity, and 60.9% had 9 or more years
of schooling. Approximately half of the participants reported
two or more diseases, and more than 80% totally agreed that
they were following social restriction measures. Participants’
sociodemographic characteristics, comorbidities, and reported
adherence to social restriction measures are described in Table 1.
The mean LSA score before the COVID-19 pandemic was 64.0
(SD 26.0) and mean LSA score since the pandemic was 37.8 (SD
22.1), and the 1was −26.2 (SD 25.0). A significant reduction was
observed in LSA scores from Level 2 up to Level 5 (p<0.001; see
Figure 2 and Table 2).
Table 3 shows mean life-space mobility scores for groups of
interest before and since the COVID-19 pandemic, as well as for
deltas. Pardo (mixed race) individuals had a significantly lower
LSA score (p<0.001) before the pandemic compared with white
individuals, and this situation persisted since the pandemic (p=
0.005). A smaller, but significant reduction in LSA (1LSA) (p
<0.001) was observed among pardo individuals compared with
white individuals. A reduction in life-space mobility (1LSA)
was observed among women compared with men (p<0.008),
among older adults aged between 60 and 69 and 70 and 79 years
compared with older adults aged 80 years and over (p<0.001),
among older people living alone (p<0.001), among individuals
with a high educational level (5 or more years of schooling) (p<
0.001), and among individuals with a high-income level (four or
more minimum wage salaries) (p<0.001).
Multiple linear regression showed the relationship between 1
LSA and explanatory variables (Table 4). There were significant
relationships between 1LSA and male sex (β=3.32, 95% CI
=0.33; 6.32), living alone (β= −3.75, 95% CI = −7.09; −0.41),
age between 70 and 79 years (β= −4.95, 95% CI = −9.13; −0.78;
ref. 80 years and over), black race/ethnicity (β= −7.76, 95% CI =
−13.14; −2.37; ref. pardo), having more than 4 years of schooling
(β=7.94, 95% CI =4.60; 11.28; ref. illiterate or 1–4 years), and
having an income of ≥4 minimum wage salaries (β=4.76, 95%
CI =1.77; 7.75; ref.<3 minimum wage salaries). The fit of the
regression equation found in the final model was [F(11,1,389) =
8.36, p<0.001], R2=0.055.
DISCUSSION
Our results showed significant changes in life-space mobility,
particularly outside of the home environment (in the
neighborhood, in the town, and beyond town). Nearly a
third of participants reported that they were completely
restricted at home and not receiving visits, and almost half
of participants were leaving home only when they needed
FIGURE 2 | Life-space mobility scores in each level before and since COVID-19 pandemic.
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Perracini et al. Impact of COVID-19 Pandemic on Life-Space Mobility
TABLE 2 | Life-space assessment (LSA) according to five levels of mobility among Brazilian older adults living in the community before and since COVID-19
pandemic (n=1,482) (33).
LSA levels and
life-space
Level 1
Home
Level 2
Outside home
Level 3
Neighborhood
Level 4
Town
Level 5
Beyond town
Total
Before pandemic
Mean (SD) 7.3 (1.6) 13.9 (4.1) 15.5 (8.5) 18.0 (10.7) 9.1 (10.2) 64.0 (26.0)
Yes (%) 1,459 (98.4) 1,432 (96.6) 1,294 (87.3) 1,320 (89.1) 888 (59.9) –
No (%) 23 (1.6) 50 (3.4) 188 (12.7) 162 (10.9) 594 (40.1) –
Frequency (%)
<1/week 22 (1.5) 42 (2.9) 125 (9.7) 248 (18.8) 559 (63.0) –
1–3/week 73 (5.0) 123 (8.6) 334 (25.8) 447 (33.8) 218 (24.5) –
4–6/week 51 (3.5) 92 (6.4) 209 (16.2) 224 (17.0) 49 (5.5) –
Daily 1,313 (90.0) 1,175 (82.1) 626 (48.4) 402 (30.4) 62 (7.0) –
Dependency (%)
Use of assistive devices 52 (3.6) 52 (3.6) 33 (2.6) 31 (2.3) 13 (1.5) –
Assistance of a person 40 (2.7) 45 (3.2) 54 (4.2) 81 (6.1) 59 (6.6) –
No use of devices or
need of assistance
1,367 (93.7) 1,335 (93.2) 1,207 (93.2) 1,209 (91.6) 816 (91.9) –
Since pandemic
Mean (SD) 7.3 (1.7) 12.8 (5.1) 7.7 (8.8) 7.9 (9.9) 2.0 (6.3) 37.8 (22.1)
Yes (%) 1,443 (97.4) 1,366 (92.2) 793 (53.5) 728 (49.1) 188 (12.7) –
No (%) 39 (2.6) 116 (7.8) 689 (46.5) 754 (50.9) 1,294 (87.3) –
Frequency (%)
<1/week 15 (1.0) 52 (3.8) 181 (22.8) 244 (33.5) 101 (53.7) –
1–3/week 66 (4.5) 180 (13.2) 298 (37.6) 316 (43.4) 63 (33.5) –
4–6/week 62 (4.2) 125 (9.2) 84 (10.6) 46 (6.3) 7 (3.7) –
Daily 1,300 (87.7) 1,009 (73.9) 230 (29.0) 122 (16.8) 17 (9.0) –
Dependency (%)
Use of assistive devices 43 (3.0) 42 (3.1) 12 (1.5) 8 (1.1) 0 (0.0) –
Assistance of a person 37 (2.6) 32 (2.3) 21 (2.6) 36 (4.9) 14 (7.4) –
No use of devices or
need of assistance
1,363 (94.5) 1,292 (94.6) 760 (95.8) 684 (94.0) 174 (92.6) –
p-valuea0.363 <0.001 <0.001 <0.001 <0.001 <0.001
LSA, Life-Space Assessment; SD, Standard deviation.
aWilcoxon test.
to get groceries or go to the pharmacy. Regardless of gender
and socioeconomic status, participants showed a reduction in
their life-space mobility since COVID-19 pandemic. However,
reductions in life-space mobility were higher among older
people living alone, those aged between 70 and 79 years
compared to older people aged 80 years old and over, and
black individuals compared to pardo individuals, exposing
underlying inequalities that might have been aggravated by
the pandemic.
We found post-pandemic reductions of around 20 points in
LSA scores. A score above 10 points is considered a marker of
poor health outcomes (12). Similar ranges of decline in life-space
mobility have been associated with future disability in performing
activities of daily living (>11.7 points (34), hospital admissions
(10.3–22.4 points; (35) and injurious falls (5–24 points; (34,36).
The continuous restriction in life-space mobility due to COVID-
19 might increase the risk of developing chronic conditions and
functional decline.
We found older adults who were male, who had a moderate
to high educational level, and who had a higher income
level enjoyed more life-space mobility compared to women,
individuals with lower educational and income levels. This can be
partly explained by the fact that compared to older women; older
men already had greater life-space mobility before the COVID-
19 pandemic. Older women are almost twice as likely not to
work in comparison to men (37); when working, women are
more frequently unpaid, doing activities such as caring for others,
home-based work, or domestic chores (38). Previous studies have
shown that women’s life-space mobility was more frequently
restricted (6,39). Possibly, the life-threatening situation of the
COVID-19 pandemic might have not alarmed older men. This
is particularly interesting because men were found twice as
likely to be at increased risk of severe COVID-19 in all age
groups (3). Men were possibly less concerned than women about
being contaminated and engaged in more risky activities (40).
Societal expectations such as the responsibility of being the family
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Perracini et al. Impact of COVID-19 Pandemic on Life-Space Mobility
TABLE 3 | Mean life-space mobility scores before and since COVID-19 pandemic and the 1LSA (before minus since COVID-19 pandemic) according to gender, social
determinants, multimorbidity and response to social restriction (n=1,482) (33).
Characteristic Mean LSA (SD)
Before
COVID-19
pandemic
p-valueaMean LSA (SD)
Since
COVID-19
pandemic
p-valueaMean 1LSA
(SD)
p-valuea
Gender <0.001 <0.001 0.008
Women 62.2 (25.7) 35.0 (20.0) −27.1 (24.9)
Men 69.3 (26.3) 46.0 (25.8) −23.2 (25.2)
Age group (years)
60–69 70.1 (24.0) <0.001 42.8 (22.6) <0.001 −27.3 (25.8) <0.001
70–79 63.2 (24.6) <0.001 36.2 (20.3) <0.001 −27.0 (24.4) <0.001
80 and over 43.4 (25.2) Ref. 23.5 (16.4) Ref. −19.9 (22.2) Ref.
Ethnicityb
White 67.0 (25.1) Ref. 39.4 (22.9) Ref. −27.6 (24.9) Ref.
Black 64.6 (26.0) 0.389 34.5 (20.5) 0.038 −30.1 (25.2) 0.341
“Pardo” 58.1 (27.0) <0.001 35.8 (20.7) 0.005 −22.3 (24.7) <0.001
Marital Status <0.001 <0.001 0.582
Single/Divorced/Widowed 66.6 (24.5) 40.9 (22.6) −25.8 (24.9)
Married 61.0 (27.4) 34.5 (21.1) −26.5 (25.0)
Living alone <0.001 0.476 <0.001
Yes 69.3 (25.9) 39.0 (23.0) −30.7 (26.5)
No 63.1 (25.8) 37.9 (22.1) −25.1 (24.6)
Educational level <0.001 <0.001 <0.001
Low (illiterate or 1–4
years of schooling)
50.3 (24.7) 32.5 (20.7) −17.9 (21.0)
High (5–8/9 or more) 69.1 (24.7) 39.9 (22.3) −29.2 (25.7)
Income (minimum wage
salaries) c
<0.001 <0.001 <0.001
<1/2–3 58.6 (25.9) 35.8 (21.1) −22.9 (23.7)
4–7/8–10/10 or more 73.0 (23.9) 41.5 (23.4) −31.5 (26.1)
Occupation <0.001 <0.001 0.232
Active 72.6 (24.0) 45.5 (23.3) −27.1 (27.0)
Inactive/Unemployed 59.0 (25.9) 33.5 (20.2) −25.5 (23.7)
Multimorbidity (two or
more) d
<0.001 <0.001 0.656
0–1 69.9 (24.3) 43.5 (23.5) −26.4 (25.9)
two or more 59.5 (26.5) 33.7 (20.1) −25.8 (24.2)
Social restriction
measures
0.822 0.026 0.082
Totally and partially
agree and indifferent
64.0 (26.1) 37.7 (22.0) −26.3 (25.1)
Totally and partially
disagree
64.9 (25.8) 45.0 (25.2) −19.9 (22.2)
LSA, Life-Space Assessment; 1LSA is the difference in composite scores of LSA before and since pandemic; SD, Standard deviation; aWilcoxon signed-rank and Kurskal-Wallis
test. b“Amarelo” and Indigenous categories were treated as missing due to the low distribution in the sample. cBrazilian minimum wage salary 1,045.00 BRL (corresponding to 189.3
USD; 1st May 2020). dMultimorbidity included stroke, Parkinson’s disease, arthritis, osteoporosis, urinary and fecal incontinence, acute myocardial infarction, intestinal and depressive
disease, anxiety, visual and hearing impairment, spine, overweight, hypertension and dizziness.
provider, a sense of invulnerability, and misleading messages
from the government may have contributed to these behaviors.
However, these conjectural explanations may be sample-biased
due to the reduced number of men who participated in the
current study (26.1%).
Compared with older adults aged 80 and older, participants
aged between 70 and 79 years experienced a greater reduction in
life-space mobility, but people between 60 and 69 years did not.
In our study, among women and men aged 60–69 years old, 42
and 65% reported actively working compared to 24% of women
and 40% of men aged between 70 and 79 years (p<0.001).
This in part might explain why this age group did not experience
substantially reduced life-space mobility. Our data also revealed
that multimorbidity was more prevalent among individuals
aged 80 and over (92%) and aged between 70 and 79 (86%)
compared with individuals aged between 60 and 69 years old
Frontiers in Public Health | www.frontiersin.org 7April 2021 | Volume 9 | Article 643640
Perracini et al. Impact of COVID-19 Pandemic on Life-Space Mobility
TABLE 4 | Linear regression analyses to identify the association between 1LSA (Life-space mobility) and gender, social determinants, multimorbidity and response to
social restriction measures (n=1,482) (33).
Characteristic Model crude Model adjusted
βcrude 95% IC βadjusted 95% IC
Gender, men (ref.: women) 3.92 1.02; 6.81 3.32 0.33; 6.32
Age group (ref.: 80 years and over)
60–69 years −7.43 −11.07; −3.79 3.11 −7.12; 0.92
70–79 years −7.14 −11.15; −3.79 –4.95 –9.13; –0. 78
Ethnicitya(ref: “pardo”)
White −5.25 −8.08; −2.41 −1.96 −4.91; 1.00
Black −7.70 −13.11; −2.29 –7.76 –13.14; –2.37
Living alone −5.14 −8.46; −1.82 –3.75 –7.09; –0.41
Complete years of schooling >4 years (ref.: Illiterate or 1–4) 11.30 8.48; 14.11 7.94 4.60; 11.28
Income ≥4 minimum wage salaries (ref.: <3) 8.59 5.99; 11.18 4.76 1.77; 7.75
Occupation active (ref.: inactive/unemployed) −1.61 −4.25; 1.03 0.57 −2.23; 3.37
Multimorbidityb0–1 (ref.: two or more) −0.58 −3.16; −1.99 −1.12 −1.53; 3.78
Social restriction measures (total and partial disagree and
indifferent) (ref.: total and partial agree)
6.44 −0.83; 13.70 3.34 −4.00; 10.69
Adjusted R2=0.0546; F11,1389 =8.36, df =11 of 24; p <0.001. β, standardized regression coefficient; CI, confidence interval.
aAs “Amarelo” and Indigenous categories were treated as missing due to the low distribution in the sample. bMultimorbidity included stroke, Parkinson, arthritis, osteoporosis, urinary
and fecal incontinence, acute myocardial infarction, intestinal and depressive disease, anxiety, visual and hearing impairment, spine, overweight, hypertension and dizziness.
Model adjusted for sex, age, race, living alone, schooling, income, occupation, multimorbidity, and response to social restriction measures (e.g., lockdown, stay-at-home recommend).
(80%; p<0.001). Common reported health conditions that were
more prevalent with increasing age were diabetes, hypertension,
congestive heart failure, hearing loss, urinary incontinence, and
dizziness. Being more vulnerable to severe COVID-19 might
have alarmed the oldest individuals and discouraged them from
moving around.
Higher reductions in life-space mobility were observed
among black individuals compared to older pardo individuals.
Employment inequalities in this population might in part explain
this reduction. Approximately 70% of older adults in Brazil are
retired or pensioners, and 15.6% still work to supplement their
income (41). Insufficient income for daily expenses is more
frequently reported by black (50.3%) and pardo (51,1%) older
adults in Brazil compared with white older adults (38.6%; (42)),
pushing vulnerable populations to seek informal jobs. These jobs
were highly restricted during the early months of the COVID-
19 pandemic (i.e., informal market, street vending jobs, and
domestic jobs; (43) and this situation might have contributed for
the reduction of life-space among black individuals.
Systemic disadvantageous conditions, such as high health
illiteracy (44), poor health (multiple comorbidities), racism,
and poor housing conditions with many people of different
generations occupying the same spaces (42) may have influenced
how older black people coped with the social and economic
restrictions resulting from the pandemic. In our study, black and
pardo individuals had significantly lower incomes compared to
whites (74 vs. 79 vs. 53%; p<0.001, respectively) and were
also less educated (illiterate or 1–4 years of schooling: 39 vs.
40.5 vs. 19%; p<0.001, respectively). Low socioeconomic status
and physical inactivity during the pandemic combined with
underlying health conditions that are common in this population
may increase the risk of poor management of non-communicable
diseases, disability, and frailty. A population-based study in
Brazil showed a worse health pattern for black individuals, with
substantially higher prevalence ratios for hypertension, diabetes,
stroke, and cognitive decline (42).
Living alone was another social determinant that accounted
for a greater restriction in life-space mobility during COVID-
19. In Brazil, more than 4.3 million older people were living
alone before the pandemic (45), and nearly 60% were women
aged between 65 and 74 years (46). In the present study, 85% of
the participants who lived alone were women, and nearly 60%
were aged between 60 and 69 years. A Brazilian population-
based study of 11,967 older adults living alone confirmed a
higher prevalence of this household type among women and
showed that older people living alone more frequently reported
musculoskeletal conditions, hearing loss, falls, and limitations to
instrumental activities of daily living (47). Older people living
alone are more likely to face emergency department visits and to
have general practitioner appointments compared to older adults
living with others (48). Unmet basic needs, social isolation and
disruption of health services during the COVID-19 pandemic
might increase the risk of loneliness, malnutrition, and functional
decline (49). Older women in particular are at greater risk of
financial abuse and lack of care (50).
Older people with moderate to high educational levels and
higher income levels had greater life-space mobility scores before
the pandemic compared to the group with lower education
and income levels; for them, the impact of the COVID-19
pandemic contributed less to reduction in life-space mobility.
These groups were able to appraise health-related information
and use resources to adopt shielding strategies. Higher levels
of education and social status have been associated with higher
health literacy (51). However, it is also argued that higher
Frontiers in Public Health | www.frontiersin.org 8April 2021 | Volume 9 | Article 643640
Perracini et al. Impact of COVID-19 Pandemic on Life-Space Mobility
health literacy scores are associated with lower fear of COVID-
19 and lower likelihood of depression (51), which may have
influenced better educated older people to take risks. Having
a private vehicle for transportation and access to locations
outside urban centers might have increased the areas wealthy
older people moved around. Socioeconomic inequalities from
birth onward favor better health trajectories for individuals with
higher educational and income levels, and these gaps commonly
increase with age (52).
The implications of our findings are 2-fold. First, our
results underline the need to structure urgent comprehensive
responses to mitigate pandemic consequences among older
adults living alone, among black individuals, and for people
with lower income and education levels. Prioritized actions
should be set up urgently to assist these vulnerable groups in
the community, strengthening existing policies in the public
sector, particularly the Family Strategy Program in the National
Health Service (or SUS). In Brazil, the older population (more
than 80%) largely relies on public health care, and this
percentage is even higher among Afro-Brazilians and the poor
(53). Integrated person-centered care can include life-space
assessment and monitoring over time, helping service providers
and health care teams capture short- and long-term functional
consequences of the pandemic. The provision of long-term
care services at the national and subnational levels should also
be envisioned.
Second, innovative digital technologies should be envisioned
to scale up best-buy interventions, such as digital platforms
to deliver physical activity and rehabilitation programs (54).
Mobile apps that can track life-space mobility over time, creating
alerts for unusual reductions, are promising resources (55,56).
Digital technologies are increasingly important strategies for
engaging older people and for providing access to a wide range
of services. The use of digital technology has been increasing
annually among older people. In Brazil, the proportion of older
adults who access the Internet has increased from 24.7% in
2016 to 31.1% in 2017 (57), and about 80% of households
in the Southeast region have Internet access (58). However,
digital illiteracy and high costs to purchase mobile phones with
internet connection packages are still a greater barrier, affecting
the ability of low-income older people to use services that
are being required during the pandemic (59). Public-private
partnerships can ensure that services are available to these
groups to prevent further aggravation of health inequities during
COVID-19 pandemic.
The results of the present analysis have some limitations.
Some geographical regions of Brazil were less represented,
such as the south and central regions. However, the southeast
region, which is the most populated and contains a higher
proportion of older people, is well-represented in our sample.
Although we made efforts to reach vulnerable older adults
in some urban communities (i.e., slums), these areas may
be underrepresented, but face-to-face interviews were unsafe
for both participants and researchers during the COVID-19
pandemic. Recall bias is also possible, since the participants
self-reported their life-space mobility conditions before
COVID-19. We also cannot assume that the restriction
in life-space mobility that we observed is solely related
to the pandemic. Timing and intensity of the pandemic
might have influenced the reductions in life-space mobility.
Furthermore, we used a broad and general question to capture
adherence behavior to stay-at-home and social distancing
recommendations. That question alone might not be able
to capture all older adults’ views and experiences during
the pandemic.
Mobility concerning life spaces includes not only walking, but
also other modes of transport (e.g., subway, train, private vehicle,
or bus), particularly for moving beyond one’s neighborhood
(town and beyond town zones). Future studies should specifically
address restrictions on transportation during the pandemic,
which may have varied according to the sizes of cities, population
density, and regulatory policies determined by local governments
to deal with coronavirus transmission. Environmental barriers
and enablers inside the house and in the community also
require further studies. This study focuses on the first wave
of a cohort study and is cross-sectional, which limited causal
relations and the determinations of trajectories of life-space
mobility for different groups. We believe that the results of a
12-month follow-up will help to better understand the short-
and long-term impacts of the COVID-19 pandemic on life-
space mobility.
Social restriction measures due to a pandemic caused
substantial limitations in older adults’ life-space mobility in
Brazil. Social inequalities should be recognized, and concerted
action should be taken to overcome the deterioration in
life-space mobility among the most vulnerable groups
of older people. Worldwide, failure to minimize health
inequalities—amplified by the pandemic—may jeopardize
the desired achievements of the Decade of Healthy
Aging (60).
DATA AVAILABILITY STATEMENT
The datasets presented in this study can be found in online
repositories. The names of the repository/repositories
and accession number(s) can be found in the
article/supplementary material.
ETHICS STATEMENT
The studies involving human participants were reviewed and
approved by Ethics Committee of Universidade Cidade de São
Paulo (protocol number 4.032.523). The ethics committee waived
the requirement of written informed consent for participation.
AUTHOR CONTRIBUTIONS
MP participated in concept design, data collection, data analysis,
interpretation, drafting, critical revision, and approval of the
article. CL, ML, and RS participated in concept design, data
collection, data analysis, interpretation, critical revision, and
approval of the article. JA participated in data collection, data
analysis, interpretation, critical revision, and approval of the
Frontiers in Public Health | www.frontiersin.org 9April 2021 | Volume 9 | Article 643640
Perracini et al. Impact of COVID-19 Pandemic on Life-Space Mobility
article. AS, PP, FT-S, DP, and PB participated data collection,
interpretation, critical revision, and approval of the article. ED
participated interpretation, critical revision, and approval of the
article. All authors contributed to the article and approved the
submitted version.
FUNDING
MRP has received a researcher productivity grant
(309838/2017-7) from the Brazilian National Council for
Scientific and Technological Development.
CANSORT SCI AFFILIATIONS
Adriana Guedes Carlos, Professor Aurelio Dias Santos, Professor
Etiene Oliveira da Silva Fittipaldi, Professor Hércules Campos,
Professor Juliana Maria Gazzola, Dr. Mirian Moreira, Professor
Mônica Beatriz Ferreira, Nayara Tasse de Oliveira Cirino,
Professor Renata Oliveira Dantas, Renata dos Ramos Varanda,
Professor Suzana Albuquerque de Moraes, Professor Guilherme
Medeiros de Alvarenga, Professor Cristina Cristovão Ribeiro da
Silva, Sarah Giulia Bandeira Felipe and Professor Lygia Paccini
Lustosa (in memoriam).
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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.
Copyright © 2021 Perracini, de Amorim, Lima, da Silva, Trombini-Souza, Pereira,
Pelicioni, Duim, Batista, dos Santos, de Lima and the REMOBILIZE Research
Network (CANSORT-SCI). 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
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Frontiers in Public Health | www.frontiersin.org 11 April 2021 | Volume 9 | Article 643640
