4. Discussion
To our knowledge, this is the first study examining the effects of COVID-19 on movement behaviors among children aged 1 to 5 years. We found that all movement behaviors changed across all ages, reflecting important secondary detrimental effects from this pandemic. The most common sociodemographic predictors of movement behaviors change during the COVID-19 pandemic were age, main caregiver’s sex, age, and education, family income, previous enrolment in an ECEC, dwelling type, available space to play, and type of residence area (urban/rural).
This is also the first known study in Chile that examined all three components of the 24-h movement behaviors in toddlers and preschoolers. A novel finding was that children from poorer families were more physically active than those in more affluent or educated families during the pandemic. This finding is different from that commonly observed in Chilean children and adolescents [16,17]. It is plausible that those caregivers were less likely to work from home under lockdown and kept more “normal” routines with their families, while those children may have had more freedom to play indoors and less demand to stay quiet during working hours. Also, having space to play at home was consistently related to healthier levels in all movement behaviors both before and during the pandemic. This finding reinforces the need for ensuring spaces for children at home and surrounding areas to play as this is likely to promote these behaviors not only during the pandemic but also in the return to a “new normal”. In Chile, specific content was developed for promoting physical activity through social media and national TV (since the 27 April 2020) as a response to the pandemic [18,19], and an expert committee on physical activity was installed by the Ministries of Sports, Health, and Education to inform, adapt and add physical activity content into the curriculum of the classes delivered remotely in this context [20]. Nevertheless, the lockdown measures did not allow people to participate in physical activity outdoors and most public parks were still closed during the period included in our study [3], with few councils prioritizing pedestrian zones to favor physical distancing [21]. These opposing strategies where on one hand physical activity is promoted indoors while at the same time it is severely restricted outdoors need to be periodically revised and aligned with the latest evidence, so health impairing over-restrictions are prevented.
Preschoolers were the most affected by the restrictions during the pandemic, particularly for physical activity and recreational screen time. This may be explained by preschoolers needing more space to play and having greater access to screen-based devices than toddlers. The reduction in physical activity and the increase in screen time have particularly affected those with previous enrolment in an ECEC. Schools would be in a better position to respond with specific actions to prevent physical inactivity during this period than ECECs, as children and adolescents are more likely to be connected to participate in their virtual school activities than toddlers and preschoolers. Therefore, governments, policymakers, and professionals should devote particular attention to this age group.
Our results suggest that more educated parents tend to restrict their children’s physical activity more, while at the same time may provide more opportunities to engage in screen-based behaviors. This is an interesting finding as, before the pandemic, children with more educated caregivers tended to engage less with screen-based devices than children with less-educated parents. This may be partially explained as more educated caregivers may have to work from home, and this, in turn, may require the caregiver to use screens to entertain their child while working from home. This may be even more complicated in families living in apartments, one of the strongest predictors of declines in physical activity and increases of screen time observed in this study during the pandemic. This finding has implications for urban planning. As the full impact of COVID-19 is uncertain and other pandemics may occur, upgrading substandard areas that are currently plenty of small social apartments with insufficient recreational public spaces should be considered, together with stronger regulation, as part of a plan to build healthier and more resilient cities. Undoubtedly, families and caregivers play a key role in facilitating movement behaviors of toddlers and preschoolers, but some political actions such as allowing specific time for those residing in apartments to go outside with their family may boost the process. Some caregivers and family characteristics (caregiver’s sex and age, number of people and children per home) were also associated with changes in movement behaviors during the pandemic, so strategies should consider messages and actions for the entire family group, particularly small families and those whose main caregivers are aged 35 and older [22].
Overall, sleep quality worsened, but children with higher family income and less crowded homes showed less marked declines. This aspect may reflect other social issues that are not captured in this study that are related to the economic situation in Chile [23]. The decrease in sleep quality has also been described in a study conducted in Italy in children aged 3 to 6 during the early stages of the pandemic; however, after two weeks of follow-up, this decline plateaued [24]. Some key messages to promote healthy sleep duration and quality, such as creating a bedtime routine and avoiding screens before sleep should be regularly disseminated and reinforced; and particularly tailored to low-income families [4,6,25].
Having space to play at home was the most consistent factor in the home environment predicting changes in movement behaviors. A novel finding from our study is that the play space was not only important for physical activity and screen time but also had an impact on sleep quality. This is particularly important as this association reinforce the call from the World Health Organization for focusing on the interaction of all three behaviors as they benefit each other [6]. Therefore, strategies originally thought for promoting active playing at home or surroundings may impact sleep, and this, in turn, may benefit the whole home environment. Another relevant factor that resulted in healthier changes in physical activity and screen time was living in a rural area. Recent studies conducted during the COVID-19 pandemic in children and adolescents have also reported that rurality is an important correlate of movement behaviors [26,27]. A study conducted in Croatia reported that the decrease in physical activity was more evident in adolescents living in urban areas than it was in those from rural areas [26]. For children living in Canada, factors such as living in an apartment and the proximity to major roads were barriers to engage in outdoor activities [27]. Also, adolescents spent more time outdoor if they lived in a low-density area and had access to parks in high-density neighborhoods [28]. We acknowledge that one of the primary measures taken by countries to control the pandemic was the imposition of mobility restrictions. However, decision-makers should seek options to facilitate outdoor recreational activities for the population while preserving safety and physical distancing instructions. Outdoor time is not only relevant for all movement behaviors but also the lack of it may impact other areas such as mental health, vitamin D deficiency and myopia [4]. In our study, the region of residence and lockdown situation were not predictors of the movement behavior changes suggesting that regardless of location and containment measures, movement behaviors, in both toddlers and preschoolers, were similarly affected during the pandemic in Chile.
The provision of safe spaces for physical activity is critical when physical distancing is required. As parks may be limited in space, availability and accessibility, programs such as open streets (e.g., Ciclovía) or play streets can be adapted and implemented while maintaining the physical distancing and other COVID-19-safe measures [29,30,31]. Thus, councils could provide additional safe spaces by closing lanes to cars, implementing complete streets schemes, and transforming them into spaces for physical activity, play, and recreation. Colombia has been highly innovative during the pandemic as they modified their current programs, usually delivered in parks or closed areas to face the needs of the population during the pandemic [32]. For example, in Bogotá, one of the first measures taken during the pandemic was the closure of lanes to private cars and the instalment of daily open streets [33]. Also, professionals from the Ministry of Sports Colombia have delivered their physical activity programs in the neighborhoods while maintaining an appropriate physical distance [32]. These low-cost initiatives have been positively received by the general public and policymakers [34,35], so once adapted to local needs they could be implemented in other contexts and countries, including Chile, and could help to alleviate the inactivity crisis [3].
The detrimental effects of the COVID-19 pandemic in toddlers and preschoolers are still uncertain [8]. If sustained, the COVID-19 lockdown measures may have a serious impact on children, with a greater effect on those from a more deprived background, increasing the gap in other developmental outcomes such as motor development, cognition, and literacy. Actions to prevent the adverse effects of the restriction measures due to COVID-19 are needed. As younger children are mostly dependent on adults, we should embrace this challenge and offer the best possible opportunities to promote a comprehensive development in the current context [8]. Messages and strategies should be respectful and appropriate for the families as many are suffering not only from the direct effects of the COVID-19 but also from economic and social hardships. These challenges are novel and highly demanding for governments and can only be successfully addressed if coordinated actions across sectors are undertaken. Cross-country collaborative efforts are needed to understand further how the pandemic is affecting movement behaviors of people from other ages, locations, and social groups. This may guide the allocation of resources where it is more critical. This study adds evidence that allows more balanced decision-making processes where not only the need to impose mobility restrictions to prevent contagion is taken into consideration but so is the need to avoid health impairments derived from extended confinements. Government departments are encouraged to develop and update their protocols in awareness of the multiple health impacts derived from the confinements.

Strengths and Limitations
Strengths of this study include a large sample of participants from each of the Chilean regions. As recruitment was conducted online, voluntary response bias may have affected the sample composition with participants being more concerned regarding their children’s health and having therefore higher chances to notice impairments in their movement behaviors. Besides this limitation, the respondents’ characteristics were comparable from those observed in the last National Census for the respective age group in terms of dwelling type and living area, but the sample in our study was more educated [15]. Although our instrument was piloted before it was officially launched, we had a large percentage of incomplete questionnaires (40.0%). This could be explained since some people may be more reluctant to provide personal information through online platforms than in face-to-face modes. Some of the factors associated with the movement behaviors showed small predictive power (e.g., number of people at home). This may be explained as there are some other factors explaining these relationships. We recognize that movement behaviors are complex and depend on several dynamic factors that our questions were unable to capture, particularly during early stages of a pandemic. However, we measured these factors using the best assessment option possible under the very restricted circumstances imposed at the very early stages of the pandemic, when the data collection was conducted in Chile. We acknowledge that self-report measures used in this study may have biased the results (e.g., social desirability and recall). The use of accelerometers was not possible as physical distancing was mandated at the national level, including for those studies that were not strictly related to COVID-19 in clinical settings during the early stages of the pandemic [36]. Considering this, we collected data only for four weeks to minimize the risk of recall bias regarding the retrospective nature of some assessments.