key: cord-0854044-wtg6z7lq authors: Nilima, Nilima; Kaushik, Siddharth; Tiwary, Bhaskar; Pandey, Piyush Kant title: Psycho-social factors associated with the nationwide lockdown in India during COVID- 19 pandemic date: 2020-06-30 journal: Clin Epidemiol Glob Health DOI: 10.1016/j.cegh.2020.06.010 sha: d8aa92942097cd7a99d070e8bd1cccd872daf3e0 doc_id: 854044 cord_uid: wtg6z7lq OBJECTIVE: To investigate the psycho-social factors associated with COVID-19 and the nationwide lockdown in India. STUDY DESIGN: An online survey was conducted from April 11 through April 16, 2020 in 28 states and 8 union territories (UT) of India. The potential participants were recruited using snowball sampling procedure. METHODS: A cross-sectional online survey was conducted among the people of all states in India. A spatial analysis was performed and Moran's I statistic was applied to investigate the overall clustering of locations. Fisher's exact test was used to investigate associations. GeoDa and R console were used to analyze the data. A total of [Formula: see text] responses were received. RESULTS: Those worried for their family's health were likely to follow the lockdown measures [Formula: see text] Significant association was observed [Formula: see text] between following the lockdown measures and being satisfied with the government strategy to combat the COVID-19 pandemic. A significant relation was observed between the gender (p = 0.001), job profile [Formula: see text] and physical activity [Formula: see text] were observed to be associated with the psycho-social impact. CONCLUSION: Government and public health officials should consider the sentiments of the community while planning strategies relating to the pandemic. The findings of this study will assist the policymakers in emphasizing the psychological well-being of individuals, along with physical health. Coronavirus Disease-2019 (COVID-19)is a public health emergency of international concern firstly reported in Wuhan, China in December 2019. 1 The virus was named as severe acute respiratory syndrome coronavirus 2(SARS-CoV-2) by the International Committee on Taxonomy of Viruses. 2 It is defining the global health crisis and the global economic crisis of time the world has faced after many decades. Ever since its appearance in December 2019, the virus has proliferated to every continent, excluding Antarctica. 3 Manifestations of this infectious disease include fever, tiredness, dry cough, and other symptoms include shortness of breath, aches and pains, sore throat, and fewer people will suffer from diarrhea, nausea, and running nose. 4 Patients developing the extreme form of this disease constitute approximately 15% of the cases. According to the WHO (World Health Organization) report 2020 5 , almost 30% of the nations have no preparedness and response plans towards COVID-19 spread. Only a few countries have comprehensive infection prevention and control program along with water, sanitation, and hygiene standards in health-care facilities. 6 In the absence of COVID-19 vaccine, maintaining social and physical distancing aims to slow down the spread of this infectious disease by interrupting the chains of transmission of COVID-19. These measures include physical distance among people (of at least one meter) and minimize contact with infected surfaces while stimulating and sustaining active social connections within households and communities. Tele working, online learning, minimizing and avoiding crowding 7 are some of the measures for the general public to engage themselves. Public health policies requires an exceptional equilibrium between protecting the physical as well as psychological health. 8 The severe acute respiratory syndrome (SARS) outbreak in 2003 indicates that infectious diseases are linked with a high level of panic emotion among the population, which further complicates in preventing the spread of the disease. 9 Pandemics such as COVID-19excessively publicized in the mass media and can be associated with high levels of stress & anxiety. 10 Individuals may experience distress from quarantine, lockdown, travel restrictions, side effects of treatment, or fear of the infection itself. Those who are living alone currently not able to meet their parents or family might develop mild to moderate depression. 10 Older adults are also at risk of being not able to visit hospital/ healthcare facilities because of not having transportation and postponing their visits to physicians. 12 Few might go through withdrawal symptoms because of the sudden stopping of alcohol and other drugs. 13 Uncertainty of future because of this pandemic can cause post-traumatic stress disorder, prolonged grief reaction and guilt remorse followed by loss of the loved ones because of this pandemic, loss of job leading to the financial crisis which can lead to a higher number of committing suicides in days to come. 14 Stress, anxiety and depression are predators of diseases like hypertension, diabetes and depression. 15 It also causes accelerated aging (approximately 9-17 years) and premature death. 16 Spatial analysis is crucial in identifying the local occurrences and mapping the spread of any condition will help in formulation of public health policies at an early stage. 17, 18 The physiological processes in India have not received the attention it deserves from medical and public health fraternity. To the best of our knowledge, presenting the geographical distribution of the psycho-social impact due to COVID-19 and lockdown among Indian residents has not been previously reported. The main aim of this study is to investigate the psycho-social factors associated with COVID-19 and the nationwide lockdown in India employing the spatial analysis. The present study identifies the locations requiring special attention of the public health workers and the administrators in order to retain the positivity and hope in this public health crisis like situation. An online survey was conducted from April 11 through April 16, 2020 in 28 states and 8 union territories (UT) of India. The potential participants were recruited using snowball sampling The primary outcome (psycho-social (PS) impact) is a composite score assessed based on the participant's responses to the following five questions, "Do you get upset by thinking about COVID-19?" (Not at all 0; Yes, sometimes 1; Yes, often 2; Always 3), "Do you get panic and overreact to news relating to COVID-19" (Not at all 0; Yes, sometimes 1; Yes, often 2; Always 3), "Are you worried about losses/your job during the lockdown?" (Not at all 0; Yes, little 1; yes, a lot 2), "Do you get worried about your family's health more than usual?" (Not at all 0; Sometimes 1; Often 2) "Are you sleeping more/less than you normally do?" (I sleep as usual 0; more than usual 1; less than usual 2). The plausible range of PS score is zero to twelve. Under an assumption that everyone is having an impact, the individuals who scored between 0-5, 6-7, and 8-12 were considered to have a mild, moderate, and severe psycho-social impact. Characteristics including the state they currently stay, residential area (urban; rural), age (in Apart from the above-listed, few more questions on awareness regarding COVID-19 were asked viz. "Which among the following are true about COVID -19?" (It is a viral infection spread by coughing or sneezing; Fever, fatigue, cough, and breathing difficulty are symptoms; It is a deadly disease; All of the above; None of the above), "What are the preventive measures against the spread of COVID-19?" (Sanitizing/ washing hands regularly for at least 20 seconds; Social distancing; Practice respiratory hygiene; All of the above). Additionally, two more questions asked were, "Are you satisfied by the government's strategy to combat this pandemic?" (Yes, No, maybe) and "Are you able to do indoor physical activity?" (Daily; Twice-a-week; Rarely; Not at all) The quantitative measures were summarized using 'mean ± standard deviation (min, max)'.The qualitative response was summarized using frequency and percentages. Fisher's exact test was used to investigate associations. R console was used to analyze the data. A ≤ 0.05 was considered significant throughout. A choropleth map was used to present the state-wise descriptive plot relating to lockdown measures and the psycho-social impact due to − 19. Spatial analysis plays a vital role in analyzing the data and presenting the hotspots and other essential clusters. Moran's I statistic was used to investigate the overall clustering in locations. 19 Upon investigation, in the presence of spatial autocorrelation, the local measure of spatial association was employed to reveal the clusters. . The data were merged into the shapefile and analyzed using GeoDa software. A total of 1316 responses were received out of which majority were from Karnataka = Further investigations on the association of gender, job profile, physical activity, following lockdown measures, believing in lockdown being able to prevent the spread, and satisfaction with the government measures to combat the pandemic with the PS impact revealed notable findings as presented in Table 1 . Individuals with mild PS impact are likely males, those who always follow the lockdown measures, and those who do indoor physical activity daily. Gender of participants, following lockdown, and physical activity were significantly associated with the PS impact, as presented in Table 1 . Six out of the eight aggregated measures reveal almost negligible Moran's I value reporting a local measure when ! '" I is less than 0.3 is not found suitable. A choropleth map describing the measures relating to complete lockdown is presented in Fig. 1 , whereas the psycho-social measures and impact of COVID-19 illustrated in Fig. 2 and Fig. 3 respectively. The eight lockdown and psycho-social impact measures examined in the presented study are described in Table 2 . In the present study,92.6% of the respondents were following the lockdown measures, which is a very important step to minimize the spread of COVID-19. An analytical study conducted in India also signifies that lockdown and social distancing will only aid in the prevention of this pandemic. 20 The present study had similar findings as there was a significant association between following lockdown measures and government strategy to combat this pandemic. A significant association among worrying for the health of family members and supporting the lockdown measures has been observed. A recent study from the United Kingdom had similar findings emphasizing that people are more worried about their family and economic condition due to the pandemic spread. 21 Moreover, the findings reveal that 79.41% of the people had a sound knowledge about the symptoms of COVID-19. Studies reveal that excellent awareness and knowledge among people will help in reducing the initial number of cases making the outbreak easier to control. 22 It has been observed that the majority of those having severe stress do indoor physical activities rarely. Physical activity promotes well-being and recovery from stress. 23, 24 The present study also reports that people in the state of Tripura were not following the lockdown measures, and they were not satisfied with the government measures. Tripura is a state in north-east India with very few numbers of COVID-19 confirmed cases. A study conducted in Tripura concludes preventive measures to be best to tackle this pandemic, which contrasts the presented study finding. 25 People of Sikkim were least worried while those in Jammu & Kashmir were highly stressed about the losses and jobs. In most of the Northeastern states, along with Jammu & Kashmir, people were stressed and were overreacting to the situation. The distress could be because of the inequity in healthcare in these states concerning many determinants. 26,27 However, respondents from ten states and one UT have been observed not in stress due to COVID-19 and related lockdown measures. Respondents from twenty states and four UT have confirmed following the complete lockdown measures and the majority of them were also satisfied with government strategies. Controlling the spread of COVID-19 requires a comprehensive strategy, which the Indian government has managed well so far. However, the pandemic seems to affect the masses indirectly by creating a psycho-social impact due to the growing concern about their losses, job, health, and family. Moreover, these factors might have a long-term influence on wellbeing of the community. Despite several advantages, there are few limitations of the present study, including less participation from the areas with limited internet facilities. Demerits of an online survey are also limitations of the presented study. However, in this pandemic situation, an online survey was the only alternative to grasp the notion of the residents of India. Nationwide lockdown measures have been followed by the majority of states in India. Tailored intervention should be innovated for states requiring more attention. Government and public health officials should consider the sentiments of the community while planning strategies relating to the pandemic. The findings of this public data driven study will provide some insights to the policymakers in emphasizing the psychological well-being of individuals, along with physical health. Decision makers must come up with customized interventions for those affected due to staying alone, idle, loss of job, salary cut, and are worried about family's well-being. It will also assist health care providers (e.g., psychologists and psychiatrists) to offer timely services to the people of selected locations. NN and BT contributed to the study conception and material preparation. Design, data collection and analysis were performed by PKP, BT and NN respectively. SK wrote the manuscript. All authors read and approved the manuscript. pandemic Positive corona inception voltages and corona currents for air at various pressures and humidities Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention WHO and rapid advice guidelines: history and future directions Coronavirus disease 2019 (COVID-19) WHO launches crowdfund for COVID-19 response. The Lancet World Health Organization An analysis on reasons of SARS-induced psychological panic among students Fear and stigma: the epidemic within the SARS outbreak. Emerging Infectious Diseases Psychological predictors of anxiety in response to the H1N1 (swine flu) pandemic. Cognitive Therapy and Research Attachment-based family therapy for depressed adolescents: A treatment development study COVID-19 and the consequences of isolating the elderly. The Lancet. Public Health Consequences of multiple withdrawals from alcohol. Alcoholism: Clinical and Experimental Research Health and the financial crisis in Greece. The Lancet Oxidative stress and cardiovascular disease: novel tools give (free) radical insight Ageing induces apoptosis and increases HSP70 Stress Protein in the epididymis of Octodon degus Prevalence, patterns, and predictors of diarrhea: a spatial-temporal comprehensive evaluation in India Determinants of antenatal care utilization in India: a spatial evaluation of evidence for public health reforms. Public health Spatial evaluation of prevalence, pattern and predictors of cervical cancer screening in India. Public health The impact of social distancing and epicenter lockdown on the COVID-19 epidemic in mainland China: A data-driven SEIQR model study. medRxiv Measuring Emotions in the COVID-19 Real World Worry Dataset Feasibility of controlling COVID-19 outbreaks by isolation of cases and contacts. The Lancet Global Health Restoration and stress relief through physical activities in forests and parks. Urban forestry & urban greening Physical activity and exercise to achieve healthrelated physical fitness components. Public health reports COVID-19): History, Current Knowledge and Pipeline Medications World Health Organization. Social determinants of health. WHO Regional Office for South-East Asia Health inequality in India: evidence from NFHS 3. Economic and Political Weekly Consider sentiments of the community while planning strategies 2. Emphasize on the psychological well-being of individuals, along with physical health Tailored intervention should be innovated for states requiring more attention regarding psycho-social measure This research received no external funding. Ethical approval for survey research in the pandemic situation was obtained from Institutional Research Board of Indian Institute of Health Management Research, IIHMR University, Jaipur, In-principle. The authors declare no conflict of interest. The authors claim no conflict of interest.