COVID-19 in India: Problems, Challenges and Strategies (Psychological Aspects)

The pandemic COVID-19 is a global challenge which has infected and killed people worldwide. Some people do not show any symptom while some have fever, cough, sore throat, general weakness and fatigue and muscular pain and in most severe cases, severe pneumonia, acute respiratory distress syndrome, sepsis and septic shock all leading to death. It has adversely affected the economy and social integrity of countries. There is rising concern about the mental health challenges of the general population (children, adults, or elderly), along with health workers and family of infected people. This study aims to determine effect of COVID-19 on mental health of people in India. It also focuses on the stigma and discriminating factors in our society and ways to cope with such conditions. A structured survey was conducted with 250 participants of different age groups. Our analysis focuses on the factors affecting mental health of any person, changes in behavior and daily routine due to stress, anxiety or fear of transmission of virus in their family and friends, some are worried for their lifestyle and career. There is a need to understand that pandemic is affecting everyone, either physically or mentally. There must be increase in the study of the aspects of mental health during the pandemic and methods to cope with issues like discrimination for better mental health during pandemic period.


Introduction
Along with great increase in mortality and morbidity due to this pandemic in India, COVID-19 has caused mental health issues among general population, children, adults, elderly, migrant workers, healthcare workers and their families. As per a study performed to assess the youth mental health after COVID-19 in China, it is observed that mental health problems are majorly found in youth group. This study indicates that low education level, post-traumatic stress disorder (PTSD) and negative coping styles were the influence factors of youth mental health [1].
A recent study indicates that structured websites and toll free helpline numbers may be launched for alleviating psychological distress among the general public regarding this ongoing pandemic. Social media is to be used in good sense so that people can get education regarding transmission dynamics and symptoms of disease. To protect social media from devaluations, strict government laws and legislation regarding fake news, social media rumors, disinformation and misinformation are to be implemented [2].
It is important to understand different reasons of mental health issues, ways in which they are affecting our society and resilience of people and the ways they try to cope up with such situations. Therefore, the current study will aim to show impact of COVID-19 on mental health of people in India.
Human beings are social species which require most satisfying environment with social relationship and physical well beings. The pandemic has affected lifestyle, education, career, development and economy in few months as there has been sudden increase in number of patients. Isolation, contact restrictions and economic shutdown impose a complete change to the psycho-social environment. These measures have the potential to threaten the mental health of children, adolescent and elders significantly.

Mental health issues during COVID-19
During COVID-19 pandemic, people were bound to stay at home and maintain social distancing. This sudden change in their lifestyle along with fear of COVID-19 created discomfort in their life. Long term anxiousness and fear leads to negative psychological effects including post-traumatic stress symptoms, confusion and anger. Personality disorders and Alzheimer's disease, irritability, restlessness, difficulty in concentration, fatigue, dizziness are also some psychological disorders.
As pandemic was spreading rapidly, complete lockdown had been implemented at most of the places and due to non-availability of transport system people were not able to move around. People from various age groups are reporting loneliness as they were away from their family members. A study revealed that depression, anxiety, and stress play an important role in enhancing the fear of COVID-19.
The general population can experience the fear and anxiety of dying, helplessness, blame the people who are already affected and precipitate the mental breakdown. Let us briefly discuss the impact of COVID-19 on different age groups.

Children
Unaware of everything happening young children are enjoying the company of their family members with no efforts of going school. As children were not permitted to play outside home they feel irritated sometimes sitting at home. They are also curious to know the reason of drastic change in lifestyle as they cannot judge the actual reasons. Some youngsters are happy to stay home, especially those who are family focused. According to a study done over children and adolescents in the age groups of 9 years to 18 years during COVID-19 outbreak in India. Children and adolescents who were under quarantine had faced more psychological problems than those who were not quarantined. Fear (p < 0.0001), nervousness (p < 0.0001) and annoyance (p < 0.001) were most significantly seen in the quarantined group. Anxiety related insomnia, isolation, boredom (not statistically significant) and sadness was also more common in the quarantine group [3].
Teenagers caring most about their privacy, peers and independence are under depression living with their family while younger kids are happy to get much attention. The notion of social distancing becomes difficult for youngsters who think of themselves not getting ill and takes it as restriction. So primarily being unhappy they start being cutoff from other family members, which results their aggressive behaviors. Having healthy conversation can make them understand and they can be given their personal space at home, even can be allowed to play video games and stay connected to their friends through internet.
Children are also worried about their future. Some self motivated kids have set their goals to achieve something during this period. They are busy with video of their interest and some tutorial, but have become physically less active and have much screen time, irregular sleep pattern and less favorable diets resulting in weight gain and loss of cardio-respiratory fitness.

Adults
During the pandemic, this age group are afraid of losing their jobs as few companies were not able to survive and few were still operating offline. This age group decided not to go to office and choose work from home as they were concerned about the spread of virus. In this case, the fear of losing jobs increases. Some are getting depressed and feeling alone as maintaining distance. According to Italian study, during the second week of mandatory lockdown, Italian adults paid much attention to information about COVID-19, they perceived it as very severe, and they were particularly worried about infecting their relatives [4]. Loneliness is recognized as a contributing and maintaining factor in the development of Alcohol abuse. Alcohol does affect the user's ability to perceive, integrate and process information. This distortion in the user's thinking does not cause violence but may increase the risk that the user will misinterpret his partner or other's behavior [5]. Consumption of alcohol make a person emotionally weak and might give rise to domestic violence. Which affects the whole family and cause loss of concentration of each family member and make emotionally weak. Some poor labor just focused to reach their home, lost their life due to psychiatric disorders.
Women have started taking measure to protect their family from virus, each item bought to home is sanitized and then used. This increases burden on women due to which they feel tensed, depressed and facing psychiatric disorders like mood extremes. The disruption of social and protective networks, loss of income and decreased access to services, all can exacerbate the risk of violence for women [6]. Women are ones who are more affected by nosophobia of COVID-19 as allergy or climate change may also result some illness. They are more worried about family members.

Elder and special population
Person with pre-existing mental illness have been inevitably affected by the pandemic. In patients, especially aged and those who require long term hospitalization in closed wards are under great risk [7]. Elderly people were at a higher risk of spreading and catching virus so other family members started keeping themselves away from them. Neither elders are having proper conversations with family nor getting absolute care. Even they are not taken to hospital for any other disease as they can come in the contact of some corona infected person. Watching news related to COVID-19 whole day is depressing them as it seems to be the end of human life (Figure 1).

Survey
To clearly understand the pandemic impact on different age group a survey on 250 people has been done by preparing a questionnaire. Each questionnaire was divided into four sections. The questionnaire included scaled questions that have already been used worldwide in the previous studies and we are using same type of questionnaire for India [8]. In the first section, questions were framed to gather data on the personal profile of the respondents. The second section consisted of questions on personal awareness and attitude. The third and fourth sections of the questionnaire comprised attitude towards family and country. Questions asked the respondents to inform their choices (i) (not at all), (ii) (many times), (iii) (mostly), (iv) (every time) about various factors that affect their awareness, attitude, behavior and methods they follow to keep themselves fit.

Participants
We used a snowball sampling approach to distribute questionnaire online. The questionnaire was shared on different platforms, when a participant completed it, they forwarded it to their group of friends to expand the size. Out of total 250 respondents, 138 are males that is 55.2% and 112 are females that is 44.8%. Based on the distribution of age, majority of respondents belonged to the age group of 25-44 (50.8%). Whereas 34.8% of the respondents belonged to the age group of 18-24 years and 9.6% were in the age group of 45-above years and 4.8% of the respondents were of the age group of 1-17 years of age ( Table 1).
The work from home permission of the respondents indicates that most of the respondents as (47.2%) lies in yes and (28.8%) lies in the category of no and there were 8% respondents who were partially allowed to work from home while 16% falls in category of not applicable.

Awareness
People awareness plays an instrumental role in determining their behavior. This section describes the effectiveness of the awareness for people in the pandemic. The people awareness has been measured with indicators (0 to 4) which include the level of awareness as (0) do not know anything, (1) know very less things, (2) know few things, (3) know many things, (4) know everything ( Table 2).
The above group (4-17) maximum results come in favor of 2, 3, 4, In age group (18-24) and (25-44) maximum results come in favor of 3 while in age group (44-above) maximum respondents lie in category of 4. This implies that most of the people were aware about the pandemic situation (Figure 2).

Attitude
In age group of 18-24 and 25-44 approximately 35% people were worried more about their health while 10.5% are worried every time with 33% of 18-24 and 28% of 25-44 do not worry at all (Figure 3).
In age group of 18-24 there are 32% people worrying about nation or world everytime and in 25-44 age group there 21% people worrying about nation or world everytime. While 34% of 18-24 years and 37% of 25-44 years worrying most of the time. While only 8% and 11% of 18-24 and 25-44 resp. do not worry at all (Figure 4).

Behavior
According to Survey, 28% of teenagers, 9% of 18-24 age group people, 8% of 25-44 age group people and 10% of 44+ have been every time noticed moving or   speaking slowly. Approx 14% and 28% of children are mostly and many times seen moving slowly while 28% are not at all effected. In case of 18-24 age group 16% and 24% have been noticed mostly and many times moving slowly than usual ( Figure 5).
Most people have accepted the situation to look after of their mental health, 86% of 13-17 years, 38% of people of 18-24 years, 45% of people of 25-44 years and 40% of people of 45+ age group have engaged themselves in doing meditation or yoga. People of 18-24 years opted to eat well (52%), care others (45%) and talk to someone they have not talked for long (42%) for their better mental health. In 25-44 age group, opted to keep themselves active (53%), eat well (52%), to do things they are good at and care others are (35%). While in 44+ people tried to be active (35%), contact people they have not contacted so long (50%), care others (45%) and drink sensibly (20%).
Similarly, this questionnaire gives us more details about people's anxiousness, tiredness and concentration problem being faced. Survey shows that most of the people have only one hour of news watching time a day, some are irritated and facing arguments resulting into fights. Few families are also facing Domestic violence during period of pandemic and lockdown.

Resilience and adaptive coping
Resilience helps to protect one from mental illness by using the available resources. Resilience is a protective factor against development of mental disorder and a risk factor for a number of clinical conditions, e.g. suicide [9]. On one side, the nation as a whole focuses on controlling the pandemic by adapting different strategies like isolation and quarantined period, other side some organizations are paying attention towards mental health during COVID-19. Lack of social interactions and staying home for longer time effects mental wellness. One should not be over exposed to media coverage, should maintain happy relationship, get in touch   of friends and relatives through social media to whom you have not been contacting since too long. Reaching out to children and others is good for everyone as feeling close to others reduces anxiety and boost the immune system. For coping with mental health issues people should follow a particular routine such as regular exercise, proper sleep, follow a strict routine which helps us to be active, efficient, reduce the need of will power, reduces procrastination, builds momentum and a person's self-confident by reducing stress, staying calm also helps you to overcome stress and other diseases such as hypertension diseases, one should practice breathing exercises which maintains the proper blood flow in the body with calmness in mind (Figures 6 and 7).

Adjustment problems
India's coronavirus forced many citizens to return their countryside homes with family. After few days of pandemic, daily wagers were in a great trouble because of non-availability of work so their survival become very difficult. The COVID-19 lockdown has the most daunting impact on such people whereby most of them must fight for survival on a daily basis. Many agencies are trying to support daily wage workers, but the entire cycle of revenue has been greatly troubled in few weeks.
During this time of uncertainty, employers may experience changes in productivity. When productivity drops, it has direct impact on jobs. One cannot get new job during this period and siting home in this situation makes it more difficult and effect can be seen on faces of family members too. Millions of lives have been heavily affected by several psychological changes such as increased levels of loneliness as being locked in home, no interaction with neighbors and relatives result in overthinking, loneliness and depression.
Aged people are particularly susceptible to the risk of infection from COVID-19, especially those with chronic health conditions such as hypertension, cardiovascular diseases, and diabetes. Older persons are not just struggling with great health risks but are also less capable of keeping themselves in isolation. Although social distancing is necessary to reduce the spread of diseases, but some families are understanding that elders also require proper care and interaction. Mostly getting locked in a room alone irritates them, and inability to use technology and differentiate between real and fake news also makes them worried and unable to adjust with family. Pandemic and lockdown increased the burden of household work for all families. Children are off school, no service provider (dhobi, cook, driver, gardener, etc.) and regardless to whether they hold job or not. Women are taking care of cleanliness and disinfecting everything and everyone coming in house other than daily works.

COVID-19 related stigma among people
Social stigma in the context of health is the negative factor between a person or group of people sharing certain characteristics or symptoms of specific disease. During this outbreak, individuals are branded, treated badly, discriminated, and suffer status loss due to merging with infected people. Such treatment impacts adversely to those with symptoms as well as their caregivers, family, friends and communities. People who do not have the disease but share other characteristics with this group may also suffer from stigma [10].
The level of stigma associated with COVID-19 is based on three main factor: 1.It is a disease that is new and for which there are still many unknowns; 2.We are usually afraid of the unidentified; and 3.It is easy to associate that fear with 'others' there is confusion and anxiety among the public.
Unfortunately, these factors are also fueling harmful stereotypes. Effects that stigma can cause: Drive people to hide illness to void discrimination, prevent people from seeking health care immediately and discourage them from adopting healthy behaviors. To understand the ways in which this can incite violence and push public in harm, one needs to look at a case of Himachal Pradesh, where Mohammad Dilshad, a 37 year old resident of Una district, hung himself after being continuously taunted and harassed by community despite he tested corona negative (Figure 8) [11].
In the COVID-19 emergency, medical workers and security services were at high risk of infection. They were facing overwork, frustration, discrimination, isolation, patients with negative emotions, a lack of contact with their families and exhaustion. This situation causes mental health problems such as stress, anxiety, depressive symptoms insomnia, denial, anger and fear. These mental health problems not only affect attention, understanding and decision-making capacity of medical workers, which could hinder the fight against COVID-19 but they could also have a lasting effect on their overall well being. Stigmatized groups may often be deprived of the resources they need to take care of themselves and their families. Stigma can present major barriers against healthcare seeking, social marginalization, distrust in health authorities and distortion of public perception of risk, resulting in massive panic among citizen.
Groups experiencing stigma related to COVID-19 are mostly the health workers and emergency respondents, people returning from travel, people with the disease, their family and friends and people released from quarantine. The stigmatized people may be excluded or shunned in social situations, denied some kind of opportunity, may be denied access to adequate housing and health caregiver and they might be targets of verbal, emotional and physical abuse.

Stigma and discrimination with corona positive people
The threat of getting infected can change our responses to ordinary interactions, leading us to behave in unexpected ways. Publishing the personal data of people infected with COVID-19 or data of those who are suspicious of having the virus, jeopardizes their safety and well being. This way people themselves are exposed to public lynching, and declared dangerous to public health, the blame for the infection is sought on them and they are marked as irresponsible, reckless, and dangerous citizen. The WHO has also issued specific psycho-social considerations for abating the growing stigma of COVID-19 [12].
People who tested positive often become fearful of seeking help or even discussing symptoms. They put themselves and society into risk and increase the rate of transmission. We are all fed by fear, internalized racism and misinformation. And this will increase with increase of no. of cases, rising mortality rate and limited testing facilities.
How are corona positive been discriminated?
1.Food is thrown through a passage in a quarantine center.
2.Society does not allow their family members to enter their society.
3.They are not allowed to go in public even after treatment and recovery.
4.They are teased as they got infection by their own mistake.
Effects of stigma and discrimination with corona positive: 1.Family members of COVID-19 positive patients who have been tested COVID-19 negative will also face trouble in society and will be considered as guilty which in result will affect them mentally.

2.
A treated patient will also feel insecure in the society as everyone will look at him as a risk for society.
3.Family members even after getting symptoms similar to COVID-19 will neglect the test in fear of social discrimination.
4.Affected family might be having trouble in fulfilling their needs.
5.After all this bullying and ignored by society they may take a step towards suicide.

Mental disorder and COVID-19
Mental disorders are the conditions that affect your thinking, feeling, mood and behavior. They may be occasional or long lasting. They can affect our ability to relate to others and function each day.
There is no single cause of mental disorder, factors causing it in case of COVID-19 are: 1.having few friends and feeling lonely.
2.having a serious medical condition.
3.life experience as person having symptoms like COVID-19 is started to be discriminated.

4.use of alcohol and recreational drugs.
Some common type of disorders being faced during COVID-19 pandemic: 1.Eating disorders: these are serious mental health disorders. They involve severe problem with your thought about food and your eating behavior, you may eat less or more than you need. They affect ability of our body to get proper nutrition. Causes of eating in this case are psychological and social factors. In long term it can result in some problems like: Muscle weakness, low blood pressure, brain damage, multi-organ failure, feeling tired all time and infertility [13].
2.Depression: depression is serious medical illness. it's more than just a feeling of being sad. Symptoms may include: loss of interest in favorite things, overeating, feeling hopeless, irritated, digestive problems and thoughts of death or suicide. Depression is a disorder of brain which can be caused at any stage of life but it begins often in teens and adults. It can be treated by being socially active or going to psychiatrist [14].
3.Obsessive compulsive disorders: it is a disorder in which we have thoughts of something again and again, but one cannot control them.
Obsession are repeated thoughts such as fear of infection in case of COVID-19, fear of losing and misplacing something as one might have fear of losing their parents of family member during this pandemic.
Compulsions are the behaviors that you feel like you need to do repeatedly to try to reduce or stop your obsession thoughts. Some compulsions include: excessive cleaning hands and items, ordering and arranging things in a particular way [15].

India vs. global situation
This pandemic not only impacted India, but its impact can be seen worldwide. In terms of mental health, the situation globally was also similar. Children, adults, and aged people were facing same type of problems. The pandemic impact can be seen both on developed and developing countries. Initially mortality rate was very high in both developed and developing countries. But due to high population and less resources, India faced more challenges during this situation. The medical facilities were also not as good in India as they are in other developed countries.

Conclusion
COVID-19 causes strong mental health issues, as number of deaths, death of family members and friends and lockdown are factors affecting the thought of a person. During the pandemic people facing the problem with inadequate supplies, inadequate information, financial loss, stigma and infection fear. According to our survey children are having lesser knowledge about pandemic while they are curious to know but are not able to understand scientific complexities. Children are little bit irritated locked at home but mostly happy with their families and do not have any anxiety or fear of death. While teenagers are not much happy and worried for their family and friends' health. They were eagerly waiting to meet their friends as being unsocial makes them lonely, irritated and anxious which motivates them to fight with other family members. Adults are most mentally affected, as they have load on their shoulder and see whole life been affected due to corona virus. This group has people mostly worried about its effect on studies/jobs/financial condition. They are not very easily irritated and annoyed but hard to sit still. Most people in this age group are accepting situation, eating well and keeping themselves active. Aged are mostly facing loneliness, anxious and irritated due to being separated from other family members. They watch news channels for atleast one hour a day and afraid that something awful might happen. The number of person infected and died were increasing every day. Even isolation, lockdown and physical distancing are prolonged. Opportunities are decreasing and as a result financial problem are increasing. This leads to increase of mental health issues exponentially. There is stigma related to COVID-19 among people which might be initiating factor of mental health issues. To avoid stigma one can believe that not all who are having symptoms like cough and sneeze have COVID-19, despite precautions if anybody catches COVID-19 its not their fault, one should face fear and anxiety with facts not discrimination, stay positive and remember COVID-19 will heal but stigma and mental trauma left behind will not. In India there is lack of clear and effective communication and a knowledge-based stigma reduction strategy that can translate into public education, community engagement and trust in the health care system. Firstly, we should have knowledge that virus will not be going away any time soon. Any long term strategy must be introduced, broad based and transparent with key public figures who can help the state to communicate on this daily. Secondly, we must move from language of fear and paranoia to one of empathy. We can stop using terms such as "infected" "carrier" and switch to "affected" and "acquired." This reminds people that patients and those at risk are people like us. A public awareness campaign around breaking stereotypes that harm social cohesion and empathy is the need of the hour. We have already seen sections of mainstream media demolishing certain communities and ethnicity. This is not just unethical, but also has an impact on disease control and people lives. There is need to understand the side of mental health during the pandemic, increase the number of researches and find the actions to cope with issues for their effective management.

A.1 Questionnaire
Dear Sir/Madam, I request you to please take a few minutes of your precious time to complete the questionnaire of study on "COVID-19 IN INDIA: PROBLEMS, CHALLENGES AND STRATEGIES, PSYCHOLOGICAL ASPECTS". Hence, your participation in the survey will be highly appreciated. I ensure the anonymity of all the participants and complete confidentiality of responses collected. The responses will only be used for my research and not for any other commercial purposes. The study aims at surveying the Mental health of people during COVID-19 pandemic.