PSYCHOLOGICAL IMPACT OF COVID-19 LOCKDOWN (PHASE 2) AMONG INDIAN GENERAL POPULATION: A CROSS-SECTIONAL SURVEY

understand the variations in the and stress levels among population after 21 in the initial lockdown while under the shadow of pandemic. Authors of this paper acknowledge that the lockdown measures were instrumental in protecting the physical health of the populations, however, long-term consequences related to psychological outcomes warrants a detailed assessment. Given innumerable changes already happened to our daily lives due to pandemic, it is critical to monitor the psychological impact, especially in the light of the uncertainties surrounding phased approach of lockdown. Therefore, this study aims to examine the perceived stress and anxiety among general population in India during the (extended) phase 2 lockdown imposed in India. This analysis study ABSTRACT COVID-19 has caused unprecedented disruption of all spheres of life, including health, nancial, and socio behavioral. Given the rampant nature of the pandemic, several nations, including India has instituted stringent public health measures, with one being nationwide lockdown, to mitigate COVID-19 transmission. Previous studies reported increased stress and anxiety levels among general population during phase 1 (complete) lockdown, however, the effect of extended lockdown (phase 2) on mental health outcomes remains the subject of investigation till today. Therefore, this cross-sectional study endeavors to assess the psychological outcomes among general population during phase 2 lockdown. The online questionnaire surveyed 627 individuals from the general population using a non-probability snowball sampling technique. Descriptive statistics, including the frequency distribution, mean and standard deviations were generated. Mean differences across groups were analyzed through independent-samples- t and analysis of variance tests. Consistent with previous studies, our results indicated a higher mean score of anxiety and stress among females compared to males. Young adults aged between 21-39 years had the highest mean stress and anxiety scores compared to other categories. The mean anxiety score increased from retired (M=3.96, SD=4.76, to students (M=7.04, SD=7.11), to unemployed (M=9.0, SD=6.53) occupation groups. The ndings of this study highlight the need for designing psychosocial regulatory frameworks and suitable interventions to address the needs of those being mentally traumatized by the pandemic and associated lockdowns. The study also advocates for establishing psychological health monitoring and telepsychiatry systems for identifying and treating mental health problems.

To limit the spread of COVID-19, Governments across the globe implemented strict measures, such as staying at home orders, school and business closures, ban on mass gatherings, mandatory quarantine for regions with a high number of active cases, and national lockdown directives (Atalan, 2020; Wilder-Smith & Freedman, 2020). Likewise, Indian government responded to the surging COVID-19 trends by instituting immediate national lockdown on 24 March 2020 (Gettleman & Schultz, 2020). Per the lockdown guidelines (issued by Government of India), all businesses, schools, and travel (international, national, and interstate) were closed with a few exemptions applied to some emergency and essential services. These included groceries, hospitals, pharmacies, fuel, telecom and postal services (Gettleman & Schultz, 2020). This lockdown was rst instituted for 21 days as a part of phase 1, which was later progressed to phase 2 (April 15-May 3), with some conditional relaxations applied while adhering to the social distancing protocols established by the government (Bhaskar, 2020). Previous studies assessed the psychological impact on general population subsequent to initial yet stringent phase-1 lockdown and found that restrictions, such as closure of schools and businesses, commercial activities and social activities, resulted negative psychological outcomes, such as stress, anxiety, and depression (Lolwal, 2020  . Our study extends the assessment of psychological outcomes to phase 2 of the national lockdowns imposed in India to understand the variations in the anxiety and stress levels among population after they already spent 21 days in the initial lockdown while living under the shadow of pandemic. Authors of this paper acknowledge that the lockdown measures were instrumental in protecting the physical health of the populations, however, long-term consequences related to psychological outcomes warrants a detailed assessment. Given innumerable changes already happened to our daily lives due to pandemic, it is critical to monitor the psychological impact, especially in the light of the uncertainties surrounding phased approach of lockdown. Therefore, this study aims to examine the perceived stress and anxiety among general population in India during the (extended) phase 2 lockdown imposed in India.

Study design and study population
This cross-sectional analysis was conducted among Indian population from April 19, 2020 to May 5, 2020. The study period corresponds with the phase 2 of the national lockdown in India. Participants who were 18 years or above, with a current residency status in India, and those with the ability to provide informed consent and comprehend English, were included. Individuals with any status, including students, workers, retired, self-employed, general public were included. Minors, and nonresident Indians were excluded from this study.
Data collection A web-based survey was developed through Google forms. All participants were requested to sign a voluntary informed consent prior to the data collection. Informed consent included a detailed information related to aim and signicance of the study, so participants will make informed choices about whether to participate or withdraw at any time if they wished. The survey link was disseminated through emails and different social media platforms such as WhatsApp groups, Facebook, Messengers etc. among the contacts of investigators. A chain referral sampling or snowball sampling was used to recruit participants from different regions of India. The survey link was primarily distributed by researchers to a group of participants, who then propagated it to future subjects from among their acquaintances.

Survey instruments and variables
The online survey questionnaire had three sections: (1) sociodemographic information (2) questions related to symptoms of anxiety, (3) questions related to perceived stress.

Statistical analysis
Participants' responses, from Google forms, were exported to Microsoft Excel, and then imported to IBM SPSS version 26.0 (IBM Corp. Armonk, NY, USA). Descriptive statistics, including the frequency distribution, mean and standard deviations were generated. Proportions of individual responses for each item were generated rst to compute composite proportions of that response in the anxiety and stress survey questionnaire. To analyze the differences in perceived stress and anxiety scores across groups, independent-samples-t test and analysis of variance were utilized. Priori power analysis and sample size determination was done by G power (version 3.1). Pvalues less than 0.05 were considered statistically signicant and data were reported as 95% condence intervals.

Results
Sample size justification G power software (version 3.1) was used to perform priori power analysis (Lenth, 2001;Faul, Erdfelder, Buchner, & Lang, 2009). The priori power analysis was conducted to ascertain the required sample size for a test with a predetermined alpha and beta (power) level. Power was ascertained separately for t and ANOVA tests by using Cohen's effect size conventions (effect size = 0.5 for t-tests; effect size =0.25 for ANOVA) (Cohen, 1988). The total sample size estimated with a power of .95 for was 210 and 252 for t test and ANOVA test respectively. The sample size with the greatest value (n=252) was considered appropriate since it satises the minimum requirement of all the statistical tests used.

Demographic characteristics
A total of 627 responses were recorded during the survey period. The demographic prole of the respondents shows that 310 (50.3%) respondents were males and 317 (49.2%) were females (Table 1). Nearly 1/3rd of the study population (30.2%) were entrepreneurs by profession. Over 70% of the sample population were the residents of Rajasthan. The predominant age groups in the sample include young (20-29 years), and middle-aged (40-49 years), constituting approximately 50% of the sample population (Table 1). Most participants reported no use of smoke (89.3%) and alcohol (73.5%). Over 25% of the population reported to be engaged in physical activity for at-least 2-3 days/week (Table 1).

DISCUSSION
The study assessed the perceived stress and anxiety levels among the general population in India during lockdown phase 2, in which previously imposed restrictions were lifted with some business-related activities being progressively resumed. Determining psychological impact during these times is vital in understanding how the Indian civilians adjusted with the "new normal" amidst surging trends of COVID-19 cases. The ndings of the study indicate that females experience the higher levels of stress and anxiety compared to males ( Table 2 & Table 5). These ndings were consistent with previous reports published during phase 1 lockdown (Moghanibashi-Mansourieh, 2020; Wang et. al., 2020). The gender differences in anxiety and stress levels may be attributed to the higher sensitivities  Maeng & Milad, 2015). According to the American Psychiatric Association (2013), more than 50% of the cases of generalized anxiety disorders and preexisting mental disorders comprised of females. Moreover, females were reported to be twice likely to have anxiety disorders compared to males (Tolin & Foa, 2008). Interestingly, the mean stress and anxiety scores of married couples and those living with children were lower compared to those being unmarried and living without children (Table  4). This may be explained on the premise that being surrounded by the loved ones result in reassurance and helps in buffering against the feelings of vulnerability and inability to control (Chin et al., 2017;Ta et al., 2017).
The results also indicate that the mean scores of anxiety and stress were the highest among 20 to 29-and 30-39-years' age groups (

Strengths
This study offers a unique perspective to understand the psychological impact of extended lockdowns among general population, who have already lived in the shadow of pandemic with subsequent lockdowns for 21 days. To our knowledge, this is the rst study to report the anxiety and stress at the point of transition from stringent lockdown to conditional or partial lockdown after some economic activities being resumed. Additionally, the current study extends the observations to the population across different demographic dimensions, which will serve as baseline data for determining the extent of the long-term consequences of COVID-19 pandemic and to assess the effectiveness of the psychological interventions in the future.

Limitations
This study has a few limitations, which merit discussion. First, the sample of the study was not nationally representative, which limits the generalizability of these results to other populations. Second, our psychological investigation was only limited to self-reported anxiety and stress symptoms; the post-traumatic stress disease symptoms were not investigated. Third, the information related to current employment status was not included in the demographic questionnaire, which would have given us a valuable insight about an economic stressor of our population.

Conclusions and public health implications
COVID-19 has taken a signicant toll on mental health of the general population. National lockdowns were helpful in limiting the spread of COVID-19, however, effects on mental health were among unintended consequences. Anxiety and stress levels were higher among some demographic groups, which may have stemmed from the fear of losing loved ones, job insecurity, and social disconnectedness etc. These are important predictors, which warrant further elucidation. The study highlights the importance of establishing psychological services for helping individuals to combat stress generated after unprecedented obstruction that arose without warning. In addition, the study advocates for the establishment of career and counselling services in India to help those being hurt economically. The ndings of this study highlight the need for designing psychosocial regulatory frameworks and suitable interventions to address the needs of those being mentally traumatized by the pandemic and associated lockdowns. The study also advocates for establishing psychological health monitoring and telepsychiatry systems for identifying and treating mental health problems.