Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : October | Volume : 16 | Issue : 10 | Page : LC34 - LC39 Full Version

Psychosocial Impact of Pandemic and State Imposed Lockdown on Caregivers of Patients Presenting with Respiratory Complaints Mimicking COVID-19: A Short-term Follow-up Study


Published: October 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/57196.17057
Ravi Kumar Garg, Kranti Garg, Vishal Chopra, Nitin Gupta, Roopesh Bharti

1. Assistant Professor, Department of Paediatric Surgery, Government Medical College, Patiala, Punjab, India. 2. Associate Professor, Department of Pulmonary Medicine, Government Medical College, Patiala, Punjab, India. 3. Professor and Head, Department of Pulmonary Medicine, Government Medical College, Patiala, Punjab, India. 4. Ex-professor, Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India. 5. Ex-house Surgeon, Department of Paediatric Surgery, Government Medical College, Patiala, Punjab, India.

Correspondence Address :
Dr. Ravi Kumar Garg,
Assistant Professor, Department of Paediatric Surgery, Government Medical College, Patiala, Punjab, India.
E-mail: gargdrravi@gmail.com

Abstract

Introduction: Pandemics and subsequent lockdowns affect mental health of different subgroups of populations. In Coronavirus Disease-2019 (COVID-19), caregivers of those patients who have respiratory complaints is one such subgroup which is more vulnerable to disturbances in mental health, because of the fear that their patient’s respiratory symptoms could be because of COVID-19.

Aim: To assess the psychosocial impact of COVID-19 and subsequent state imposed lockdown on the caregivers of patients presenting with respiratory complaints and also to evaluate the effect of relaxation of lockdown after following-up them over a period of time.

Materials and Methods: This prospective observational study was conducted in the Department of Pulmonary Medicine, Government Medical College, Patiala, Punjab, India (tertiary care institute), from April 2020 to June 2020. Baseline assessment was done using socio-demographic performa, lockdown related questionnaire {3 domains, summed as total score (Lockdown)}, COVID-19 related questionnaire {Total score (COVID-19)} and General Health Questionnaire-12-Hindi version (GHQ-12). Reassessment was done twice i.e., at 11-15 days and 41-45 days after relaxation of lockdown. Quality Of Life (QOL) at first and second follow-up versus pre-lockdown times (score A and C) and first follow-up versus un-lockdown (score B) was also noted. Analysis was conducted using Statistical Package for Social Sciences (IBM, SPSS)version 22.0.

Results: Mean age of the participants was 40.2±11.812 years with maximum caregivers 25 (41.7%) aged between 31-40 years. Majority (83.3%) were men. Psychological distress was experienced in 50% of caregivers at baseline and 23.7% caregivers at first follow-up (p-value=0.001). Worry for COVID-19 (p-value=0.035), Domain 1 scores (p-value <0.001), Domain 2 scores (p-value=0.003), Domain 3 scores (p-value=0.001), and Total score Lockdown (p-value <0.001) decreased significantly at first follow-up. Mean C score was significantly better than mean A score (p-value <0.001). Baseline psychological distress was significantly more in those with worry for COVID-19 (p-value=0.018), poorer scores of domains 1 (p-value=0.005), domains 2 (p-value <0.001), domains 3 (p-value <0.001), total score (Lockdown) (p-value <0.001) and total score (COVID-19) (p-value=0.010). Follow-up psychological distress was more in those with “worry for COVID-19” (p-value <0.001), negative thoughts (p-value=0.001), poorer follow-up scores of three domains, total score (Lockdown), mean A, B and C scores (p-value <0.001).

Conclusion: Caregivers experienced extreme levels of psychological distress, which decreased, but persisted even after relaxation in lockdown.

Keywords

Coronavirus disease-2019, Mental health, Psychological distress

Coronavirus Disease-2019 (COVID-19) pandemic shook the world unexpectedly and brought life to a standstill (1). Various countries underwent strict lockdowns as a social distancing measure to prevent the spread of infection to the masses. In the state of Punjab, complete lockdown was announced on 22nd March, 2020, during which only essential services were allowed (2). Subsequently, 21 days strict nationwide lockdown was announced in India on 24th March 2020 (3). The lockdown was extended in phases one after the another. In Punjab, it was eased for a few hours since its imposition first on 30th April, 2020 (4).

The COVID-19 and lockdown measures caused disturbances in mental well being. Various advisories were issued by World Health Organisation (WHO) and Ministry of Health and Family Welfare (MOHFW), Government of India for the protection of mental health (5),(6),(7),(8),(9),(10). However, the recommendations were by and large ignored. Enough evidence has generated that the unprecedented strict lockdown measures are a threat to mental health and overall well being, as we juggle through different waves of the pandemic (11),(12),(13),(14),(15),(16),(17),(18),(19). However, studies remain focused on specified subgroups of vulnerable populations like healthcare professionals, children, elderly, patients suffering from chronic ailments (11),(12),(13),(14),(15),(16),17],(18),(19).

It is known that different groups of people as per their age, socio-demographic profile, type of personality and mental makeup may respond differently to a given situation. The responses also differ markedly with innumerable confounders like underlying disease, co-morbidities, suffering in a family member and so on (20). Caregivers is one such distinct group which needs attention. Mental well being of caregivers of patients with chronic illnesses has been studied in the past in non pandemic situations (21),(22).

The existing COVID-19 literature has investigated the mental health of caregivers of some special subgroups like caregivers of cancer patients, health professionals as caregivers of COVID-19 patients, caregivers of children and adolescents with psychological disturbances, caregivers of people with dementia (23),(24),(25),(26),(27). However, caregivers of patients with respiratory complaints have not been studied in this pandemic.

The state of Punjab and the nation had witnessed steep rise in case numbers and had battled through the devastating second wave of the pandemic (28),(29). The fear of COVID-19 for their patients, because of the similarity in clinical presentation, is expected to have a distressing effect on the metal well being of the caregivers. Infectiousness of the disease, resultant isolation, stigma and lockdowns add to the problem. Hence, the aim of present study was to explore the psychosocial impact of COVID-19 and state imposed lockdown on such caregivers, living with the dilemma of their patient being infected or not, because of the resemblance of the symptoms with COVID-19.

Material and Methods

This prospective observational study was conducted in the Department of Pulmonary Medicine, Government Medical College, Patiala, Punjab, India (tertiary care institute), from April 2020 to June 2020. The study was approved by the Institute’s Research and Ethics Committee {(Trg)EC/NEW/.INST/2020/997/4407}. Informed consent was taken from all participants.

Inclusion criteria: All the caregivers of patients, presenting with respiratory complaints which could be mimicking COVID-19 (like cough, fever, shortness of breath, nasal congestion, sore throat, generalised weakness) and were more that 18 years of age were included in the study.

Exclusion criteria: Caregivers having any respiratory complaint, underlying respiratory disease or psychiatric illness, were less than 14 years of age, had lack of competency in completing the questionnaires, had evident memory deficits on clinical assessment, had lack of capacity or had organicity (delirium, dementia) were excluded from the study.

Total 65 caregivers who presented to the Outpatient Department for treatment of their patients were enrolled into the study by convenience sampling, due to limitations in availability of study population during the period of strict lockdown.

Assessment

Assessment was done at 3 points of time.

Baseline: The caregivers were assessed at baseline, in person, during strict lockdown (7th April, 2020 to 29th April 2020) and

First follow-up: At follow-up from 11th to 15th day after the strict lockdown was eased (10th to 14th May, 2020).

Second follow-up: The third assessment was done from 9th to 13th June, 2020, after about 41-45 days of the first relaxation in lockdown (Table/Fig 1).

The follow-up assessments were either in person or through telephonic interviews. At the third assessmnet, only the overall QOL at that point of time was compared with the pre-lockdown phase on a scale ranging from -10 to +10.

Procedure

Study tools: The study tools consisted of a proforma containing socio-demographic characteristics, COVID-19 and lock down related questions, GHQ-12 and quality of life.

Baseline assessment was done using the following instruments:

1. Socio-demographic proforma: A structured proforma was used to record the data like age, gender, occupation, residence, family related information etc.
2. COVID-19 related questionnaire: All caregivers were asked if they felt the symptoms of their patients are because of COVID-19 or they are worried for COVID-19.Those answering ‘yes’ to any of these two questions were administered Visual Analogue Scale (VAS), ranging from 0 to 10, for evaluating their extent of worry (30). Those who scored more than zero on VAS were asked the 8 questions related to frequency of anxiety, nervousness, depression, loneliness, stigma, sleep disturbances, thoughts of death, need for addictive substances and thoughts of hopefulness for future during the last one week. It was a self structured questionnaire devised by the authors and administered by the interviewer. The questions were taken and adapted from literature (31). They were then subjected to extensive review by three experts to add to face validity. VAS was not administered to those answering ‘no’ to both the questions, as it was a 0-10 scale to gauge the extent of a positive response.

The answers were noted as rarely or none of the time/ some or a little of the time/occasionally or a moderate amount of time and most or all of the time and scored as 0,2,4 and 6 respectively.

Addition of scores of all these answers was taken as the Total score (COVID-19). This total score (COVID-19) was the sum of scores of each of the eight questions, with minimum score being 0 and maximum being 48. The scores were taken as absolute values thus obtained after addition of answers of 8 questions.

3. Lockdown related questionnaire

All caregivers were assessed on three domains for the impact of lockdown on day to day living.

• Domain 1 dealt with difficulties in approaching medical care and assess to daily needs due to strict administrative measures and questions were asked as: delay in seeking medical care, availability of doctors at local level, availability of medications at local level, managing travel to hospital due to administrative reasons and availability of daily needs.
• Domain 2 asked questions dealing with financial condition like: bearing the cost of medications, bearing the cost of travel to the hospital, threat to future financial situation and expenditure on items of daily living.
• Domain 3 assessed psychological aspects with queries on: threat to day to day routine, experiencing social isolation, threat to integration with family due to excessive use of gadgets, threat to professional life/employment and if feel like escaping from the guarded surroundings.

Domain 1 and 3 had 5 questions each and Domain 2 had 4 questions. Each patient was rated as facing ‘none’, ‘minor’ and ‘major’ difficulty and scored as 0, 2 and 4 respectively. Addition of scores of the 3 domains was taken as Total score (Lockdown). Total score of each domain was the sum of scores of all the questions. Thus, Domain 1 and 3 could have a maximum score of 20 while domain 2 could have a maximum score of 16. Minimum score of any of the 3 domains was 0. Scores were analysed and interpreted as absolute values of individual domains and as total score (Lockdown).

Predominant thought process was noted as positive if the patient reported that he was hopeful that the situation will normalise in next few weeks. It was noted as negative if the patient felt that the situation will worsen/stay the same. COVID-19 related questionnaire and lockdown related questionnaire were carefully designed self structured questionnaires devised by the authors. They were subjected to extensive review by three experts to add to face validity. However, they could not be subjected to proper assessment of the psychometric properties because of time constraints and situation arising out of the pandemic. Reliability exercise could not be carried out.

4. General Health Questionnaire-12-Hindi version (GHQ-12): It is a 12-item screening instrument commonly used for measuring psychological distress and is validated in the Indian population. It was administered to evaluate the impact of lockdown on mental health. Any caregiver scoring ≥3 was defined as a case with psychological morbidity (32).

All the above four listed instruments were administered. Those caregivers scoring GHQ-12 score ≥3 at baseline were considered as experiencing psychological distress and counseled by the pulmonologist. At first follow-up assessment, those with a GHQ-12 score of ≥3 were deemed to be suffering from psychological distress and additionally advised to consult a Psychiatrist.

In addition, overall quality of life (QOL) at first follow-up (after relaxation of lockdown) was compared with the pre-lockdown phase on a scale of -10 to +10 (Score A). QOL before lockdown was scored as 10. If the patient reported his present QOL to be even poorer than his pre-lockdown QOL, he was scored on a Likert scale as a negative score (0 to -10). If his QOL seemed reaching the pre-lockdown score of 10, he was scored on a Likert scale as a a positive score (0 to +10). The caregivers were also studied for the impact of relaxation of lockdown on their QOL (day to day living) vs the lockdown phase on a scale ranging from -10 to +10 (Score B). At second follow-up, only the overall QOL at that point of time was compared with the pre-lockdown phase on a scale ranging from -10 to +10 (Score C) (Table/Fig 1). Score C was calculated similar to Score A, with pre-lockdown score for each caregiver being taken as 10 for uniformity at baseline.

Data collection was done by one to one interviews and administration of the questionnaires and study tools, in person, by the clinician.

Statistical Analysis

Categorical variables were reported as counts and percentages. Group (GHQ-12<3/GHQ-12≥3) comparisons were made with Chi-Square test or Fisher’s exact test, as deemed appropriate. Normality of quantitative data was checked by measures of Kolmogorov-Smirnov tests of Normality. Since the data was non normally distributed (skewed), hence values were given as mean±SD, range, median and inter-quartile range. For data, based on the basis of different groups (GHQ-12<3 /GHQ-12≥3), comparison was made by Mann-Whitney U test. Spearman correlation coefficient was calculated to see relation of different variables (quantitative data). For time related variables of skewed data, Wilcoxon Signed rank test was applied and McNemar’s test was applied for comparison between categorical values of different timings. The factors which came out to be significant in Bivariate analysis by Chi-square test/ Fisher’s exact test or Mann-Whitney U test were put to Bivariate Logistic Regression analysis. Analysis was conducted using Statistical Package for Social Sciences (IBM, SPSS) version 22.0. A p-value <0.05 was considered as statistical significant.

Results

Total 65 caregivers were enrolled in the study. Five participants were lost to follow-up. Hence, 60 caregivers were finally analysed. At first follow-up, 24 caregivers were interviewed in person, remaining 36 caregivers were telephonically interviewed. At second follow-up, all the caregivers were interviewed telephonically.

Mean age of the participants was 40.2±11.812 years with maximum caregivers 25 (41.7%) aged between 31-40 years. Majority of the caregivers 50 (83.3%) were males and 52 (86.7%) were employed. Majority of the caregivers 52 (86.7%) were not suffering from co-morbidities (Table/Fig 2).

At baseline and at first follow-up, 30 (50%) and 16 (73.3%) caregivers had a GHQ-12 ≥3, and hence were experiencing psychological distress respectively. At first follow-up, significantly lesser number of caregivers 17 (28.3%) were worried for COVID-19 (p-value=0.035). Significantly lesser number of caregivers 16 (73.3%) experienced psychological distress at first follow-up (GHQ ≥3) (p-value=0.001).There was a statistically significant improvement in Domain 1, 2 and 3 scores and total score (Lockdown related questionnaire) (p-value <0.001, 0.003, 0.001 and <0.001 respectively) (Table/Fig 3).

The association of psychological distress at baseline and at follow-up with various parameters/ scoring systems was done to see if disturbances in any of these parameters/scoring systems can be indicative of the psychological distress and thus alert the physician, and is depicted in (Table/Fig 4). At baseline, psychological distress was higher in those who were worried for COVID-19, had poorer domain 1, 2 and 3 scores, total score (Lockdown) and total score (COVID-19) (p-value=0.018, 0.005, <0.001, <0.001, <0.001 and 0.010 respectively). At first follow-up, it was significantly higher in those worried for COVID-19, who had negative thoughts, poorer baseline domain 1, 2 and 3 scores, poorer baseline total score (Lockdown), poorer follow-up domain 1, 2 and 3 scores, poorer follow-up total score (Lockdown), and poorer scores A, B and C (p-value <0.001, 0.001, 0.028, 0.025, 0.010, 0.002, <0.001, <0.001, <0.001, <0.001, <0.001, <0.001, <0.001 respectively) (Table/Fig 4).

Mean A. B and C scores were 4.42±3.03, 5.59±4.07 and 6.94±2.74 respectively. Mean C score was significantly better than A score (p-value <0.001). Mean C scores were poorer in those with psychological distress at baseline and follow-up (p-value=0.001). C scores significantly and positively correlated with score A.

Discussion

In the Indian subcontinent, family as a unit plays an integral part of the society. Because of strong familial and societal ties, caregivers play a substantial role in the management of their patients. Their psychological makeup, is very important for the well being of their patients.

Majority of the caregivers in the present study were males, reflecting the gender bias. In the male dominated Indian society, it is believed that males can handle problems better than females. A similar study in the past had all the female participants, as it was conducted on nurses as caregivers (23). Majority (86.7%) of the caregivers were employed, and representative of the financial heads of their families. In a similar previous study, 54.8% of the caregivers were employed (26).

Caregivers were enrolled after 15 days of announcement of lockdown. Due to travel restrictions, none of the caregivers was a COVID-19 suspect (6). Two caregivers felt the symptoms of their patients to be because of COVID-19. Twenty six caregivers were worried for COVID-19. Majority of our caregivers resided nearby, and hence approached us in-person. But many reported a difficulty in reaching the hospital. A few caregivers even requested for financial and travel related support and for a follow-up visit at a later date than advised.

Though all the caregivers were completely asymptomatic and apparently healthy, 50% were experiencing psychological distress. The ongoing pandemic, strict lockdown and its associates were the reasons. The present study results are similar to the caregiver psychological burden as reported in the past, where psychological burden of 42.3% in short-term caregivers and 46.5% in long-term caregivers was identified (27). Another study found 79.4% of the children to be psychologically disturbed due to lockdown (25). Other studies also reported similar results (23),(26),(33).

Caregivers felt difficulty in access to medical care for their patients and tried postponing it. Local practitioners were not available and medical shops, were closed. There was difficulty in procuring items of day to day use due to limited timings. This resulted in poorer domain 1 scores, which improved significantly with relaxation in lockdown, but were still far from normal.

Assessment on domain 2 showed that financial issues were facedby almost every participant, except those in regular Government jobs. There was near complete closure of work and no means of livelihood. Some people lost their jobs and exhausted their savings while others had to bear major salary cuts because of impending economic recession. The labor class and daily wagers were unable to purchase essential food items and were left at the mercy of others for feeding their families. The score immediately improved with relaxation in lockdown. With the slow and gradual resumption of work and business, people felt hopeful and financially secure. Still, the return to normalcy was far from reality.

Domain 3, which dealt with psychological aspects revealed that people were bothered for their employment and professional life, and financial losses arising henceforth. Loss of social circle, increased screen time, and little unauthentic information on social networking sites added to the psychological burden. Though some caregivers felt more integrated and closer to their families than ever before, however, financial insecuritywas bothersome. The score improved at follow-up, but did not reach pre-COVID-19 times. The results of the present study are consistent with the issues highlighted by the World Health Organisation (34).

As soon as the lockdown was relaxed, significantly lesser number of caregivers experienced psychological distress (GHQ ≥3). There was a ‘limited’ time bound return of professional and social life, however, return of livelihood to a ‘common man’ in a developing country like ours emerged as the biggest contributors to mental health in majority, as reflected in the present study results. Similar findings of improvement in mental health on relaxation in lockdown have been reported in the past too, where an improvement in the score of generalised anxiety disorder scale and impact of events scale-revised was noted (35).

At follow-up, significantly lesser number of caregivers were worried for COVID-19, showing adaptive behaviours over a period of time. However, few reported worsening of their thoughts, leading to even poorer mean VAS scores at follow-up than baseline.

Results of total score (lockdown), at baseline and follow-up confirmed the high inter-dependency of the three domains on each other. Correlation of higher psychological distress (at baseline and follow-up) with poorer scores of the different scoring systems shows the need to foresee the impact of lockdown in totality, and use these scoring systems as screening indices for identification and persistence of psychological distress. Its consequences on a common man should be dealt in a comprehensive manner during decision making and formulation of policies at administrative level. Same has been proposed by DA Silva M (36).

At follow-up assessments, the mean B score was higher than the Mean A score. People were adapting themselves to the ‘new normal’. Mean C score, hence was even better than score A, however, the scores were still far from the ‘real normal’ pre-lockdown scores (taken as a 10). This persistence of psychological distress in some caregivers shows that it may take a long time before reaching back to the pre-COVID-19 era.

The findings of our study regarding the ‘apparently healthy’ caregivers gains special relevance during preparations of subsequent waves of the pandemic. Varying degrees of lockdown may again be imposed (37). There were reports of breach in law and order due to distress of the caregivers (38). Mental healthcare professionals should be actively engaged in identifying such caregivers in ‘distress’ on priority and help in improving their coping strategies. Caregivers may have to play an equally important role in supporting our over-burdened healthcare system for streamlined management of such atrocities in future.

The present study is methodologically sound as it is a longitudinal study, with minimal drop out. Besides, unlike previous studies, questionnaire was not self-administered or online based but administered by a single clinician (KG) throughout the study using face-to-face/telephonic interviews.

Limitation(s)

Being an Outpatient based study with direct contact with caregivers of patients with respiratory complaints, there was a potential risk of exposure to COVID-19. Hence, a more comprehensive assessment of psychological aspects could not be done. Additionally, the questionnaire used in the present study was not subjected to proper assessment of its psychometric properties due to time constraints.

Conclusion

Psychological distress was experienced in 50% and 23.7% of the ‘apparently normal’ caregivers at baseline and at follow-up even after postlockdown ‘relaxation’. This huge burden of psychological distress, if left unevaluated, would have remained undetected. There is a need for future studies with larger sample size and use of simplified screening tools to detect this psychological distress early so that corrective steps are taken in the initial phases of such pandemics.

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DOI and Others

DOI: 10.7860/JCDR/2022/57196.17057

Date of Submission: Apr 19, 2022
Date of Peer Review: Jun 06, 2022
Date of Acceptance: Aug 16, 2022
Date of Publishing: Oct 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

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