**4. Psychosocial aspects of COVID-19**

Prolonged exposure to stress, regardless of age or race and ethnicity, adds another dimension to the pandemic's major public health threat. As a consequence, the COVID-19 infection and physical ailments produce pandemic-induced mental health issues that are critical challenges that must remain at the forefront of response. Studies reported heightened attention to evaluating social impact and community tension in order to facilitate psychosocial support to the population during this pandemic. The COVID-safe behavior such as social distancing, home isolation and security measures have grossly affected the social relationships among individuals and their perceptions of compassion towards fellow-beings. During the current unprecedented times in India, a large number of families are grieving their loss of near and dear ones. Prevailing mental health conditions triggered by a distressing or fearful event (either because of experiencing it first hand or by witnessing it) is commonly reported.

The current situation of COVID-19 is not only distressing for those grieving the loss of life, but it is also distressing individuals and families beyond, or irrespective of, their grief. People who are directly affected by the virus, or hit indirectly due to fear of infection, social isolation, and/or financial crisis, are struggling. More specifically, a large proportion of the Indian population have diverse and vulnerable life situations, such as people who are elderly and poor with chronic or acute ailments, migrant labourers, senior citizens, quarantined individuals in their homes or health facility, and families of those suffering or quarantined. Such large numbers of individuals are vulnerable and may show signs and symptoms of mental distress and emotional problems.

The pandemic has given rise to situations where these signs and symptoms of mental distress and emotional problems manifest in the risk of anxiety and depression, substance use, loneliness, and domestic violence; and with schools closed, there is a very real possibility of an epidemic of child abuse [16]. Several studies emphasized COVID-19's effect on mental well-being on vulnerable groups, including children, college students, and health care personnel, as they are more likely to develop post-traumatic stress disorder (PTSD), anxiety, depression, and other symptoms of distress [17]. While dealing with such public health emergencies, the past experiences have also testified that the generalized public fear and anxieties increase due to uncertainty, fatality, and lack of public health preparedness. Researchers must continue to investigate the strong link between mental and physical health [18, 19].

Across the world, anecdotal literature elucidates the large-scale reporting of mental health suffering of people. The literature calls for concentrated behavioral and mental health programmes to minimize and ameliorate psychosocial issues caused by the outbreak. In the current circumstances, crucial behavioral strategies such as physical distancing, hand hygiene and wearing masks, etc. are the only effective approaches to combat and survive the pandemic. Even so, there are a number of protective factors which may help alleviate these stressors and assist with maintaining good mental health among families and communities. Therefore, it is essential to systematically study the emerging psychosocial impacts and public health issues suffered by individuals in response to the lockdown or quarantining. Secondly, research needs to ascertain the psychosocial impact on specific vulnerable groups due to physical distancing, school closures, restricted health and social care provision, and loss of group activities. Thirdly, generating evidence for effective behavioral interventions, strategies and mechanisms to mitigate the psychosocial stressors and prevention of infections are equally important for developing policy and programmes for community mental wellbeing.

Similar to the recommendations above, comprehensive management and treatment of mental health issues at the institutional and community levels are just as significant as the various COVID-19 related protocols for physical health. Moreover, management and treatment of pre-existing mental disorders and new onsets are of an enormous concern. Lastly, it is imperative to understand the indirect effects of the pandemic and how these factors differ among population groups. The following discussions elucidate the psychosocial impact of Coronavirus disease on a few selected vulnerable populations. These notable lessons learned during the pandemic are highlighted here with a view to improving the effectiveness of policy planners, researchers and interventionist in the forthcoming months and improve future response.

## **5. COVID-19 and At-risk population**

The country's coronavirus pandemic response with regard to the people living in poor urban and rural settlements, migrant workers and other vulnerable populations has been meager and slow. The current situation raises concerns about health inequity in terms of accessibility and availability of basic health care services to survive during the deadly pandemic.

Therefore, in order to best plan for preventative care and appropriate interventions to move public health policy and programming forward, it is essential to further understand the indirect effects of the pandemic, including the psychosocial impact of COVID-19 in India, which has been well documented [20–24]. While the pandemic has not discriminated among the Indian population, several population groups, and even their subgroups, have been particularly at-risk of psychosocial impact. In particular, special attention must be given to respond to the unique risk factors of women, children, health care professionals, migrant workers, and people with disabilities, who are among some of the populations that are disproportionately vulnerable to the impact of the pandemic in most facets of their lives.

Adverse effects, such as the risk of abuse, significantly rise during global emergencies [25–27]. Violence against women, including intimate partner violence (IPV), further presents a public health concern that is impacting already strained public health systems during the COVID-19 pandemic. Several factors contribute to the anticipated, and confirmed, rise of IPV during the pandemic. With restricted movement and stay-at-home orders, consistently close contact, additional stress, and potential income reduction or loss of livelihood, women who have previously been abused can experience increased violence in the home. Further, contact with supportive friends and family may also be reduced as a result of social/physical distancing. Concurrently, caregiving responsibilities for women increase while school closures also add to the care work of women. Since many women work in the informal wage-earning sector, the loss of their livelihoods leaves families further vulnerable to resource scarcity, ultimately resulting in placing women at "greater risk for experiencing economic abuse" [27–29]. A case vignette is provided below to exemplify the increased risk women face during this pandemic.

#### **COVID-19 and the Increased Risks for Women**

When a domestic worker and her husband have both lost their jobs, Mrs. T. takes the responsibility to make ends meet to manage the household and feed her children while her husband spends their savings on his alcohol use. Mrs. T. explains that prior to the pandemic, her husband beat her at night after he got home from work. However, since he lost his job (he was a rickshaw driver), he beats her unpredictably in the day [30].

Furthermore, for women experiencing IPV, access to essentials such as hand sanitizer and soap may be restricted, while information shared with them about COVID-19 may be misleading and stigmatize partners [27]. Access to services is also further limited due to the reduction in services resulting from organizations having to scale back services due to the pandemic.

Additionally, as options for essential travel are reduced, women may find themselves in a double bind. They may be both further exposed to risks of violence as well as infection. With metros shutting down, and any available transportation responsible for disinfection and limiting passengers to one at a time, the connection from home to destinations has significantly increased in cost while simultaneously reducing the cost saving opportunity to rideshare [27]. Several researchers note that women, comprise 81.6% of the informal work sector and are precluded from accessing social protections such as unemployment and cash transfers [31–33]. Moreover, women have reported being harassed both inside, and while waiting for, public transportation [34, 35]. An updated 2019 nationwide survey of women commuters found that only 9% of women felt very safe on public transportation [36]. Therefore, not only do women find themselves potentially further exposed to infection when commuting, but they also incur further expenses due to limited options and increased prices for intermediary public transportation. Finally, with women's reluctance to use public transportation for fear of being vulnerable to both sexual and other forms of violence, more effective urban planning to create a safer physical environment is essential. However, equally important are the coordinated efforts of civil society organizations, police, and transport authorities to ensure the protection of women travelers [37].

The violence against women often results in physical injuries, including affecting sexual and reproductive health, mental well-being, and perpetuating sexually transmitted diseases [38]. Risk factors that predispose vulnerability to violence, include economic stress, social isolation, poverty and associated factors (such as overcrowding and unemployment), poor neighborhood support and cohesion, unwillingness of neighbors to intervene when witnessing violence, and traditional gender norms and gender inequality [27–29]. Such risk factors are further exacerbated due to the pandemic. Although crimes against women are mostly unreported, or underreported at best, records suggest that this is a significant social and public health epidemic. Prior to the onset of the COVID-19 pandemic, of the 4.05 lakh registered crimes against women in 2019, over 30% of them were domestic violence occurrences [39]. Since the onset of the nationwide lockdown in response to the COVID-19 pandemic, the National Commission for Women has reported an increase of domestic violence being more than 2.5 times the previous rate of occurrence [40].
