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Abstract
Introduction: The COVID-19 pandemic has left an array of direct physical consequences unevenly on the elderly apart from leaving a wide range of indirect consequences of mental health problems on them. This study aims to understand the effect of a Yoga-Meditation based mobile phone application intervention to reduce the duress by mental health issues via a qualitative analysis. Methods: A phenomenological qualitative succession of an explanatory sequential design of a prior quantitative study followed by a Yoga-Meditation mobile phone based intervention, where 30 participants who had mild or moderate Depression, Anxiety or Stress as assessed by DASS-21 were chosen by random sampling and were asked to take part in an interview. The interview was transcribed, coded, patterns identified and themes were created to understand the perceptions. Results: Three major schools of thought were identified and explored to understand the general perception of Mental health, COVID-19 and the intervention: a) Knowledge Axis patterns of COVID-19, which included their prior knowledge about the disease, its consequences and their cues to action based on those beliefs, b) Mental Health and Strategies to Positivity, involves all their actions to promote, restore or propagate a positive mental attitude from religious activities to physical activities and c) Application related thoughts, involved their perceptions of the app, the barriers to use and suggestions to improve. Conclusion: This study gave deeper insight into the schools of thought which will be important in designing future interventions and yoga-meditation based programs in the future, essentially for geriatric populations as it serves as a feasible simple measure for the same.
Keywords: DASS, geriatric psychiatry, meditation, mental health, quarantine, yoga
How to cite this article: Introduction 
The coronavirus disease pandemic has left the world with consequences ranging from physical health to economic destabilization yet, a rather unspoken side of indirect consequences does exist. In efforts to remission of the pandemic, an uneven spread of psychological consequences has emerged and do exist as the immediate problem in the early post-pandemic era. The geriatric population were at an increased risk of morbidity and mortality due to COVID-19 due to an array of preexisting conditions and age related physiological changes in immunity.[1],[2],[3],[4],[5] Taking into consideration the magnitude of these consequences, various international organizations and governments have taken initiatives to arrest the mental health pandemic.[6] This special emphasis was due to the additional burden faced by individuals, especially the elderly, due to the pandemic, beyond the domains of physical health, as during quarantine periods (lockdowns), the elderly faced frustration, depression, and anxiety due to separation from family and friends, boredom due to lack of social interactions and movement restrictions, irregular or inadequate access to daily needs and utilities such as food, medicines, toiletries, and a constant input from media sources about the disastrous consequences of the pandemic, which invoked further fear in them.[5],[7]
Many studies have assessed the efficacy of yoga on cognitive and mental health parameters among the elderly. Yoga-based interventions have had positive results in attention improvement, executive functions, and memory. However, methodological limitations and a small number of studies hold us back from confirming the potential benefits of yoga-based interventions on cognition and mental health among the elderly.[8] Results from studies conducted show that yoga-based interventions improve multiple physical functions and Health-Related Quality of Life outcomes in the elderly population. Promoting yoga in physical activity guidelines for older adults as a multimodal activity helps in improving aspects of fitness, physical well-being as well as mental well-being.[9] Current research work done in the field of yoga shows a heterogeneous and subjective impact on the well-being and mental health of individuals but has been generally favorable toward the application and incorporation of yoga in the daily routine in a nonclinical population setting. Yoga contributes to a significant increase in psychological well-being in comparison to no intervention but not in comparison to physical activity.[10] The practice of yoga and meditation is associated with better mental well-being during the COVID-19 pandemic. The frequency of practice of yoga was positively associated with a higher level of mental well-being in the case of both yoga as well as meditation, with daily practice having the highest well-being scores.[11]
Yoga is an ancient Indian science, and it helps the individual attain equilibrium of the mind and body by adopting meditation, pranayama (regulated breathing), and asanas (physical postures). As yoga represents an amalgamation of the body, mind, and soul, yoga is not merely a physical exercise but has a lot more dimensions to it. Hence, yoga is both similar to and very different from mainstream physical exercises. Evidence suggests that yoga interventions appear to be equal and/or superior to exercise in most outcome measures.[12],[13] Practicing yoga and incorporating the yogic lifestyle with one's own can be beneficial to improving psychological health and physical health[14] Yoga is now recognized as a form of alternative medicine that uses holistic, mindful practices and has been interpreted as a process of uniting the body via mind and spirit to promote physical and mental wellness. Yoga was found to be a beneficial, cost-effective, feasible, and safe intervention. The positive physical or psychological outcome of Yoga intervention has been hypothesized to be a result of complex pathways involving relaxation, physical flexibility, breathing exercise, coping strategies, acceptance, and self-efficacy.[15] Another feature that aids the process of having Yoga being incorporated into the mainstream lines of therapy for mental health issues is that the elderly Indian population is already aware of yogic practices and in positive beliefs of their benefits.[16]
Yoga, along with the usual psychotherapy and pharmacotherapy, was found to be effective in reducing symptoms of depression compared with regular treatment alone.[17],[18],[19] COVID-19 restrictions provided a unique situation to put in practice the use of online yoga participation and its acceptability, limiting the effect of social distancing to mere physical distancing for many elderly. Online delivery of yoga via apps increases access to a potentially helpful and low-risk activity to a much broader population, particularly important to people who need a structured plan for practicing yoga where facilities are not available. This study is especially important as the app developed videos keeping the elderly population and their comorbidities in mind by a team of trained professionals and doctors.
Mental health and mood benefits were rated as the most important aspect of yoga practice in this sample, and these perceived benefits obtained through online yoga were comparable with those reported from in-person yoga.[20],[21]
Tele-yoga intervention is safe, feasible, and very helpful for improving individual well-being with a holistic approach. The importance of switching from a traditional face-to-face delivery of yoga classes to a tele-yoga format is especially important in times of COVID-19.[22]
This provides a modality that can be modified to suit one's lifestyle and daily routine, which the user can use at their discretion. The primary aim of this study was to assess the effects of a Yoga-meditation-based intervention among the elderly in altering the effects of mental health problems during the lockdowns in India.
Objectives
Primary objective
To document their perceptions, practices, attitudes, feedback, and suggestions regarding yoga and meditation-based intervention.
Secondary objective
To document the factors responsible for the change in levels of stress, anxiety, and depression among the elderly.
Methods Overview
Study design
An explanatory sequential design in a mixed methods study where the first phase of quantitative data collection and analysis was followed by the collection of qualitative data, which was used to explain the initial quantitative results.[23]
A qualitative study was conducted as a component of a larger mixed methods study, of which the quantitative study has been published elsewhere.[24] The study conducted involved the baseline assessment of the mental status of the geriatric population due to COVID-19 and its lockdown in India using a DASS Scale in a tertiary care centre in Central India. The screened participants who had stress, anxiety or depression were asked to practice yoga-meditation using a mobile application.[25],[26] Individuals over the age of 60 at the time of reporting for COVID-19 vaccination who were then free of any COVID-19 symptoms, were recruited via convenience sampling methods as consecutive recruitments until the required sample size was met.
In total, 705 were recruited in the study, and the individuals were provided with a detailed information sheet and consent forms before any diagnostic test. The participants were explained the purpose, process, reason for their eligibility, benefits of the study (mental health assessment, free Yoga-meditation app, and post program completion incentives), and all possible disadvantages. The methodology has been schematically represented below in [Figure 1].[27]
Figure 1: Schematic representation of Methodology. Created using biorender.comOf all the individuals who were screened to have mild or moderate depression, anxiety or stress, stratified random sampling was used to select 30 individuals for the qualitative study. If any of the participants disagreed, the next strata forward was selected until all 30 slots of interviews were filled. All the selected participants were requested to participate in a narrative interview with predesigned interview questions to unearth, comprehend, and explain the possible effects of COVID-19. Our study assessed the consequences of the pandemic on mental health in the geriatric population. Their experiences, attitudes to the COVID-19 pandemic, the benefit they had while using the yoga and meditation based software app, its advantages, challenges, as well as recommendations were documented.
Data collection
A trained qualitative researcher who was not involved in the mental health assessment and participant interaction before the interviews conducted the interviews either face to face at the participant's residences or via telephones based on the participant preferences at the time from August 2021 to December 2021, and conversations were recorded for further transcription. The interviews were conducted in Hindi or English, as per the participant's preference using a pretested and language-validated questionnaire. The interview guide was designed to be open ended to avoid leading and probing onward specific lines of thought, which were designed to capture participant responses in detail and develop better in-depth comprehension of each statement. The interviews were exported onto a singular laptop, and the qualitative researcher went through the recordings multiple times to familiarize themselves with the interviews. The interview questions comprised of a series of topics as follows: personal opinions on COVID-19, its impact on people, their mental health, the major stakeholders of the consequences of the pandemic and lockdown, their health profiles, measures adopted to overcome the mental health scenario, and based on whether they completed the yoga-meditation program or not, their perception, perceived benefits and suggestions or reasons for nonparticipation, shortcomings, and suggestions, respectively. All 30 interviews were completed even though data saturation was apparent before completion to ensure no data mis-outs and inclusion of all possible points of view. The interviews were primarily transcribed verbatim in the language of the interview by the interviewer. The language predominantly used was Hindi.. All transcriptions were converted to English by a professional translator. The legitimacy and correctness of the translation was checked by comparing again to the initial interview. These were verified by the researcher.
Post transcription-translation, all data were uploaded into N-Vivo windows on a password-protected laptop, to ensure the confidentiality of responses, and all interviews were coded to maintain anonymity. The interviewer, based on experience, logical flow of thought and categorization, and an analytical approach, coded all statements of the interviews on the N-Vivo Windows software where the a priori categories/nodes were designated by the interview guide questions. The method involved segregating the codes and on completion of coding, themes, sub-themes and sub-sub-themes were designated based on the commonalities in the flow of thought, which guided the summary writing process. Pattern sequences and themes were extrapolated from the interviews with continuous discussion and consensus from senior qualitative research and the entire investigative panel for ensuring authenticity and quality of work, and each thematic pattern was reflected back to the original transcripts to ensure no false interpretation and ensure accurate, appropriate, and adequate views of the participants.
Data analysis and interpretation
Themes from the interviews were apparent by the streamline flow of thought that was found to be common, as explained by the interpretative phenomenological approach.[28] The data analysis was divided into stages; where in the premier stage, the entire transcribed-translated interviews were read with open thought with no coding done. The second stage involved highlighting interesting or unique lines in each text which the researcher assumed to be significant for each individual interview, and then in the third stage, each question of all interviews was analyzed in one go, in comparison to the entire individual in the previous step, to ensure no common pattern or link is missed. In the fourth stage, the emergent patterns were recognized, and significant ones were identified as themes. The recognized themes were then suitably connected or grouped together to form subthemes and organized in chronological order, as per the interview guide and further after analysis, they were reconstructed to a different order based on logic, theoretical sense, and conceptual flow of thought (in the cause-effect relationship) to better depict the connection between them and the overall patterns that emerged. The final emergent themes were validated by the research team, and any changes, if suggested, were incorporated at the discretion of the majority. All reporting of the qualitative data was performed as per the COREQ checklist [Supplementary Material 2].[29] The entire methodology is summarized schematically in [Figure 1].
Results The interviews of 30 individuals who were diagnosed to have moderate to mild depression, anxiety, or stress by the DASS scale had durations ranging from 7 min to 44 min with an average of 14 min. Since the sampled population for interviews were chosen at random, i.e., representative of the sampled population, the socio-ecodemographic parameters were assumed to be similar to the sampled population, as shown in [Table 1]. Four-fifths of the sampled population were either retired or housewives during the course of the COVID-19 pandemic and majorly resided in urban areas and had an education above primary levels, with the majority of the population being males. The population reported a very low level of tobacco and alcohol use. A majority of the population did report an increased financial burden during the COVID-19 pandemic. A significant portion of the population reported no significant physical or mental health deterioration during the pandemic.
Table 1: Depicting the sociodemographic and baseline characteristics of the entire sampled population (n=705)[Table 1] depicts the overall socio-ecodemographic characteristics of the entire sampled population, whereas it is essential that a comparison be made between the objective perception of their mental health status with respect to the overall perception of their mental state, and in comparison to their self-perceived mental and physical health awareness [Table 2]. A parallel comparison has been depicted below.
Table 2: Depicting the average DASS values for the 30 participants interviewed, in comparison to overall scores and overall self perceived mental and physical healthOn reflection, the entire pattern of flow of thought of the participants was segregated into three major categories, which wholesomely represented with exhaustion, the effects of COVID-19 on the mental health of the elderly and all others, strategies to overcome them, perceptions about the yoga-meditation app as a strategy and amendments of the same.
These patterns were further analyzed and classified into schools of thought that are the detailed under the following subheadings: Knowledge Axis patterns of COVID, Mental Health and Strategies to Positivity, Application related thoughts.
Knowledge Axis Patterns This school of thought refers to all aspects of understanding which pertain to the individual interviewee themselves tagged as a facilitator or a barrier toward improving mental health during the pandemic, which ranges from primarily knowledge-based factors, where their beliefs about COVID-19 and Mental Health exist. This limitation generally exists as a linear axis, beginning from knowledge or perceived truth about COVID-19, Mental health's existence, their beliefs on perceived effects and severity of mental health problems and COVID-19 alike and their cues to action based on said beliefs. The entire knowledge axis pattern's major nodes have been represented in [Table 3] and [Supplementary Table 1].
Understanding COVID-19 and its consequences
Most participants stated that COVID-19 was a dangerous viral disease that has now spread across the world and has affected many individuals, while some participants believed that COVID was a “warning from nature” to humankind. The consequences of COVID were not of singular domains, and many participants stated that COVID affected children and the youth, while some mentioned that old people and poor people were affected the most gravely by the disease. With respect to how they were affected, most participants stated that mental health issues such as fear of death and disease, lack of confidence and motivation, depression, anxiety, disinterest in doing work, irritability, loneliness, and loss of social and familial relationships, stress existed among all people apart from other effects such as physical weakness, fever, and vomiting. Some participants also stated that COVID-19 caused a significant financial loss and logistical problems for oxygen, medicines, and hospital accommodation during the disease. Some individuals also stated that there was absolutely no mental health burden by COVID-19 at all.
“No, there is nothing like depression. We or our children have not had depression” said a participant (Elderly male).
Mental health and strategies to positivity
Strategies to improve mental health
Almost all participants, especially the elderly, stated they had tried some method to prevent the deterioration of mental health or to improve it during COVID-19. Most participants stated that Yoga was their primary strategy and method to overcome mental health issues, with many others also saying a positive attitude and continuing life as per normalcy before COVID, meditation and physical exercise/activities are also key contributors to improving mental health. Less common strategies were praying and religious faith. When questioned about the time and effort needed from each strategy to improve mental health, most participants stated a continuous effort for 12 h a day is necessary to improve or prevent deterioration.
Other less common responses were 15 min a day for weeks to months, while some specified that it was not a specific amount of time or effort, rather depend on how emotionally destabilized the individuals were. Other rare responses specified that one needed to spend more than 2 h a day to satisfy mental health needs alone.
“In a whole day at least 1 h should be given to our body. We have to practice yoga and meditation for at least 1 h to relax us as the whole day physical and mental activities are going on.” said an elderly male participant.
Perceived benefits of yoga and meditation
As almost all participants stated that they practiced yoga or meditation in some form, questions about their perceived benefits were put forth to them. Most of the participants stated that yoga provided a dual benefit of both physical fitness and mental health during the COVID-19 pandemic for them. Many also specified how it helped energize them every day and provided a sense of peace and helped pass the time as they incorporated it into their daily routine, while some also did specify there exists no benefit of doing yoga at all.
“There is no point in doing Yoga at this age” argued a participant.
Application related thoughts
Participant experiences of yoga app
To provide a source of motivation and tutorship, we also created an online application for the participants which had prerecorded videos of various asanas (yogic postures) and progress trackers for participants over a 6 weeks course for them to complete. When inquired about the application, most participants stated that they had not used the app due to problems of logistical and technical issues, such as the application was hard to download and was not opening on their devices. Some elderly participants stated that “they did not have anyone to help or teach them how to use the app”. Some shared that “They were already practicing yoga regularly with another source and did not want to discontinue that. Some participants also stated that they were traveling or simply just did not try the application due to personal reasons and prior commitments. Of those who did use the application, they specified no problems but rather spoke about the systematic methods and approach of the application, easy postures for all old age groups to perform and was very informative to the participants.
To improve the application, suggestions were welcomed from the participants, and most participants suggested that it be made available on the Appstore/Playstore so that it is easy to download, to provide live classes whenever possible and allow participants to contact medical support via the application itself for postures, diet, and positive motivation. Some other rare suggestions were the introduction of personalized postures and meditations based on the needs of the individual and an increase in the attention grasp of the videos to enable adherence to the use of the application. Most participants also stated that they would recommend the application to more people so that they may reap the benefits of the application too.
The geriatric population invariably shows an increased risk of COVID-19-related complications ranging from morbidity to mortality across the globe, yet this study stems to highlight the consequences of the disease on the mental health of the geriatric population and the effects of a Yoga-meditation based intervention to aid them. Similar qualitative studies performed by Finlay et al.,[30] McKinlay et al.,[31] McKenna-Plumley et al.,[32] and Mishra et al.[33] do indicate a diverse and wide sources of strength and resilience among older adults to cope with adverse psychosocial, sociocultural, behavioral, and socioeconomic consequences of the pandemic. In this study, we identified various psychological expressions as responses to the pandemic and to the yoga-meditation-based intervention conducted, ranging from knowledge and beliefs, fears relating to physical health, mortality of self or dear ones, mental health, and socioeconomic health.
The entire spectrum, when studied, an overwhelming majority did not indicate any significant mental health problem in the designations of depression, anxiety, or stress as assessed by our preliminary study, contrary to the belief that most of the geriatric population are brittle, weak and would easily succumb to the emotional distress.[16],[34],[35] This qualitative study focused on the individuals who did complain of significant emotional distress and their perceptions, beliefs, and attitudes toward the pandemic and the intervention. As most participants began isolation significantly earlier, to shield themselves from the consequences of the virus while accounting for their increased vulnerability to the disease, there was a greater coherence to the demand of physical health by physical distancing, but their mental health did not face the same benefit. To overcome this physical distance, social networking and the Internet must have played a large role in reducing the severity of depression in many of the elderly.[36],[37] This very tool was employed to reach as many affected elderly as possible via the Yoga-meditation program and based on the intervention, which revealed three major schools of thought: (a) Knowledge Axis patterns of COVID which depicted the linear axis from knowledge of COVID-19 to actions that curated the beliefs such as greater need of physical distancing as compared to the necessity of physical socialization, the various stakeholders of the negative aspects of COVID-19, (b) Mental Health and Strategies to Positivity which mostly entailed work endeavours that helped distract the population from the subjective feeling of loneliness through various physical activities (such as prayer, yoga and meditation and assumption of a normal routine, regardless of the physical restrictions) and social networking, (c) Application related thoughts which revealed a plethora of benefits of the app, such as overcoming the physical barrier of not being able to attend live group sessions and hence resorting to some motivation to do it online, continuous support and benefits of yoga and meditation on physical and mental health and finally suggestions to improve the application to include age varied postures, diet and health consultations. The general trend of the participants was a positive response toward the application as depicted by the study, to aid in the mitigation of fear, depression, anxiety, loneliness, and stress.
In the app provided to the participants, one of the exercises included deep breathing. This helped to loosen the grip of fear on consciousness. By relaxing with every exhalation, and inhaling deeply but slowly, the circulation came back to normal especially in elderly subjects who were overcome with the dread of contracting COVID-19 disease. Most venous deoxygenated blood is converted to oxygenated blood by deep breathing. Inhalation, holding of breath, and exhalation are all part of the pranayamic breathing process. It provides the body with an enhanced supply of oxygen via the lungs, and this oxygen “burns” or oxidizes the waste pollutants in the venous blood, primarily carbon. This purification process is aided by a significant increase in waste carbon dioxide evacuation from the lungs during exhalation. As a result, just a little amount of tissue remains in the blood as waste. As blood flow to the lungs for purification slows, there is less demand for breathing. The heart and lungs are given extraordinary rest.
Uniqueness of the app
The niramaya bhava app taught the elderly to live a balanced and successful life by awakening their connection to the Divine. It is easy to feel overwhelmed by the stress and pressures of everyday life and become distracted by the expectations placed upon us by others and society. But through yoga and meditation the elderly realised that they had everything inside them they needed for ultimate peace, security, and happiness in trying times of COVID-19. The Niramaya Bhava App included guided yoga sessions taking into consideration of the flexibility of the elderly. They were able to practice yoga in the comfort of their homes during COVID-19. The elderly were able cultivate a habit of daily meditation.
Conclusion This study gave deeper insight into the schools of thought which will be important in designing future interventions and yoga-meditation based programs in the future, essentially for geriatric populations as it serves as a feasible simple measure for the same. Fear of virus was worse than the virus itself. Understanding the qualitative effects of the application apart from just scores and values helped us understand our shortcomings which we will use to better our services
Limitations of the study
The study had and in both its sequential steps had more male participants than female, which may have affected the results, but this was accounted for by the random selection of participants for the interviews, which had the same proportion of sexes as the quantitative study, so the same trends of thought can be analyzed. The study suggestions and recommendations were also sequentially resolved; thus, the problems faced as the interviews progressed may have also changed.
Ethical clearance
Ethical clearance was granted by the Institutional Ethics Committee of the All India Institute of Medical Sciences, Bhopal, after due recommendations from the Research Review Board, the entire protocol, the participant information sheets, consent forms, and interview guides were submitted and approved by the committee vide LoP number IHEC-LOP/2020/EF0221.
Acknowledgments
The authors would like to express their gratitude to Dr. Anindo Majumdar, who trained the qualitative researcher with extensive knowledge, classes, and examples to conduct the interview and also served as the expert reviewer in times of conflict or lack of clarity. The authors also express their gratitude to all the participants of the study who took time to take part in the interviews for the purpose of this study.
Financial support and sponsorship
This project was performed under a grant provided by the Department of Science and Technology under the project Titled SATYAM (Science and Technology of Yoga and Meditation) vide number DST/SATYAM/COVID-19/2020/137 Sanction Order.
Conflicts of interest
There are no conflicts of interest.
References 
Correspondence Address:
Ananyan Sampath
All India Institute of Medical Sciences, Bhopal, Madhya Pradesh
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijoy.ijoy_121_22
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