This was a cross-sectional, observational survey conducted online, open to participants from different states of India between 4^th to 16^th May 2020. Study was approved by the Institutional Ethical Committee vide letter no HIMS/RC/2020/147. The objectives, benefits and use of the study were shared with each participant in written format prior to administration of the questionnaire. Form setting was done in a way that participants could answer the questionnaire only after providing consent. No personal identifiers were collected during the interview and no personal identifiers were disclosed anywhere in the study.

Considering the fact that country was in lockdown and face to face interviews were not possible snowball sampling technique was used for the recruitment of participants.

Online survey was initiated using Google forms. A self-administered semi structured questionnaire (containing 40 questions) was prepared in English with closed and open ended questions which was divided into sections for demographic details, knowledge and awareness (six questions with 17 selectable items including mode of transmission, preventive measures and symptoms) of COVID-19. Questions were made with data available from literature and advisories in WHO and Ministry of Health and Family welfare India websites [3,5,7]. Questionnaire was checked by providing link to peers in department prior to release of the link for assessment of ease of filling and to know any discrepancies in filling.

GAD 7, a self-administered questionnaire developed by Spitzer RL et al., was used as a tool to measure the anxiety among participants. Sampling universe of this study was parents of the children (who are less than 18 years of age) with access to internet and ability of understanding English [16]. The form was released in peer groups on whatsApp on 4th May 2020 at 6 PM, responses were accepted up to 16th May 2020 10 PM. Questionnaire took about ten to fifteen minutes to fill during pilot study. Five participants from department were included in pilot study questionnaire was released on peer groups of social media and not sent individually, convenient sampling was used and sample size analysis was not undertaken. No modification was made in the questionnaire after pilot study.

Collected data was cleaned and coded, entered in Microsoft excel sheet. Data was analysed using Statistical Software Social Sciences (SPSS) version 22 for windows. Descriptive statistics were calculated for socio-demographic variables, media exposure, anxiety and depression. Continuous variables such as age are expressed as mean±SD and categorical variables (demographic and knowledge and awareness of COVID-19) expressed as frequency (percentages). Independent t-test and one-way ANOVA was applied to test the statistical significance among outcome and independent variables. The p-value less than 0.05 was considered as significant.

Of the 121 individuals accessing the survey, 85 (54 males; mean age 38.1±5.9 years, 31 females; mean age 37.9±7.4 years) consented to participate. Maximum number of responses were from Uttarakhand 43(50.6%) followed by Delhi 11(12.9%). The mean age of their children was 7.5±4.7 years. It was observed that 27% respondents had single child, 32.9% had one sibling. A small number of children (5.9%) were on long term medications for other illness. The baseline socio-demographic characteristics of the participants are depicted in [Table/Fig-1]. More than half of the participants 76.5% (n=65) were healthcare workers. Majority of them reported that their children neither have a known chronic illness (96.5 %) nor a history of any chronic medicine intake (94.1%).

We observed that all respondents had some information regarding the current pandemic. The major source of information was internet (84.7%) followed by television (80%). Nearly half of them (50.6%) were accessing information daily. Around 64.7% (n=55) participants were satisfied with the available information. A considerable proportion of the participants were aware of the ways of transmission of coronavirus infection. Around 97.6% knew that it gets transmitted by direct contact with the infected person, 96.5% of the participants were aware of the different ways of prevention and 91.8% were aware of presentation of coronavirus infection, while 8.2% denied knowledge of symptoms of COVID-19 [Table/Fig-2].

Many of them (87.1%) agreed to have shared the information regarding the current pandemic with their children. A significant proportion of the respondents were worried either about themselves or their children getting infected from the coronavirus infection. Around 58.8% (n=50) visited the hospital during the lockdown period and 87.1% (n=74) were apprehensive of the hospitals being a high risk area, with the most common fear being of getting infected from others. Unavailability of regular doctors (n=15, 17.6%) and extra time in screening for COVID-19 (n=11, 12.9%) were among other problems faced by study participants. 89.4%, responded yes and 10.6% responded no when asked if their family members got ill during lockdown.

It was observed that the current pandemic has impacted daily routine of most children (81.2%; n=69), with 83.5% (n=71) being unable to play outside their home and 81.2% (n=69) reported increased screen time. Around 41.2% (n=35) parents noticed behavioural change in their children with the most common change being getting addicted to mobile and video games (61.2%; n=52). Nearly half of the children (52.9%), missed their friends and 22.4% were worried about their studies being affected. We observed that 25.9 % parents were worried that the behaviour changes may become permanent.

It was found that a significant proportion 80% (n=68), felt anxious due to the COVID-19 pandemic. The mean GAD 7 score was 7.4±4.0. Individual responses to GAD 7 questions are presented in [Table/Fig-3]. No difference in the mean GAD score was noticed between the healthcare and the non-healthcare workers (7.8±4.3 versus 6.2±2.4, p=0.109). Mild anxiety was observed in a significant proportion of the participants (76.5%, n=65), moderate anxiety was seen in 15.3% (n=13) and severe anxiety in 8.2% (n=7). Variables compared with GAD 7 score are depicted in [Table/Fig-4]. A one-way ANOVA revealed a statistically significant difference in the GAD among parents differing in the gender {F(2, 82)=3.275, p=0.043} and their opinion on behavioural changes observed in their children {F(2, 82)=4.697, p=0.012}. Among the various coping methods assessed, finding preventive ways to getting infected was opted by the majority (83.5%; n=71) while 60% tried to develop a new hobby or skill for coping.

Infectious outbreaks have an adverse effect on the mental health of the population. Lack of knowledge and awareness about the pandemic leads to inadequate preparedness to meet the unprecedented challenges arising out of these outbreaks [17]. Parents by virtue of an added responsibility of safeguarding their children are more prone to such mental health consequences. This study was, therefore, undertaken to evaluate the knowledge, awareness and anxiety towards COVID-19 among the parents; and to identify the behavioural changes in their children.

In the present study, we found that majority of the participants (8.2%) had severe anxiety as assessed by GAD 7 score. This is in agreement to other published reports on healthcare workers, and other vulnerable groups [15]. Any significant difference between the mean GAD 7 scores of the healthcare and non-healthcare workers was not found. This is in contrast to previous studies where healthcare workers were found to have less stress and anxiety compared to general population [18]. This could be explained by smaller sample size of this study. People generally adapts to various coping methods in order to comfort themselves during anxiety. It was found that a majority of study participants opted to find various preventive measures as coping measure. This could be a result of the active interventions taken by Government of India and other Institutions in order to instigate knowledge and awareness among general population.

Adverse influence on the daily routine of children was observed to be more if the parents had higher GAD 7 scores (severe anxiety). Also, those with higher GAD 7 scores, noticed behavioural changes in their children and reported that their children were unable to follow social isolation measures. This can be attributed to the fact that parental behaviour is likely to influence the child’s psychological well-being [19].

As shown by previous studies [17], better knowledge and awareness towards the pandemics influences the behaviour of the people in community. Similar to previous studies [14], we too found a satisfactory level of knowledge and awareness towards the current COVID-19 pandemic among the study participants. This could be explained by the fact that majority of participants of the present study were educated and thus were able to get themselves acquainted to the disease, and its preventive aspects. The major source of information was internet followed by television. This was in agreement with the past studies which reported internet and television as the prime source of information during infectious outbreaks [20]. No difference in the mean GAD 7 score was seen among participants accessing different information sources. This is in contrast to the previous reports where an increased anxiety was associated with the internet as the major information source during the infectious outbreak [21].

Small sample size, restricted to those with an ability to understand English and access to smartphones. The results of this study cannot therefore be generalised to all sections of the society.

Nation-wide lockdown instituted to curtail the spread of COVID-19 infection, has to some extent, disrupted the normal routine of children. This along with a high level of anxiety among Indian parents influences child’s mental health. Increased awareness among general public towards the current pandemic and the ways to tackle the situation is crucial in preventing both short- and long-term mental health complications. Large survey with support from local organisations in future will help in identifying the issues in a better way.