An observational cross-sectional study was conducted in the Department of Community Medicine, Nilratan Sircar Medical College and Hospital, Kolkata, West Bengal, India, over one month (September 2020 to October 2020). Ethical permission was obtained from Institutional Ethics Committee (N0/NMC/3724 dated 09.09.2020).

Inclusion and Excluision criteria: The women residing in West Bengal for more than six months period, more than 18 years of age, having access to electronic media, internet services, and/or with an account in any social media were approached for an online survey through the social network. Those who did not have an account in social media were approached through e-mails and short message services. Women not willing to participate in the study were excluded. Those participants already suffering from any psychological illness were excluded from the research based on past history.

Sample size calculation: Taking prevalence of moderate to severe anxiety of 28.8% [12], the sample size was calculated by the formula, N=Z²pq/L²; where N=sample size, p=prevalence, q=100-p, Z=standard normal deviate=1.96, L=allowable error=10%. The sample size was estimated at 979. Thus final sample size was calculated as 980.

The electronic version of a semi-structured questionnaire was developed with a consent form attached to it. Initially, contacts of the researchers were requested for verbal consent for participation in the study. The link of the questionnaire was sent through e-mails, WhatsApp, and other social media to the contacts of the researcher. The participants were then asked to forward the questionnaire to the adult female contacts who were residents of West Bengal for atleast six months. The snowball sampling method was used to recruit participants further till the desirable study population was achieved. Those fulfilling the inclusion criteria were considered as the study population. It was an anonymous survey and data confidentiality was assured. All eligible participants were required to fill up all the sections of the link form and submit it online.

The self-reported questionnaire collected information regarding socio-demographic features, personal characteristics, past episodes of chronic morbidity, present complain of any significant symptoms, family history of a major illness or non-communicable disease, and their anxiety disorder was assessed by Generalised Anxiety Disorder-7 item (GAD-7) scale [13]. The reliability along with criterion, construct, factorial, and procedural validity of the GAD scale to measure anxiety was evident in the general population [14,15]. The scale had an optimised sensitivity of 89% and specificity of 82%. The total GAD-7 score was calculated by assigning scores of 0, 1, 2, and 3 to the response categories, respectively, of “not at all,” “several days,” “more than half the days,” and “nearly every day.” GAD-7 total score for the seven items ranges from 0 to 21. A score of 0-4 as minimum anxiety, 5-9 as mild anxiety, 10-14 as moderate anxiety, and 15-21 was considered as severe anxiety. A score of 10 or greater on the GAD-7 scale represented reasonable anxiety among the study subjects [15,16]. No identifiable information was collected. At the end of the questionnaire, the method of scoring was described and asked the participants to seek medical attention if the score was above the cut-off value of 10. Data were compiled after data collection.

The analysis was done with help of Microsoft Excel 8.0, Epi Info: Version: 7.2.2.6/February 2, 2018, and Statistical Package for the Social Sciences (SPSS) version 16.0 (IBM). Results were presented as percentages and proportions and the Chi-square test along with Multiple Logistic Regression analysis were applied as the tests of significance. A p-value less than 0.05 considered significant.

In the present study, 980 women participated by filling up the electronic version of the questionnaire in Google forms. Age varied from 21-78 years with a mean of 34.12 years, median 30 years, mode of 23 years, and standard deviation was of 12.84. The majority of the study population (830, 84.7%) were from urban areas, 198 (20.2%) were professionally qualified, 385 (39.3%) postgraduate and 214 (21.8%) of study subjects were graduate [Table/Fig-1]. Among the study population, 96 (9.8%) were addicted to smoking, 52 (5.3%) to chewing tobacco, and 73 (7.4%) were addicted to alcohol. About 556 (56.7%) of the study population were suffering from any form of chronic morbidity. The co-morbidity found were hypertension (183, 18.7%), thyroid disorder (146, 14.9%), diabetes mellitus (130, 13.3%), and others like ischemic heart disease, Chronic Obstructive Lung Disease, liver disease, stomach ulcer, arthritis and psoriasis were present in 242 (24.69%) of study population. About 713 (72.8%) of the study subjects were suffering from any form of recurring symptoms like non-specific aches and pains, fatigue, restlessness, headache, indigestion, palpitation, etc., in last 14 days.

It was found that 203 (20.7%) of the study population was suffering from reasonable anxiety, 459 (46.9%) of minimum to 318 (32.4%) of mild; 150 (15.3%) of moderate to 53 (5.4%) of severe form of anxiety disorder. The range of GAD score among the study population was 0-21. A mean score of 5.73, a median of 5.0, and a mode of 0 were found among the study population with a standard deviation of 4.647.

Among the socio-demographic factors, it was found that urban population, other minority religion followers like Christianity, Sikh, Jainism, Buddhism, etc., professionally educated and homemakers were more significantly susceptible to reasonable anxiety. Age, family type, and marital status did not contribute to the reasonable anxiety status of study subjects significantly [Table/Fig-1].

The present study found that women who were addicted to tobacco and alcohol, suffering from chronic morbidity, and experienced recurrent non-specific signs and symptoms were significantly prone to reasonable anxiety. It could not elicit any significant association with having any leisure activity [Table/Fig-2].

A multiple logistic regression was performed to assess the effects of non-modifiable risk factors like occupation, addiction, associated chronic morbidity, leisure activity, and recurrent non-specific symptoms on the likelihood of suffering from reasonable anxiety. The logistic regression model explained 13.9% variability in the outcome variable i.e. anxiety disorder. The model explained that working women had 0.545 times less chance of suffering and those with recurrent non-specific symptoms were a 6.993 times more chance of suffering from reasonable anxiety. No significant association was found between addiction to tobacco and alcohol, associated chronic morbidity, presence of leisure activity with reasonable anxiety [Table/Fig-3].

The present study was conducted among 980 adult women to assess their general anxiety status by GAD scale. It was found that 20.7% of the eligible women were suffering from reasonable anxiety. Other studies found variable prevalence, when conducted among the general population. It was observed as low as 7.8% by a study conducted among women attending a primary care clinic in Malaysia [8] to as high as 87.7% as found by a study to assess depression and anxiety among university students during the COVID-19 pandemic in Bangladesh [11].

Several studies proclaimed that the prevalence of anxiety disorder increased during COVID-19 pandemic, especially among the young females and students. These groups were more vulnerable and hence, the prevalence also increased compared to the pre-COVID era. Higher prevalence was also noted among university students which may be due to their career-related anxiety [Table/Fig-4].

The present study found that 32.4% of women were suffering from mild anxiety, 15.3% from moderate anxiety, and 5.4% from a severe form of anxiety disorder. But Mazza C et al., in a nationwide survey of psychological distress among Italian people during the COVID-19 pandemic in terms of immediate psychological responses and associated factors found that women were more stressed. Study found that 81.3% were suffering from average level anxiety, 7.2% from high anxiety and11.5% suffered from extremely high anxiety [19]. This can be contributed to the fact that the COVID-19 pandemic had hit Italy at a quick pace and devastated the country in a short period compared to India.

In the present study, socio-demographic factors like rural population, other minority religion followers like Christianity, Sikh, Jainism, Buddhism, etc., professionally educated and homemakers were more significantly susceptible to reasonable anxiety, whereas age, family type and marital status did not contribute to reasonable anxiety status significantly. Similar to our study, age was not found to be significantly associated with an anxiety disorder as found by Xiao H et al., in a study on the effect of social distancing among the students [20]. Gualano MR et al., observed effects of COVID-19 lockdown on mental health and sleep disturbances in Italy. Unlike the present study, they found that median age was significantly lower in participants with an anxiety disorder (p-value <0.001) [4]. Özdin S and Özdin SB, also found that younger age had a significant association [10], as well as Wang C et al., and Hyland P et al., [12,21]. Probably this is due to the anxiety related to education and career among the lower age group than the higher ages who were already economically stable. Anxiety disorder was significantly associated with the place of residence of the participants, which may be due to the disadvantaged position of the study participants. But this was not consistent with the findings by Özdin S and Özdin SB, educational status was observed to be significantly associated with the prevalence of anxiety disorder in the present study [10], which was also evident in a research by Gualano MR et al., (p=0.046) [4]. Similarly, a study conducted among the general population in China during the COVID epidemic by Wang C et al., noticed that educational status did contribute to the anxiety score of the participants [12]. It was also evident in case of employment status of the participants like the present study. Verma S and Mishra A in their study on depression, anxiety, and stress, and socio-demographic correlates among the general Indian public during COVID-19 pandemic found that those who were employed, were likely to be anxious (OR=1.77) [19]. Hyland P et al., observed that socio-demographic risk factor like income was significantly associated with screening positive for GAD [21]. Özdin S and Özdin SB, found that marital status had no significant association with participant’s anxiety status [10], comparable to the finding of the present study. Similarly, Wang C et al., conducted a research and noted that marital status, household size were not associated with the score for anxiety of the population [12]. However, Gualano MR et al., reported that marital status was significantly associated with the prevalence of anxiety (p-value <0.001) [4].

The present study found that addiction, suffering from chronic morbidity, and experience of recurrent non-specific signs and symptoms were significantly associated to reasonable anxiety but no significant association with leisure activity. Verma S and Mishra A in their study on depression, anxiety, and stress during COVID-19 pandemic found that those who were addicted to binge drinking (OR=2.62) were more than two times likely to be anxious [19]. The present study also elicited a highly significant association between addiction and anxiety disorder. Addiction might be a sequel to anxiety disorder. Gualano MR et al., found that chronic morbidity did not contribute significantly to the participant’s anxiety status [4], unlike the highly significant finding by the current study. Analogous to it, Özdin S and Özdin SB, found that accompanying chronic disease did not contribute to the participant’s anxiety level [10] but the present study elaborated significant association. Although the present study could not elicit a relation between leisure activity and anxiety disorder, but Cheval B et al., found that increased leisure-time physical activity during the COVID epidemic was associated with better physical and also mental health [22]. Variables independently associated with anxiety among women were identified after controlling the confounding factors by multivariable logistic regression. It was found in the present study that working women were less likely to suffer from anxiety during the pandemic. This can be due to the reason that the working women have got some time for relaxation due to lockdown. They may have more friends and colleagues to share their worries as well. It was also detected in the present study that those with recurrent non-specific symptoms were at more risk of suffering from anxiety. This may be due to the reason that because of nonspecific symptoms, diagnosis and treatment of specific disease was hampered increasing their anxiety.

There is sparse research on the psychological impact of COVID-19 pandemic on women in India. In this regard, the present study unearthed the impact of pandemic along with lockdown and social distancing on the female population in India. Although, it could assess the impact on the psychological status of an individual by the cross-sectional design long-term effects could only be assessed by longitudinal studies.

The limitation of the study was selection bias. Because of lockdown and social distancing, the research was conducted among those literate individuals who had access to the internet, smartphone, and social media. Respondents could not be traced back as anonymity and confidentiality were ensured due to ethical issues. Interpretation of the total score was mentioned at the end of the questionnaire and they could self-report to seek medical help if necessary.

The study assessed the burden of anxiety disorder faced by women during the pandemic. It has provided further insight into the risk factors associated with it and a person’s vulnerability to anxiety disorder. Thereby, it has helped to develop targeted intervention strategies for the vulnerable segment of the population. At the end of the questionnaire, participants were informed about the calculation of GAD scale score. Women with a total score of >10 were considered to have reasonable anxiety. Those screened positive women were advised to self-report to the health facility if they need help. They may require further investigation to confirm GAD diagnosis. As the current scenario of the pandemic was having a greater effect on women, priority must be given to this group with psychological support and necessary intervention to prevent further worsening of the condition.