Yoga Practice Is Beneficial for Maintaining Healthy Lifestyle and Endurance Under Restrictions and Stress Imposed by Lockdown During COVID-19 Pandemic

Uncertainty about Coronavirus disease 2019 (COVID-19) and resulting lockdown caused widespread panic, stress, and anxiety. Yoga is a known practice that reduces stress and anxiety and may enhance immunity. This study aimed to (1) investigate that including Yoga in daily routine is beneficial for physical and mental health, and (2) to evaluate lifestyle of Yoga practitioners that may be instrumental in coping with stress associated with lockdown. This is a pan-India cross-sectional survey study, which was conducted during the lockdown. A self-rated scale, COVID Health Assessment Scale (CHAS), was designed by 11 experts in 3 Delphi rounds (Content valid ratio = 0.85) to evaluate the physical health, mental health, lifestyle, and coping skills of the individuals. The survey was made available digitally using Google forms and collected 23,760 CHAS responses. There were 23,290 valid responses (98%). After the study's inclusion and exclusion criteria of yogic practices, the respondents were categorized into the Yoga (n = 9,840) and Non-Yoga (n = 3,377) groups, who actively practiced Yoga during the lockdown in India. The statistical analyses were performed running logistic and multinomial regression and calculating odds ratio estimation using R software version 4.0.0. The non-Yoga group was more likely to use substances and unhealthy food and less likely to have good quality sleep. Yoga practitioners reported good physical ability and endurance. Yoga group also showed less anxiety, stress, fear, and having better coping strategies than the non-Yoga group. The Yoga group displayed striking and superior ability to cope with stress and anxiety associated with lockdown and COVID-19. In the Yoga group, participants performing meditation reportedly had relatively better mental health. Yoga may lead to risk reduction of COVID-19 by decreasing stress and improving immunity if specific yoga protocols are implemented through a global public health initiative.


INTRODUCTION
WHO declared Coronavirus disease 2019 (COVID- 19), originating from Wuhan, China, caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS CoV-2), as a pandemic on March 11, 2020. To prevent spread and provide sufficient time for hospitals' readiness, the Governments worldwide had to impose "Lockdown" in their respective countries. Under lockdown, people were restricted from remaining outdoors with certain exceptions resulting from emergencies. general population. This study investigated that including Yoga in daily routine is beneficial for physical and mental health. Also, Yoga practitioners have a healthier lifestyle, which improves their ability to cope with the restrictions and stress under lockdown.

MATERIALS AND METHODS
The current study received ethical approval from Swami Vivekananda Yoga Anusandhana Samsthana (S-VYASA) University, Karnataka, India. CHAS, a unique self-assessment scale, was designed for the survey in 10 different languages, English, Hindi, Assamese, Bengali, Kannada, Malayalam, Marathi, Odia, Tamil, and Telugu. A committee consisting of 11 experts was constituted who undertook three rounds of discussions as per Delphi protocol and agreed to the CHAS questionnaire that assessed the positive and negative aspects of physical and mental health, lifestyle, and associated coping methods during the lockdown period ( Table 1). Among 11 experts, 6 had PhD in Yoga with more than 15 years of experience in yoga research, 3 were post-graduate in yoga with experience of more than 10 years in yoga, one is a professor of statistics, a mathematician with masters in psychology and PhD in yoga, and one is a psychologist with PhD in yoga. Content valid ratio (CVR) was 0.85 for CHAS as per Delphi method (21)(22)(23). CHAS also collected the demographic (questions 1-10) and lifestyle (questions 39-64) details of the participants.
Questions 11-15 accessed COVID-19 exposure of participants; these included self-reported symptoms, travel history, details of interaction with COVID-19-positive patient, and quarantine history. Physical health was accessed by rating physical strength and endurance (question 16) and disease history (question 17). In question 16, two extreme options were considered as a single option during analysis.
Twelve questions (questions [18][19][20][21][22][23][24][25][26][27][28][29] were included in CHAS to assess the mental health during the lockdown. The questions were designed to evaluate fear and anxiety during the lockdown and evaluate the individual's general personality or character. Standard neuropsychological questionnaires were not used to evaluate stress and anxiety. The coping ability of participants was accessed by a direct question with four options, i.e., "Poor, " "Average, " "Very good, " and "Excellent" (question 30). During analysis, "Poor" and "Average" were merged into a single attribute, i.e., "Poor." Similarly, "Very Good" and "Excellent" were merged to constitute "Good." Questions 31-38 enquired about different activities of participants during lockdown; these questions indicate coping strategy of participants during lockdown.  in lifestyle domain also provide information on coping strategy.

Data Collection and Study Participants
The survey items for CHAS were prepared on Google forms and circulated in public through social media. Snowball method was used to acquire the data nationwide. Phone calls and special requests were sent to different sections of the society (∼200 universities, Corporate companies, healthcare institutions, government organizations, wellness centers, and their networks) to acquire data within this short period. No inclusion and    Table 2). This study was sponsored and conducted by S-VYASA. The participation was voluntary, and the response sheets were downloaded daily. The CHAS data were collected between May 9, 2020 and May 31, 2020, and 23,760 responses were received. Incomplete and unreliable responses, respondents from outside of India and respondents aged <18 years were excluded (n = 470). The remaining 23,290 responses were evaluated to assign participants in Yoga and non-Yoga groups. Inclusion criteria were age should be ≥18 years and all respondents should be residing in India. Yoga and non-Yoga group was defined according to the responses of question numbers 52, 53, 55, 56, and 57 of the CHAS questionnaire ( Table 1).

Criteria for Defining Yoga Group
The Yoga group was defined as individuals who performed Yoga both before (question 52) and during (question 53) the lockdown, which included practicing one or more among Asanas (question 55) (Yoga postures), Pranayama (Yogic breathing exercises) (question 56), and meditation (question 57) for a few hours to more than 6 h per week during the lockdown. Participants, who replied "Did Yoga" for questions 52 and 53, but marked "Don't practice" for questions 55-57 were excluded from the Yoga group. According to these criteria, 9,840 participants qualified for the Yoga group.
Furthermore, the Yoga group was divided into four subgroups, i.e., Yoga practitioners who practiced Asana, Pranayama, and meditation (all three together; n = 6,156), practitioners who practiced only Asana (n = 149), only Pranayama (n = 89), and only meditation (n = 1,485). The combination of two practices among Asana, Pranayama, and meditation was not considered as a sub-group.

Criteria for Defining Non-Yoga Group
The non-Yoga group included respondents who did not perform Yoga before (question 52) or during (question 53) the lockdown and replied "Don't Practice" for the questions on Asana (question 55), Pranayama (question 56), and meditation (question 57). Following the aforementioned inclusion criteria, 3,377 participants were accepted in the non-Yoga group.

Statistical Analysis
R Statistical software, version 4.0.0, was used for data cleaning, extraction, and analyses. The arsenal package in R was used to determine cross-tabulations and χ 2 test; logistic and multinomial regression was used. Age, gender, occupation, education, and working status during lockdown were used as covariates.
The dependent variables were the study groups. We used multiple predictors in each of the regression models. Sequential contrast was used for ordinal variables. The predictors were selected based on the domains presented in the survey. The domains were demographic details, physical health, mental health, coping strategy, and lifestyle. Table 2 summarizes the demographics of the non-Yoga group (25.6%), Yoga group (74.4%), and total participants. Participation of males in the survey was proportionally higher in both non-Yoga (67.5%) and Yoga (55.3%) groups. The young population in the age group of 20-30 years was higher in the non-Yoga (50.5%) group than in the Yoga group (22.8%). The participation from the age group > 50 years was higher in the Yoga group (26.8%) than in the non-Yoga group (6.0%). Our data also revealed that the percentage of employed and professional participants was higher in both groups, with 44.1% in non-Yoga and 40.4% in Yoga. The non-Yoga group had 37.0% participation from young students. Most of the participants had a good educational background as they were either graduates or post-graduates. We noted that 85.0% of the participants stayed with their family during the lockdown, apparently lending help to cope with stress. On further analysis, we found that the non-working participants were fewer in the non-Yoga group (36.5 vs. 43.9%). Furthermore, the proportion of participants going to the office during lockdown was more in the non-Yoga group (25.7 vs. 15.2%).

COVID-19 Exposure
Participants with no symptoms are less likely to be in the non-Yoga group than participants with cough, fever, breathing difficulty, and other symptoms ( Table 2). The symptoms of COVID-19 were self-reported. Approximately 98.1% of non-Yoga and 97.8% of the Yoga group did not undertake any international travel since January 2020. Further, the non-Yoga group is more likely to have exposure to COVID-19 than the Yoga group.

Lifestyle
Although the proportion of participants using substances was lower in both groups, the non-Yoga group was more likely to depend on alcohol, tobacco, and other substances ( Table 3). The non-Yoga group was less likely to have a good quality of sleep before and during the lockdown than the Yoga group, odds ratio (OR) < 1 ( Table 3).
Participants of the non-Yoga group were less likely to have food in a disciplined manner [unadjusted OR

Physical Health
The Yoga group reported very good physical strength and endurance, with only 7.5% of participants reporting an average or below average physical strength and endurance ( Table 4). The non-Yoga practitioners were less likely to have good physical strength and endurance (OR < 1), suggesting physical endurance attributes might be superior in Yoga practitioners. Disease risk     for co-morbidities, including heart diseases, lung disease, blood pressure, and others, was lower in both the groups ( Table 4).

Strategies for Coping With COVID-19 and Lockdown-Related Stress
Most of the Yoga group members reported good coping ability (82.8%), while most of the non-Yoga (58.8%) group reported poor coping ability thereby highlighting a significant difference in two groups ( Figure 1C). Figure 1D shows that the non-Yoga group could cope using the Internet, watching TV, reading/writing, cooking, religious activity, and exercise (>50%). In contrast, the Yoga group was engaged in yoga Asanas, meditation, and religious/spiritual activities besides using the Internet, reading/writing, cooking, and exercise (>50%).

Meditation Is Highly Effective to Bring Mental Stability and Strength
We also examined whether practicing a combination of Asanas, Pranayama, and meditation has a different influence on outcome variables than practicing one of these three yogic practices, individually. Table 5 summarizes the different parameters of physical health, mental health, and coping strategies of four subgroups. Meditation was frequently performed by the age group of 41-50 years (26.3%), while Asana (49.7%) and Pranayama (39.3%) were favored by young people between the ages of 20 and 30 years. The consolidated Yoga practice was preferred mainly by participants of 31-40 years (24.5%).
Physical health, predicted by strength and endurance, revealed that the Asana group might have lower physical health, whereas co-morbidities were higher in the meditation group (19.3%). Good mental ability was revealed by lower anxiety and stress in the meditation group, followed by the combined group, Asana and Pranayama, sequentially. In addition, the ability to cope with the stress of COVID-19 was highest and comparable in the meditation group (85.3%) and the combined yoga group (83.2%). The preference of watching TV during lockdown was least in the meditation group (30.2%); their preferences included reading/writing (90.0%) and meditation (96.5%). The combined group preferred a range of activities, including reading/writing (92.2%), cooking (75.7%), exercise (93.2%), Yogasana (96.9%), meditation (97.1%), and religious activity (86.2%). TV watching was preferred by the Pranayama group (66.3%) followed by the Asana group (62.4%), and the Internet was preferred by the Asana group (87.9%) followed by the Pranayama group (76.4%). The aforementioned observations suggest that meditation might be more effective in reducing stress and anxiety and improving coping abilities in lockdown situations.

DISCUSSION
Despite limited public health intervention strategies, Yoga has remained the mainstay for improving well-being, disease risk reduction, and improving mental and physical health (17-20, 24, 25). We had earlier reported significant barriers in access to Yoga resources even though the prevalence of Yoga in India and elsewhere was significantly noteworthy (26,27). Regardless, several studies have reported over time better physical health, mental health, and quality of life both among healthy individuals and those with disease or disorder (17-20, 24, 25). Yoga has been known to improve physical and mental health compared with a physically active group or a physically inactive group, yet the reliance on its anticipated benefits has never been assessed in any nationwide study during a health crisis (28,29).
Yoga represents a regulated lifestyle that involves Asanas, Pranayamas, and meditation. It makes an individual selfaware of his/her body, mind, thoughts, and soul. The Yogic  In (A,B), odds ratio and CI (in brackets) for each parameter are mentioned on the right side of the bar. The small alphabets represent the pair of tested variables when Yoga group is compared with non-Yoga group. The representation are (a) not at all vs. somewhat, (b) somewhat vs. very much, (c) disagree vs. maybe, and (d) maybe vs. agree. Sequential contrast was used for ordinal variables. *p < 0.05, **p < 0.01, ***p < 0.001.    teaching is based on the fundamentals of Yama (restraints) and Niyama (observances) (30). Yama includes teachings of non-violence, truthfulness, non-stealing, moderation, and nonhoarding, whereas Niyama includes teachings of cleanliness, contentment, self-discipline, self-study, and wellness. Yoga practitioners routinely isolate themselves from the general population to achieve higher spiritual goals (31). Thus, one who follows the Yoga and Yogic lifestyle can easily maintain cleanliness and social distancing without an agitated mind. Therefore, Yoga practitioners can be hypothesized to quickly adapt to lockdown rules without experiencing chronic anxiety and stress. The present study extends the above hypothesis operationalized as an investigation carried out when the world is gripped with fear and uncertainty due to an impending pandemic. In this context, the present study has evaluated the outcomes of physical and mental health, including lifestyle and coping strategies of Yoga and non-Yoga groups, during the lockdown imposed by COVID-19 pandemic. A CHAS questionnaire was generated following the Delphi protocol and was circulated among the Indian mass by snowball method as Google Forms. Phone calls and special requests were sent to different sections of the society including ∼200 universities, Corporate companies, healthcare institutions, government organizations, wellness centers, and their networks to acquire data. The data were collected between May 9, 2020 and May 31, 2020; data were downloaded daily.
In the present survey, among the total respondents of 23,290, 42.2% (n = 9,840) were Yoga practitioners, which is much higher than the previous report of 11.8% of a nationwide randomized structured survey in 2017 (27). This may not indicate a true rise in the number of yoga practitioners in the country as this was not a randomly selected population.
The current study reports proportionately higher response from males than females. Non-Yoga group has a higher percentage of young participants than the Yoga group, which is a limitation of the study. In both Yoga and non-Yoga groups, most of the participants were employed or well-educated professionals. Furthermore, the analysis of the data collected during this survey revealed that both groups represented a similar proportion of participants living with family; however, a small proportion of participants were also reported to be living alone in both groups. Thus, loneliness cannot be a leading attribute of anxiety, stress, and fear in this study. Another feature of the participants who responded to the survey was that a greater proportion of the working and office going population was represented in the non-Yoga. Working and attending office during the lockdown may be considered as a reason for not practicing Yoga.
Emerging data have shown differences in the susceptibility to COVID-19 symptoms based on age and co-morbidities (4). Studies have shown the benefits of Yoga intervention in reducing the risk and severity of diabetes and other co-morbidities (24,25). Such interventions may, therefore, be helpful for the risk reduction of COVID-19. Our data show increased non-Yoga group susceptibility to COVID-19 compared with those belonging to the Yoga group; however, RT-PCR for COVID-19 was not carried out to confirm this. Regardless, this calls for new public health and cost-effective intervention strategies based on a digital Yoga interface, compliant to Tele-Yoga regulations. Recently, a breathing technique known as Liuzijue has been reported to improve pulmonary function and quality of life in discharged COVID-19 patients (32). However, it cannot be neglected that the Yoga group is mainly constituted by participants who are "not working" or "working from home, " because of which they have a lower COVID-19 risk and are less fearful about COVID-19.
Sleeping and eating habits in the Yoga group were more health promotive. Furthermore, it also revealed that the dependence on substances use, as resources to cope with anxiety and stress, was lower in the Yoga group. Moreover, good physical strength and endurance coupled with the absence of chronic disease were also proportionately higher in the Yoga group, suggesting better health outcomes corresponding to COVID-19. Our study, however, did not estimate the non-Yoga exercise groups consisting of sportsmen or other physical activities.
We observed that the non-Yoga group was coping with COVID-19 lockdown by relying on the Internet, TV, reading/writing, cooking, and exercise, while the Yoga group was more engaged in Asana, meditation, and religious/spiritual activities besides using the Internet, reading/writing, cooking, and exercise. The Yoga group maintained their routine consistently, while the non-Yoga group could not sustain their regular practices.
The comparisons between the two groups unanimously showed that the non-Yoga group faced mental challenges. They reported higher anxiety and fear associated with COVID-19, including fear of getting infected with COVID-19, death, financerelated stress, and spreading COVID-19 in addition to other unknown causes. Instead, compared with the non-Yoga group, the Yoga group was reportedly more goal-driven and methodical, eliciting responses that showed a helping and caring attitude. The latter group displayed more openness to new ideas and enjoyed sharing their thoughts, being less insecure. Reports from China also show similar psychological distress (8,17,33).
COVID-19-related stress creates panic and reduces quality of life in patients as well as in healthcare workers (HCWs). Hence, introducing Yoga in the healthcare system would be beneficial for the patients, HCWs, and other service providers: they may successfully cope with psychological stress (34)(35)(36)(37). Stress, anxiety, and depression among HCWs in COVID-19 pandemic was reduced by practicing Sudarshan kriya (38). Perceived stress in COVID-19 patients was also reduced by multimedia psychoeducational intervention, which included relaxation and mindfulness techniques (39). Not limited to COVID-19, integrative medicine including modern medicine, Yoga, mindfulness techniques, Ayurveda, and many more can be helpful for managing health and quality of life, and have the ability to reduce severity of disease. However, randomized trials are required to develop integrative healthcare.
It has been shown that meditation can potentially decrease the risk of acquiring cold and flu by improving physiological function and quality of life (40). Yogic breathing techniques improve respiratory and cardiac function, rendering it an effective tool to combat COVID-19 (41). Yoga will help calm down the mind and enhance immunity (17)(18)(19)(20). PTSD due to natural disasters, epidemics, and wars has been shown to regress after practicing Yoga (42). Its application in the current pandemic using the digital module of Yoga and mindfulness may be helpful. If administered to COVID-19 patients under supervision, it may even reduce psychological stress (43). A few randomized controlled trials are taken up in the present pandemic that are investigating the efficacy of various breathing techniques including Yogic breathing in COVID-19 (44)(45)(46).
It is pertinent to note that we had stratified the Yoga group into a consolidated Yoga group, only Asana, only Pranayama, and only meditation groups. Meditation seemed to evoke beneficial outcomes than those practicing all, i.e., Asana, Pranayamas, and meditation. However, a longitudinal randomized trial is imperative to establish evidence. Our observation that the younger population preferred Asanas and Pranayama, while meditation was mainly preferred by the elderly, can help deliver innovative yoga protocols that make meditation more attractive to the young population and, consequently, useful for mental hygiene if presented as integrated yoga protocols (available at www.svyasa.edu.in). Our report highlights that a large number of subjects practiced consolidated Yoga (including Asanas, Pranayama, and meditation), proving the acceptability of an integrated module for school and college teachers. This could partly be due to the widespread popularity of both the Common Yoga Protocol released by the Ministry of AYUSH on the eve of International Day of Yoga, celebrated on June 21, as well as the widely published efficacy of Diabetic Yoga Protocol and COVID-19 Yoga Protocols released by the S-VYASA University (47,48). These protocols include Asana, Pranayama, and meditation.

LIMITATIONS OF THE STUDY
The study is limited by the fact that the sampling does not generate a study group that represents the general population as it was collected through social media. Second, the duration and regularity of Yoga practice before the lockdown was not assessed in the Yoga group, which would have given details of practice before lockdown. The same was assessed for lockdown period. Third, a proportionately higher number of younger subjects were found represented in the non-Yoga group; this might have influenced the outcome in a few components of the scales like the use of the Internet, physical strength, and others. Fourth, the self-reported COVID-19 symptoms could not be verified and RT-PCR for COVID-19 was not performed to establish increased susceptibility of non-Yoga group because of the lockdown restrictions. Fifth, a non-standard questionnaire was used. Mental health was not evaluated by any neuropsychological questionnaire such as the Perceived Stress Scale, but was based on the responses of CHAS.
We also could not rule out the role of physical exercises in improving mental and physical health; however, outdoor activities were restricted due to the lockdown. Furthermore, whether the restrictions mentioned earlier provided the environment conducive for the practice of Asanas, Pranayamas, and meditation, available through digital media, cannot be ascertained unless another validation study is carried out. In addition, we did not explore means to rule out repetitive form filling by the same individual due to error or intention; however, there were no rewards or benefits attached to completing the survey. Because the survey was administered online, the possibility of cognitive bias in the study was minimal; however, we entirely relied on the answers provided online without verifying the IP address, consistent with similar reports published elsewhere.

DATA AVAILABILITY STATEMENT
The raw data supporting the conclusions of this article will be made available by the authors, upon eligible request.

ETHICS STATEMENT
The studies involving human participants were reviewed and approved by Swami Vivekananda Yoga Anusandhana Samsthana. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.

AUTHOR CONTRIBUTIONS
RN conceptualized the study, supervised data collection, and involved in discussions during article preparation. AA conceptualized the article. MR and MSS wrote and edited the article and contributed in data presentation. MNKS conceptualized the study. RK and JI performed the statistical analyses. AS created the scale and administered it nationally. HN envisioned the study, and inspired and guided the study to its completion imparting quality assurance. RN, AA, and VS critically reviewed and edited the article. All authors contributed to the article and approved the submitted version.