|Year : 2022 | Volume
| Issue : 2 | Page : 78-82
Effect of structured supervised yoga on stress, anxiety, and depression during a pandemic situation among the population of an urban resettlement colony of Delhi: A quasi-experimental study
Suprakash Mandal, Puneet Misra, Shashi Kant, Meenu Sangral, Priyanka Kardam
Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
|Date of Submission||01-Aug-2022|
|Date of Decision||22-Nov-2022|
|Date of Acceptance||22-Nov-2022|
|Date of Web Publication||15-Dec-2022|
Dr. Puneet Misra
Centre for Community Medicine, Room No. 30, Old OT Block, All India Institute of Medical Sciences, Ansarinagar East, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
Background: Increased level of stress has a potential impact on physical, mental, and social well-being. It was seen aggravated during the global pandemic situation of COVID-19.
Aim: The aim of this study was to find the effect of a community-based structured yoga program on the level of stress, anxiety, and depression.
Materials and Methods: This was a community-based quasi-experimental study of pre–post in type involving 26 adult participants without any preexisting morbidity. All of them were provided 12 weeks of structured yoga program of 50 min/session, ≥2 sessions/week. Psychometric questionnaire, Depression, Anxiety, and Stress Scale-21 (DASS-21), stress biomarker serum cortisol, C-reactive protein, erythrocyte sedimentation rate, and rate pressure product were used to assess the primary and secondary outcome variables.
Results: A total of 26 participants (male: 6 and female: 20) were enrolled and 18 participants completed the follow-up assessment. The median number of yoga sessions attended was 22. At the end of 12 weeks, there was a significant reduction of the stress component of DASS-21 (p: 0.0018) and the serum cortisol level (p: 0.032). Other variables had a reduction but it was not significant. No adverse effect was reported by the participants.
Conclusions: This community-based yoga study showed beneficial effects among the participants. The stress level was found reduced significantly. However, the sustainable effect needed to be assessed further.
Keywords: Community, stress, yoga
|How to cite this article:|
Mandal S, Misra P, Kant S, Sangral M, Kardam P. Effect of structured supervised yoga on stress, anxiety, and depression during a pandemic situation among the population of an urban resettlement colony of Delhi: A quasi-experimental study. Yoga Mimamsa 2022;54:78-82
|How to cite this URL:|
Mandal S, Misra P, Kant S, Sangral M, Kardam P. Effect of structured supervised yoga on stress, anxiety, and depression during a pandemic situation among the population of an urban resettlement colony of Delhi: A quasi-experimental study. Yoga Mimamsa [serial online] 2022 [cited 2023 Feb 6];54:78-82. Available from: https://www.ym-kdham.in/text.asp?2022/54/2/78/363803
| Introduction|| |
Stress is perceived when there is an imbalance between an environmental stressor and the individual coping ability. The increasing burden of stress has an impact on physical and mental health which is again aggravated by the rapidly changing sociodemographic, economic, and cultural scenario. In the presence of the global pandemic of COVID-19, nations have faced several challenges such as lockdowns, joblessness, social instability, and reduced health system functionalities., The burden of stress among all groups of the population has been seen high, especially among low-income urban people. A recent review during the COVID-19 pandemic has shown the prevalence of depression, anxiety, and stress were 20%, 35%, and 53%, respectively. In the presence of persistent and chronic stress, immunological dysfunction has been reported both in humoral as well as cellular immunity. In the pandemic situation, low immunity due to chronic stress may be more detrimental to the ongoing disease transmission and clinical severity of COVID-19 patients.
Yoga is a recognized mind–body practice that originated in ancient India. It helps in the reduction of stress, anxiety, and other mental health morbidities., It also improves the control of several physical morbidities such as chronic pain, musculoskeletal illness, cardiorespiratory illness, diabetes, and hypertension., In the presence of reduced health system functionaries during the pandemic period, yoga might be an adjunctive management strategy for chronic diseases.,, Regular yoga practice also increases emotional stability, resilience to stress, and social competence., It also improves the body's immunity by resisting the immunosuppressant effect of stress as well as enhancement of its function., It is also an easy, low-cost intervention that can be practiced in a home-based or community-based setting.,, Therefore, we aimed to find the effect of structured yoga among a group of adult persons in a community-based setting in an urban resettlement colony.
| Materials and Methods|| |
Study design and setting
This was a quasi-experimental study where a before–after the assessment was done. It was conducted in an urban resettlement colony of Delhi from January to March 2021 The area is situated in the South Delhi district where around 36,000 people reside and they are from a lower socioeconomic class. The study population was the resident of the community of the study area. All the adults between the ages of 18 years and 60 years living in the study area and willing to practice yoga were included in the study. Individuals already practicing/practiced yoga within the last 3 months, the presence of any illness such as heart disease, h/o stroke, uncontrolled hypertension, glaucoma, debilitating respiratory or musculoskeletal diseases, pregnancy that prevents from practicing yoga, participants not able to follow instructions, and participants not able to respond questionnaire were excluded from the study. For recruitment, one trained staff nurse and a field attendant visited the nearby blocks to enroll participants as per the eligibility criteria. The eligible participants were enlisted in the participant register noting their name, age, sex, phone number, and house number. They were called on a scheduled date for the enrolment and baseline evaluation. Since this study was conducted during the COVID-19 pandemic, all precautionary measures were taken while visiting the house and in a single day not more than five participants were enrolled. The enrolment was done by initial briefing, followed by taking informed written consent. The participants were given an enrolment number and were explained how to fill out the questionnaire. The study protocol was approved by the Independent Ethics Committee of the Institution (Letter No. IEC-557/03.11.2017).
The intervention was a structured supervised yoga session of 50-min duration at least two sessions per week for 12 weeks. The yoga module consisted of 10 min of loosening practice, 30 min of asanas, and 5 min of pranayama, followed by 5 min of deep relaxation technique. A predefined schedule of the yoga session, booklet, and session diary was provided to each of the participants. The slots were fixed for each participant to prevent any crowding in the yoga center at a single session. All the participants were requested to continue yoga practice at home after the end of the study.
The primary outcome variables were stress level which was assessed by a psychometric questionnaire measured by the Depression, Anxiety, and Stress Scale-21 (DASS-21) tool, stress biomarkers such as serum cortisol, C-reactive protein, and erythrocyte sedimentation rate. Apart from that some clinical stress markers such as systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), rate pressure product (RPP = SBP × HR), and some sets of clinical history were considered to assess stress. Secondary outcome variables were anxiety and depression measured by the DASS-21 questionnaire.
After that, the recording of the clinical history, anthropometric measurements, and clinical measurements was done. For the biomarkers, 4 ml of venous blood from the median cubital vein was collected.
The data were entered and organized using Microsoft Excel. Data analysis was done by STATA (StataCorp, Lakeway Drive, College Station, Texas, USA) V12 statistical software. For descriptive analysis, data were expressed by mean, standard deviation, median, and proportion. To find the statistical difference, continuous variables were tested by paired t-test and Wilcoxon signed-rank test for the normally distributed data and nonnormally distributed data, respectively. The categorical variables were tested by the McNemar Chi-square test to find any statistical difference between before–after observations. The level of confidence was taken at 95% and significance was considered at a P = 0.05.
| Results|| |
A total of 28 participants expressed interest in attending the yoga session [Figure 1]. Since two participants were already practicing yoga, they were excluded. The remaining 26 participants were assessed at baseline [Table 1]. After the 12-week follow-up period, 18 participants were possible to complete the follow-up assessment. The baseline characteristics of the 18 followed up participants were comparable to the total 26 [Table 1].
|Table 1: Basic sociodemographic variables of the participants (n=26) of those participants who remained in the study (n=18)|
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In the basic sociodemographic characteristics, a three fourth of the participants were female and the mean age was above 40 years. Most of the participants were married and a homemaker by occupation. Around two third participants had education up to a secondary level [Table 1].
During the follow-up period, the median number of classes by all attending participants (n = 23) regardless of follow-up was 20 ranging from 5 to 36. The median number of classes by the 18 participants who were possible to follow up was 22 ranging from 5 to 30 classes. The total number of participants who completed the minimum required 20 classes was 12.
After the end of the 12 weeks of yoga, the proportion of participants with headaches and persistent tiredness reduced significantly. Although there was some reduction in the other selected clinical symptoms, the difference was not statistically significant [Table 2].
|Table 2: Comparison of the proportions of the participants with selected stress-related symptoms before and after yoga intervention (n=18)|
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Among the different anthropometric and clinical variables, waist circumference, SBP, DBP, and RPP showed some reduction but it was not statistically significant [Table 3].
|Table 3: Comparison of the mean value of different anthropometric and clinical variables before and after yoga intervention (n=18)|
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In [Table 4], the postintervention primary outcome measures were compared with the baseline values. There was a significant reduction of the DASS-21 score in the stress component (p = 0.0018). There was also a significant reduction in serum cortisol (p = 0.032). All other variables though showed some change in either direction but it was not statistically significant [Table 4].
|Table 4: Comparison of the mean score of Depression Anxiety and Stress Scale 21, world health organization wellbeing index, and stress biomarkers before and after yoga intervention (n=18)|
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There was no adverse effect reported by the participants.
| Discussion|| |
Our study explored some encouraging evidence regarding decreased stress levels after a 12-week duration of yoga. Since the intervention was given in a community-based center and during the pandemic phase, the evidence is relevant in managing stress in the face of the variable situation of this pandemic. Moreover, it has been conducted among people from urban resettlement areas, especially those of lower socioeconomic strata.
This study assessed the stress using a validated psychometric scale and clinical and biochemical markers. The stress component of DASS-21 showed a significant reduction after the intervention. The result is similar to the study by Shohani et al. where a pre–post design study among 52 women, 12 weeks of yoga practice significantly reduced their stress levels as well as anxiety and depression. Another pre–post study done among 26 self-selected adult participants showed a significant change in anxiety and depression scores while stress scores remained unchanged significantly.
One recent cross-sectional study done during the lockdown period among 668 adults consisting of 384 yoga-practicing adults found that levels of depression, anxiety, and stress were significantly low than nonyoga practitioners.
Very few studies have assessed stress, anxiety-related symptoms, and the effect of yoga on it. Our study found all the selected symptoms became less frequent among the participants after the intervention though the change was not statistically significant. An interventional study done by Köhn et al. among 39 participants, found significant improvement in a few of the stress anxiety-related symptoms.
Although not significant, among the clinical parameters, DBP and RPP were found to decrease after the intervention. As per the systematic review by Hagins et al., yoga practice can reduce blood pressure significantly. The result of this study may be due to the small number of subjects studied and the mean blood pressure was within the normal range.
Our study was first of its kind interventional study done in an urban resettlement area focusing on the role of yoga during the pandemic situation. It has considered subjective, clinical, and biochemical stress markers simultaneously. The study targeted to create an enabling environment in the community and encourage home-based practice.
The study design was a quasi-experimental type. It was done with a small sample size. A randomized trial could have been a better design. The long-term follow-up for the adherence to the home practice was not possible which could provide more explorative evidence.
| Conclusion|| |
The community-based structured yoga practice affects stress levels. It can be a possible intervention in managing mental health problems, especially during the time of pandemic situation. However, the long-term sustainability of yoga practice and its effect are to be studied further.
We sincerely thank to the ministry of science and technology for their immense support. We express special thanks to the participants who allowed us to investigate, the study team regarding the study conduct and data collection. We also express gratitude to all the authors and co-authors for their continuous support.
Financial support and sponsorship
SATYAM, Kiran Division, Department of Science and Technology (SR/SATYAM/48/2016[G]) Ministry of Science and Technology, Government of India, Technology Bhavan, New Mehrauli Road, New Delhi.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Butler G. Definitions of stress. Occas Pap R Coll Gen Pract 1993;(61):1-5.
Toussaint L, Shields GS, Dorn G, Slavich GM. Effects of lifetime stress exposure on mental and physical health in young adulthood: How stress degrades and forgiveness protects health. J Health Psychol 2016;21:1004-14.
Nicola M, Alsafi Z, Sohrabi C, Kerwan A, Al-Jabir A, Iosifidis C, et al
. The socio-economic implications of the coronavirus pandemic (COVID-19): A review. Int J Surg 2020;78:185-93.
Poudel K, Subedi P. Impact of COVID-19 pandemic on socioeconomic and mental health aspects in Nepal. Int J Soc Psychiatry 2020;66:748-55.
Pangtey R, Basu S, Meena GS, Banerjee B. Perceived stress and its epidemiological and behavioral correlates in an Urban Area of Delhi, India: A community-based cross-sectional study. Indian J Psychol Med 2020;42:80-6.
] [Full text]
Lakhan R, Agrawal A, Sharma M. Prevalence of depression, anxiety, and stress during COVID-19 pandemic. J Neurosci Rural Pract 2020;11:519-25.
Segerstrom SC, Miller GE. Psychological stress and the human immune system: A meta-analytic study of 30 years of inquiry. Psychol Bull 2004;130:601-30.
Wahbeh H, Elsas SM, Oken BS. Mind-body interventions: Applications in neurology. Neurology 2008;70:2321-8.
Mandal S, Misra P, Sharma G, Sagar R, Kant S, Dwivedi S, et al
. Effect of Structured Yoga Program on Stress and Professional Quality of Life Among Nursing Staff in a Tertiary Care Hospital of Delhi–A Small Scale Phase-II Trial. J Evid Based Complementary Altern Med 2021;26:1-10.
Shohani M, Badfar G, Nasirkandy MP, Kaikhavani S, Rahmati S, Modmeli Y, et al
. The effect of yoga on stress, anxiety, and depression in women. Int J Prev Med 2018;9:21.
] [Full text]
McCall MC, Ward A, Roberts NW, Heneghan C. Overview of systematic reviews: Yoga as a therapeutic intervention for adults with acute and chronic health conditions. Evid Based Complement Alternat Med 2013;2013:945895.
Stephens I. Medical yoga therapy. Children (Basel) 2017;4:12.
Kumar A, Rajasekharan Nayar K, Koya SF. COVID-19: Challenges and its consequences for rural health care in India. Public Health Pract (Oxf) 2020;1:100009.
Xiang YT, Yang Y, Li W, Zhang L, Zhang Q, Cheung T, et al
. Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed. Lancet Psychiatry 2020;7:228-9.
Nagarathna R, Nagendra HR, Majumdar V. A perspective on yoga as a preventive strategy for coronavirus disease 2019. Int J Yoga 2020;13:89-98. [Full text]
Hartfiel N, Havenhand J, Khalsa SB, Clarke G, Krayer A. The effectiveness of yoga for the improvement of well-being and resilience to stress in the workplace. Scand J Work Environ Health 2011;37:70-6.
Field T. Yoga research review. Complement Ther Clin Pract 2016;24:145-61.
Gopal A, Mondal S, Gandhi A, Arora S, Bhattacharjee J. Effect of integrated yoga practices on immune responses in examination stress – A preliminary study. Int J Yoga 2011;4:26-32.
] [Full text]
Falkenberg RI, Eising C, Peters ML. Yoga and immune system functioning: A systematic review of randomized controlled trials. J Behav Med 2018;41:467-82.
Aboagye E, Karlsson ML, Hagberg J, Jensen I. Cost-effectiveness of early interventions for non-specific low back pain: A randomized controlled study investigating medical yoga, exercise therapy and self-care advice. J Rehabil Med 2015;47:167-73.
Larson-Meyer DE. A systematic review of the energy cost and metabolic intensity of yoga. Med Sci Sports Exerc 2016;48:1558-69.
Schmid AA, Fruhauf CA, Sharp JL, Van Puymbroeck M, Bair MJ, Portz JD. Yoga for people with chronic pain in a community-based setting: A feasibility and pilot RCT. J Evid Based Integr Med 2019;24:1-11.
Aparna P, Salve HR, Krishnan A, Ramakrishnan L, Gupta SK, Nongkynrih B. Salt intake among women in an Urban resettlement colony of Delhi. Indian J Public Health 2020;64:393-7.
] [Full text]
de Bruin EI, Formsma AR, Frijstein G, Bögels SM. mindful2work: Effects of combined physical exercise, yoga, and mindfulness meditations for stress relieve in employees. A proof of concept study. Mindfulness (N Y) 2017;8:204-17.
Sahni PS, Singh K, Sharma N, Garg R. Yoga an effective strategy for self-management of stress-related problems and wellbeing during COVID19 lockdown: A cross-sectional study. PLoS One 2021;16:e0245214.
Köhn M, Persson Lundholm U, Bryngelsson IL, Anderzén-Carlsson A, Westerdahl E. Medical yoga for patients with stress-related symptoms and diagnoses in primary health care: A randomized controlled trial. Evid Based Complement Alternat Med 2013;2013:215348.
Hagins M, States R, Selfe T, Innes K. Effectiveness of yoga for hypertension: Systematic review and meta-analysis. Evid Based Complement Alternat Med 2013;2013:649836.
[Table 1], [Table 2], [Table 3], [Table 4]