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Yoga as an Escape from Depreciating Mental Health due to COVID 19: A

Qualitative study analyzing the factors associated with mental status based on
the experiences of geriatric pop...

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Original Article

Yoga as an Escape from Depreciating Mental Health due to COVID 19:

A Qualitative study analyzing the factors associated with mental status
based on the experiences of geriatric population’s participation in an
Online program during COVID 19 lockdown in India

Abstract Varun Malhotra,

Introduction: The COVID-19 pandemic has left an array of direct physical consequences unevenly Ananyan Sampath,
on the elderly apart from leaving a wide range of indirect consequences of mental health problems on Danish Javed1,
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 Rajay Bharshankar,
phenomenological qualitative succession of an explanatory sequential design of a prior quantitative Shweta Mishra1,
study followed by a Yoga-Meditation mobile phone based intervention, where 30 participants who Vijender Singh2,
had mild or moderate Depression, Anxiety or Stress as assessed by DASS-21 were chosen by Dibyanshu Singh3,
random sampling and were asked to take part in an interview. The interview was transcribed, coded, Avani Kulkarni,
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 Namita Gautam2,
health, COVID-19 and the intervention: a) Knowledge Axis patterns of COVID-19, which included Rimjhim Rastogi
their prior knowledge about the disease, its consequences and their cues to action based on those Departments of Physiology,
beliefs, b) Mental Health and Strategies to Positivity, involves all their actions to promote, restore or 1
AYUSH and 2Psychiatry,
propagate a positive mental attitude from religious activities to physical activities and c) Application All India Institute of
related thoughts, involved their perceptions of the app, the barriers to use and suggestions to improve. Medical Sciences, Bhopal,
Madhya Pradesh, 3Department
Conclusion: This study gave deeper insight into the schools of thought which will be important of Community and Family
in designing future interventions and yoga-meditation based programs in the future, essentially for Medicine, All India Institute
geriatric populations as it serves as a feasible simple measure for the same. of Medical Sciences, Deogarh,
Rajasthan, India
Keywords: DASS, geriatric psychiatry, meditation, mental health, quarantine, yoga

Introduction special emphasis was due to the additional

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.[1‑5] Taking into consideration
the magnitude of these consequences,
various international organizations and
governments have taken initiatives to
arrest the mental health pandemic.[6] This
This is an open access journal, and articles are
distributed under the terms of the Creative Commons
Attribution‑NonCommercial‑ShareAlike 4.0 License, which
allows others to remix, tweak, and build upon the work
non‑commercially, as long as appropriate credit is given and
the new creations are licensed under the identical terms.
For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com
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, Address for correspondence:
Mr. Ananyan Sampath,
and a constant input from media sources
All India Institute of
about the disastrous consequences of the Medical Sciences, Bhopal,
pandemic, which invoked further fear in Madhya Pradesh, India.
them.[5,7] E‑mail: ananyansampath@
gmail.com
Many studies have assessed the efficacy
of yoga on cognitive and mental health
Access this article online
How to cite this article: Malhotra V, Sampath A, Website: www.ijoy.org.in
Javed D, Bharshankar R, Mishra S, Singh V, et al.
DOI: 10.4103/ijoy.ijoy_121_22
Yoga as an escape from depreciating mental health
due to COVID 19: A qualitative study analyzing the Quick Response Code:
factors associated with mental status based on the
experiences of geriatric population’s participation in an
online program during COVID 19 lockdown in India.
Int J Yoga 2022;15:230-9.
Submitted: 13‑Jul‑2022 Revised: 06‑Nov‑2022
Accepted: 11‑Nov‑2022 Published: 16-Jan-2023

230 © 2023 International Journal of Yoga | Published by Wolters Kluwer ‑ Medknow

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Malhotra, et al.: Understanding the perceptions and experiences of a Yoga‑meditation‑based intervention in the geriatric population
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
International Journal of Yoga | Volume 15 | Issue 3 | September-December 2022
alone.[17‑19] 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
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Malhotra, et al.: Understanding the perceptions and experiences of a Yoga‑meditation‑based intervention in the geriatric population
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]
Of 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
232
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
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of the majority. All reporting of the qualitative data was Table 1: Depicting the sociodemographic and baseline
performed as per the COREQ checklist (Supplementary characteristics of the entire sampled population (n=705)
Table 2).[29] The entire methodology is summarized Sociodemographic Details Values in %
schematically in Figure 1. Age (years)
Mean±SD 67.45±6.49
Results 95% CI 66.96‑67.93
The interviews of 30 individuals who were diagnosed to Median (IQR) 66 (60‑92)
have moderate to mild depression, anxiety, or stress by the Male 67.77±6.52
DASS scale had durations ranging from 7 min to 44 min Female 66.47±6.28
with an average of 14 min. Since the sampled population P 0.0227*
for interviews were chosen at random, i.e., representative Range (age) (%)
of the sampled population, the socio‑ecodemographic 60‑<65 39.57
parameters were assumed to be similar to the sampled 65‑<70 24.49
population, as shown in Table 1. Four‑fifths of the sampled 70‑<75 20.43
population were either retired or housewives during the 75‑<80 10.00
course of the COVID‑19 pandemic and majorly resided in 80‑<85 4.20
urban areas and had an education above primary levels, with 85‑<90 1.01
the majority of the population being males. The population Sex (%)*
reported a very low level of tobacco and alcohol use. A Male 75
majority of the population did report an increased financial Female 25
burden during the COVID‑19 pandemic. A significant Location (%)
portion of the population reported no significant physical or Urban 99.13
mental health deterioration during the pandemic. Rural 0.87
Marital status (%)*
Table 1 depicts the overall socio‑ecodemographic Married 92
characteristics of the entire sampled population, whereas Widowed/widower 7
it is essential that a comparison be made between the Unmarried 1
objective perception of their mental health status with Education (%)
respect to the overall perception of their mental state, and Uneducated 2.61
in comparison to their self‑perceived mental and physical Primary 5.80
health awareness [Table 2]. A parallel comparison has been Intermediate 22.90
depicted below. Graduate 34.78
On reflection, the entire pattern of flow of thought of the Postgraduate and above 33.91
participants was segregated into three major categories, Tobacco addiction (%)
which wholesomely represented with exhaustion, the effects Never 81.16
of COVID‑19 on the mental health of the elderly and all Occasionally 14.78
others, strategies to overcome them, perceptions about the Regularly 4.06
yoga‑meditation app as a strategy and amendments of the Alcohol addiction (%)
Never 82.32
same.
Occasionally 16.81
These patterns were further analyzed and classified into Regularly 0.87
schools of thought that are the detailed under the following COVID 19 information level (%)
subheadings: Knowledge Axis patterns of COVID, Mental Large extent 72.75
Health and Strategies to Positivity, Application related Some extent 18.41
thoughts. Minimum 6.52
No information 2.32
Knowledge Axis Patterns Financial condition in COVID (%)
This school of thought refers to all aspects of understanding No effect 72.75
which pertain to the individual interviewee themselves Minimum 18.41
tagged as a facilitator or a barrier toward improving Moderately 6.52
mental health during the pandemic, which ranges from Very much 2.32
primarily knowledge‑based factors, where their beliefs Fear of infection (%)
about COVID‑19 and Mental Health exist. This limitation Never 61
generally exists as a linear axis, beginning from knowledge Occasionally 33
or perceived truth about COVID‑19, Mental health’s Many times 6
existence, their beliefs on perceived effects and severity of Mental health (self‑assessed) (%)
Contd...
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Malhotra, et al.: Understanding the perceptions and experiences of a Yoga‑meditation‑based intervention in the geriatric population

Table 1: Contd... mental health or to improve it during COVID‑19. Most

Sociodemographic Details Values in % participants stated that Yoga was their primary strategy
Very good 51 and method to overcome mental health issues, with many
Good 36.5 others also saying a positive attitude and continuing life
Average 11.3 as per normalcy before COVID, meditation and physical
Below average 1.2 exercise/activities are also key contributors to improving
Physical health (self‑assessed) (%) mental health. Less common strategies were praying and
Very good 50 religious faith. When questioned about the time and effort
Good 41.5 needed from each strategy to improve mental health, most
Average 12.5 participants stated a continuous effort for 12 h a day is
Below average 1 necessary to improve or prevent deterioration.
Sleep disturbances (%)
Other less common responses were 15 min a day for weeks
Never 52
to months, while some specified that it was not a specific
Occasionally 41
amount of time or effort, rather depend on how emotionally
1‑2 per week 3.5
destabilized the individuals were. Other rare responses
Daily 3.5
specified that one needed to spend more than 2 h a day to
Early morning fatigue
satisfy mental health needs alone.
Never 69
Occasionally 17 “In a whole day at least 1 h should be given to our body.
1‑2 per week 10 We have to practice yoga and meditation for at least 1 h to
Daily 4 relax us as the whole day physical and mental activities are
*Values rounded to nearest whole number. SD=Standard deviation going on.” said an elderly male participant.
Perceived benefits of yoga and meditation
mental health problems and COVID‑19 alike and their cues
to action based on said beliefs. The entire knowledge axis As almost all participants stated that they practiced yoga or
pattern’s major nodes have been represented in Table 3 and meditation in some form, questions about their perceived
Supplementary Table 1. benefits were put forth to them. Most of the participants
stated that yoga provided a dual benefit of both physical
Understanding COVID‑19 and its consequences fitness and mental health during the COVID‑19 pandemic
Most participants stated that COVID‑19 was a dangerous for them. Many also specified how it helped energize them
viral disease that has now spread across the world and has every day and provided a sense of peace and helped pass
affected many individuals, while some participants believed the time as they incorporated it into their daily routine,
that COVID was a “warning from nature” to humankind. The while some also did specify there exists no benefit of doing
consequences of COVID were not of singular domains, and yoga at all.
many participants stated that COVID affected children and
“There is no point in doing Yoga at this age” argued a
the youth, while some mentioned that old people and poor
participant.
people were affected the most gravely by the disease. With
respect to how they were affected, most participants stated Application related thoughts
that mental health issues such as fear of death and disease, Participant experiences of yoga app
lack of confidence and motivation, depression, anxiety,
disinterest in doing work, irritability, loneliness, and loss of To provide a source of motivation and tutorship, we also
social and familial relationships, stress existed among all created an online application for the participants which had
people apart from other effects such as physical weakness, prerecorded videos of various asanas (yogic postures) and
fever, and vomiting. Some participants also stated that progress trackers for participants over a 6 weeks course
COVID‑19 caused a significant financial loss and logistical for them to complete. When inquired about the application,
problems for oxygen, medicines, and hospital accommodation most participants stated that they had not used the app due
during the disease. Some individuals also stated that there to problems of logistical and technical issues, such as the
was absolutely no mental health burden by COVID‑19 at all. application was hard to download and was not opening on
their devices. Some elderly participants stated that “they
“No, there is nothing like depression. We or our children
did not have anyone to help or teach them how to use
have not had depression” said a participant (Elderly male).
the app”. Some shared that “They were already practicing
Mental health and strategies to positivity yoga regularly with another source and did not want to
discontinue that. Some participants also stated that they
Strategies to improve mental health
were traveling or simply just did not try the application
Almost all participants, especially the elderly, stated they due to personal reasons and prior commitments. Of those
had tried some method to prevent the deterioration of who did use the application, they specified no problems but

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Figure 1: Schematic representation of Methodology. Created using biorender.com

Table 2: Depicting the average DASS values for the 30 participants interviewed, in comparison to overall scores and
overall self perceived mental and physical health
DASS 21 Self assessed Self assessed
Interviewees Entire 705 status mental health physical health
Average scores Mild/moderate
Depression 9.357142857 6/8 2.185915493 >85% reported >91% reported
Anxiety 9.428571429 8/11 2.397183099 good good status
Stress 12.71428571 7/6 3.307042254
DASS=Depression, Anxiety Stress Scale

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

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Malhotra, et al.: Understanding the perceptions and experiences of a Yoga‑meditation‑based intervention in the geriatric population

Table 3: Expression of certain recognised patterns

Major Nodes Verbatim quotes of participants indicative of theme
Dangerous viral “Corona is a virus, it is a viral disease and now it spread much” (70 year old, retired urban male)
disease spreading “This is a virus, it is spreading. My view is that one should keep social distancing and wear mask” (71 year old
retired urban male)
Warning from nature Corona started with a virus, and everything else…… media. In short, nature has done this to give a lesson, let
mankind correct its way of life, and the way human is moving, it is kind of a warning from nature. The way is
built in which we have to live” (68 year old urban male)
COVID affected Most of all, it affects children. Their activities have stopped completely, they are unable to go to school, the
children and the youth has been affected their colleges were also closed. I have children. They are not able to go to college. Those
youth people who are at home missing their friend circle. (Meena Khedekar)
“Many children have become orphans, how will they study…” (71 year old retired urban male)
Impact on elderly “There has been a lot of impact on old people mentally, the daily meeting which was supposed … Earlier I used
to talk a lot to my husband but now he is dead” (68 year old female, house wife)
“They (elderly?) must have affected a lot, now those people are always sitting in the house. Earlier they travels,
works, now it missed. At first it seemed okay that they are at home but how much one can stay at home it boring.
Thinking in their own, feeling sad and scared is quite common. Many people have lost their children and there
are many people whose children are out for studies or for work. Neither they can come to meet, nor the older can
go to meet. So it’s very difficult, family support is not there” (65 year old urban female)
“Elderly people find COVID‑19 a life threatening event. The way it was telecasted and shown across, it seems
pretty dangerous; elderly thought it was like a death sentence. Emotionally, elderly would have felt more
stressed, they would be mentally stressed” (72 year old male)
Depression and “.many people have come under depression, they are feeling like “what are they doing?” how long it will last,
anxiety how many more days will you have to endure. We are not able to walk, our health also affected and more disease
and fitness” (70 year old make)
“The people never thought this anxiety depression can happen, can also happen to them many have anxiety, fear
and depression. A lot of depression in people is due to lack of money and lost close ones” (65 year old urban
female)
Loneliness and loss “I lost my husband in family it was a huge impact. Loneliness everyday became worse. My mind became lighter
of social and familial after talking, but now hearing the same thing again in the house got worse, I was afraid…” (68 year old female,
relations house wife)
“Sitting at home, it felt like being locked in a jail alone” (65 year old male)
“My daughter is in U.S, I could not meet her since two years. We are here and cannot meet with anyone, it is
depressing. It was the biggest effect of COVID even though we are not directly affected by COVID (not having
disease/infection?)” (73 year old male)
“Our daily routine was to go to the nearby temple but it was closed. Now what to do, where to go, there was no
one to speak in the neighbour, our neighbour also went with his brother‑in‑law, everything was deserted. We used
to talk to our loved ones on the phone, explain to each other, feel worthless, depression is still there, what our life
was and what happened. Earlier there used to be birthday functions, celebrations, everyone used to meet on some
pretext or the other” (64 year old female)
Strategies: Yoga “The only solution for mental peace is yoga and meditation, it helps increase our attention also. We became
physically and mentally fit” (66 year old female)
“Yoga is effective, if you are physically fit then you involve in other work and mentally fit too. I tell everyone
that yoga must be done. Elders should practise yoga because they cannot do other exercise, thus the yoga is very
easy and simple way for them to keep physically and mentally fit” (70 year old female)
Strategies: Positive “They (elders)? Say that any illness is 50% physical and 50% mental. Once we start fearing, even though the
thought condition may not be serious, it will become critical. Sleep well, talk about your problems with family and
friends. Keep yourself mentally strong. Be free from all stressors. If at all any problem, stay strong, keep yourself
away from stress. If at all any medical problems comes, it is okay, there are medicines and treatments available,
nothing is incurable, only beyond a limit it becomes incurable. If anything happens, first, you should not fear,
second, you should go to the hospital and third, maintain your health by eating healthy food and sleeping
well.” (K Rajendran)
“Yes surely. Positive thinking is very important.If we stay strong by heart nothing is impossible. We have to keep
fighting in spite of these mental problems” (64 year old female)
Problems of the “No, I didn’t use it. Already doing yoga, so I didn’t use that. Already under the guidance of a yoga teacher. That’s
application why it is of no use. Not starting it. If one is already practising yoga therefore it will be useless to mix another
one” (67 year old male)
“The app was not on playstore and was not opening quickly, could not download” (70 year old male)
Contd...
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Malhotra, et al.: Understanding the perceptions and experiences of a Yoga‑meditation‑based intervention in the geriatric population

Table 3: Contd...
Major Nodes Verbatim quotes of participants indicative of theme
Benefits of the “It was very helpful. I have problem in the neck so it is difficult to me. But there are many easy postures given
application in the app which can be done easily while sitting. It is well known that in old age physically weakness occurred,
they are not able to move much due to pain. But there are many easy postures explained in the app. It is very
good as it is given in detail. It is easily understood by watching only” (68 year old female)
“I saw that app and also downloaded it. I like it very much. I have already been doing that so it was easy to
follow. I watched all the videos, I really liked it” (71 year old male)
Experiences of yoga “True fulfilment, answers the questions about life, and lasting happiness are within reach—and can become
everyday joyful experience. Meditation has hit new heights of popularity. Scientific studies have proven many
physical and mental health benefits, and how a daily practice can positively impact life. Meditation is the
doorway to Bliss‑consciousness. When meditation is practiced scientifically, one can calm the mind, breath, and
heart, and take the energies inside, where one can perceive the soul’s oneness with Bliss. This soul‑perception
dissolves the sense of mortal limitations and delivers not only the greatest joy, but also more peace, wisdom, and
love than one could ever imagine. Those who practiced yoga centered their consciousness on God or the Self,
were more relaxed in body and mind. Conditions are basically neutral but it is the state of mind that makes them
good or bad”
“Let not your heart not betroubled. Some felt it was essential to be fearless and affirmed “Bless me that I may
easily find happiness, instead of being worried at every test during COVID‑19 and difficulty;” “Nothing can
touch me if I inwardly love the Divine” This was possible through daily practice of yoga”
Fear of virus was “Fear can slow progress towards worthy goals. Then negative effect so far harbouring fear of the virus in the
worse than the virus consciousness are the following: Fear exhausts life energy. It is one of the greatest enemies of dynamic will
itself power. Fear causes the brain to send inhibiting messages to all body organs, constricts the heart, checks digestive
function and causes many other physical disturbances
Fear paralyses all efforts to succeed as many could not do their daily activities. Fear attracts the very thing that
is feared as some participants who feared contracting the disease and scored high on DASS score succumbed to
COVID‑19. Fear harboured in our mind and heart day after day has detrimental effects on life. This was felt by
many participants who had co‑morbidities and did not even venture out of their front gate of their homes for two
years. It leads to depression, stress and anxiety
Fear of sickness by turning over such thoughts in the conscious mind, till they are rooted in the subconsciousness
and finally in the superconscious. Fear is not easy to destroy once it plants itself as the original thought would be.
Thus, the need to be positive in mind. As during COVID times many worried about poverty, financial difficulties
having lost the sole bread earners in the family, about their children who were away from them”
DASS=Depression, Anxiety Stress Scale

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

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Malhotra, et al.: Understanding the perceptions and experiences of a Yoga‑meditation‑based intervention in the geriatric population
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
238
Yoga and Meditation) vide number DST/SATYAM/
COVID‑19/2020/137 Sanction Order.
Conflicts of interest
There are no conflicts of interest.
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Supplementary Table 1: VIVO nodes and sub-codes

Nodes Sub‑nodes
What is COVID 19? A viral disease
A warning by nature
A curse
Nothing, just something they created
Who was affected by COVID 19 Children and the youth
Old people and elderly
Poor people
Everyone equally
Social and family relations of all
Effects of COVID on people Anxiety
Confidence fall, loss of charisma
Depression
Boredom and disinterest
Financial losses
Irritability
No mental health problems exist at all, made up
Physically weak, fatigue
Loneliness and separation
Consequence of COVID on elderly Fear of death or disease
and their mental health during Family and interpersonal relationship loss
COVID Lack of personal care and diseased individuals
Depression
Loneliness with no family
Strategies to improve mental health Continue routines as per normal life
Meditation
Physical exercise
Positive mental attitude
Yoga
Prayer and faith
Dedication in terms of effort and 15‑30 min a day
time to each strategy 1‑2 h a day
>2 h a day
Depends on the effect size of problem
No specific time, just stay busy
Takes weeks to months continuously
Significance of Yoga and Meditation Completely energizes you
of Mental Health Problem mitigation Aids time pass by, prevents succumb to boredom
Yoga has No role, just a myth
Part of a daily routine, aids in fixing schedules
Provides peace and tranquility
Maintains Physical and Mental Health
Problems of the Yoga‑Meditation No problems of the application
Intervention (Mobile Application) Did not complete the program/use the app
Unable to open the app as it does not work on the phone
Do not have help to use smartphone
Recommendations to the app Add diet recommendations for each age group
Live classes online with groups
Longer durations of meditation sessions
Make it more attention grasping for more younger audience
Personalisation of Yoga sessions to suit one’s needs
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Supplementary Table 2: Consolidated criteria for REporting Qualitative research Checklist

Topic Item Guide Questions/Description Reported on
number page number
Domain 1: Research team and reflexivity
Personal characteristics
Interviewer/facilitator 1 Which author/s conducted the interview or focus group? Page 5
Credentials 2 What were the researcher’s credentials? E.g. PhD, MD Page 1
Occupation 3 What was their occupation at the time of the study? Page 1
Gender 4 Was the researcher male or female? N/A
Experience and training 5 What experience or training did the researcher have? N/A
Relationship with participants
Relationship established 6 Was a relationship established prior to study commencement? Page 5
Participant knowledge 7 What did the participants know about the researcher? e.g., personal goals, reasons for Page 5
of the interviewer doing the research
Interviewer 8 What characteristics were reported about the inter viewer/facilitator? e.g., Bias, Page 5
characteristics assumptions, reasons and interests in the research topic
Domain 2: Study design
Theoretical framework
Methodological 9 What methodological orientation was stated to underpin the study? e.g., grounded Page 6
orientation and Theory theory, discourse analysis, ethnography, phenomenology, content analysis
Participant selection
Sampling 10 How were participants selected? e.g., purposive, convenience, consecutive, snowball Page 4
Method of approach 11 How were participants approached? e.g., face‑to‑face, telephone, mail, email Page 5
Sample size 12 How many participants were in the study? Page 4
Nonparticipation 13 How many people refused to participate or dropped out? Reasons? N/A
Setting
Setting of data collection 14 Where was the data collected? e.g., home, clinic, workplace Page 5
Presence of 15 Was anyone else present besides the participants and researchers? Page 5
nonparticipants
Description of sample 16 What are the important characteristics of the sample? e.g., demographic data, date Page 8, 9
Data collection
Interview guide 17 Were questions, prompts, guides provided by the authors? Was it pilot tested? Page 5
Repeat interviews 18 Were repeat inter views carried out? If yes, how many? N/A
Audio/visual recording 19 Did the research use audio or visual recording to collect the data? Page 5
Field notes 20 Were field notes made during and/or after the interview or focus group? Page 5
Duration 21 What was the duration of the inter views or focus group? Page 7
Data saturation 22 Was data saturation discussed? N/A
Transcripts returned 23 Were transcripts returned to participants for comment or corrections? N/A
Domain 3: Analysis and findings
Data analysis
Number of data coders 24 How many data coders coded the data? Page 5
Description of the 25 Did authors provide a description of the coding tree? Suppl 1.
coding tree
Derivation of themes 26 Were themes identified in advance or derived from the data? Page 7
Software 27 What software, if applicable, was used to manage the data? Page 5
Participant checking 28 Did participants provide feedback on the findings? N/A
Reporting
Quotations presented 29 Were participant quotations presented to illustrate the themes/findings? Page 7, 8, 9
Was each quotation identified? e.g., participant number
Data and findings 30 Was there consistency between the data presented and the findings? Page 8
consistent
Clarity of major themes 31 Were major themes clearly presented in the findings? Page 7, 8
Clarity of minor themes 32 Is there a description of diverse cases or discussion of minor themes? Suppl 2
Developed from: Tong A, Sainsbury P, Craig J. COREQ: a 32‑item checklist for interviews and focus groups. International Journal for
Quality in Health Care. 2007. Volume 19, Number 6: pp. 349‑357. Once you have completed this checklist, please save a copy and upload
it as part of your submission. DO NOT include this checklist as part of the main manuscript document. It must be uploaded as a separate
file. COREQ: COnsolidated criteria for REporting Qualitative research. N/A: Not available

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