Effect of lockdown on activities of daily living in built environment and well-being

In an effort to arrest the spread of COVID-19 infection, a nation-wide lockdown was declared in India in March 2020. To assess how personal built environment affected the citizens in the first few weeks, an explorative online survey was conducted, eliciting responses about the work habits before the lockdown, the psychological well-being, time spent in various activities, characteristics of those who worked from home, food and sleep patterns. We received 121 (76 male and 45 female) responses with an average age of 35.5 years (Max: 70, Min: 18, SD: 12.9). The major difference entailed by the lockdown was a reduction of time and distance of one commute to go to their workplace, which was an average of 30 minutes and 9.5 km respectively. In terms of diet, subjects who were vegetarian did not experience any difference, unlike those who were non-vegetarians (p<0.05). The result show an association of dependent variable of “feeling in general” with predictor variables of “energy, pep, vitality” and “feel healthy to work” during the pandemic situation, whereas the predictor variables of “energy, pep, vitality”, “happy and satisfied personal life”, “feel healthy to work” show association with dependent variable of “feeling in general” before lockdown with a significance of p<0.02 and R 2 = 0.51 and R 2 =0.60 respectively. Among those who worked from home in constrained environments, people could find spaces and seem to adapt reasonably to built environment with employees showing preference working from bedrooms and students working from sitout spaces (p<0.05) . There was no change in the quality or quantity of sleep during the lockdown. This study in the early weeks of the lockdown documents the way in which individuals lived through it in terms of the built environment at home.


Reviewer: Simone Torresin
(1) The statement about vaccines and treatment has been modified (2) Workrelated has been elaborated (3) Both positive and negative correlations have been addressed (4) Limitations of R2 and the caveat in interpretation have been elaborated (5) Correction to Table 2 has been made (6) Table 1a has been  renamed Table 1 and Table 1b has been presented as running text in the body (7) Details made in comment 7 have been addressed, by altering the text in the body (8) Explanations were provided for 'Energy, pep or vitality and Feel healthy to work ' (9) Reduction of time and distance from home to workplace has been mentioned in "Built environment and Work from Home (WfH)" section. (10) The repeated sentence in the 'Conclusion' has been removed

Reviewer: Anna Mavrogianni
(1) The comment and suggestions on interpretation of R2 have been addressed (2) Numerical results have been provided in the abstract lockdown, beginning on 22 nd March 2020. Depending on the situation, the lockdown has been modified over the course of time.
The uncertainty about the disease coupled with lockdown across the nation led to a stressful situation for the common good. It is understandable that apprehension and anxiety could result from being lonely due to social isolation, fear of being infected, economic impact and uncertainty about the future course (1). A report that compared psychological distress and loneliness in 2018 and in April 2020 showed that the prevalence of serious psychological distress increased three-fold in April 2020 (1).
Following the outbreak of Covid-19, a number of studies were published on knowledge, attitude and practices (KAP) about the condition from across the world, including different parts of India (2,3,4).
Built environment, refers to ''environments that are modified by humans, including homes, schools, workplaces, highways, urban sprawl, accessibility to amenities, leisure and pollution (5). It is conceivable that the response to the pandemic and measures to slow its spread can be modified by built environment. To our knowledge, there have not been any studies evaluating the effect of built environment on daily living and psychological stress during the lockdown. A report from Brazil studied the spatial correlation between the incidence of Covid-19 and human development (6). Doshi et al reported that fear about Covid-19 was low due to lack of knowledge, although women, lower educational status and being a healthcare worker were associated with higher fear levels (7). In situations such as these, physical interviewing is neither feasible nor desirable. Earlier studies have shown that social media platforms can be employed to recruit as well as to communicate about Covid in both developed and developing countries (8,9). Therefore we have conducted an online survey to assess the effect during the early weeks of lockdown on living habits, attitudes and other aspects influenced by the built environment.
The twin aims of the study is to evaluate how activities of daily living (ADL) have a bearing on well-being during lockdown and how spaces at home support ADL during the "stay home stay safe" strategy. The research questions we attempt to address are (A) Is there a perceptual change in wellbeing during lockdown to that of before lockdown? (B) As a health concern, are there any changes in food habits and rest/sleep? (C) How do people accomplish their responsibilities of work/study?

Methods:
The second phase of lockdown beginning 15 th April 2020 till 03 rd May 2020 had stringent restrictions of "stay home" with 3-4 hours of relaxation in the morning to take home essential commodities. A structured questionnaire was developed covering different sections in sequence, namely demographics, food intake, activities of daily living, built environment (specifically homes), leisure and entertainment, and health and wellbeing. This self-reported questionnaire survey designed in Google forms (available in Appendix at the end of the manuscript) was administered online from 19th April 2020 to 07th May 2020, i.e. during and beyond 4 days of the second phase of lockdown ( Figure-1). The online questionnaire was circulated to the contacts of the authors by online social media. The section of Demographics has data pertaining to Age, Gender, Height, Weight, Marital status, Education and Employment. The Food intake section is related to information on changes of intake in principal meals and any change in intake of vegetarian and non-vegetarian food items. Information of activities of daily living covered day-to-day tasks. Questions on the Built environment section related to where their residence is located (area, floor level), type of house (rented/owned, individual/apartment etc.), what spaces do they have and where they spent most of the time during lockdown. Watching television and spending time with family at home being common leisure and entertainment activities, questions were included on the preferences of channels like movies, sports, education, spiritual, serials/drama, music, environment and news. Lastly the section on health and well-being relate to whether they are taking any medication along with six questions on well-being (Feeling in general; Energy, pep or vitality; Feel any tension; Happy, satisfied or pleased with personal life; Feel healthy enough and Concerned or worried about health and well-being). Following the objectives of the study, the wellbeing of the subjects is assessed for the activities of daily living (ADL) and how spaces at home support them using linear regression.

Statistical analysis
Of the 121 responses received, there is considerable demographic representation of age, gender, food habits and profession (Table-1  The study is conducted in Andhra Pradesh region of India which constitutes 10.37% of covid-19 confirmed cases to that of the total confirmed cases in the country. The population of the state of Andhra Pradesh is 52 million constituting 0.04% of 135 million population of India. The state of Andhra Pradesh ranks second in total confirmed cases of covid-19 in India (10). With prevailing limitation in conducting physical survey and limited access to online survey methods being a developing country there were 121 respondents with a composition of mean age of 35.5 years (Max: 70-Min: 18), 63% (Male) and 37% (Female), 92% (Work related) and 08% (Home-based) and 73% (Nonvegetarians) and 27% (Vegetarians). Work related are those major activities or profession of an individual that are away from home and include employment and education. The margin of error is 7% for the sample size and population of the study with 90% confidence interval and thus the results differ within 7 percentage points from the real population value 90% of the time. Linear or multiple regression analysis was employed to evaluate the relationship of dependent variables with predictor variables. Independent variables which have significance of p<0.05 with coefficients that represent positive association with the dependent variables are discussed. Smaller values of R 2 may not necessarily be insignificant, although caution must be exercised in interpretation without being combined with other statistical methods. However, based on the knowledge of the subject area in studies of human behaviour, which are difficult to predict, a high value of of R 2 has been described as being 'almost impossible' (11). Given this caveat, the result at least shows a trend that can be further studied. The variables considered throw light on aspects that could be taken into account to find ways to live with situations like covid-19 pandemic. Statistical analysis using excel is carried out for the parameters of demographics, food intake, ADL, built environment, leisure and entertainment, and health and wellbeing.

Results:
Food habits: Questions on whether there is any change in food intake of main course viz. Breakfast, lunch, evening snacks and dinner were considered. They were asked on whether there is any increase, decrease or remained the same for the food intake during and before the lockdown. Also information was taken on what type and quantity of food in vegetarian and non-vegetarian is consumed. The cumulative quantity in terms of increase, decrease, remained the same of various food items in vegetarian and non-vegetarian are divided by the number of items for respective groups to normalize. Items like chicken, mutton, fish etc. were considered for non-vegetarian and various types leafy vegetables, tubers, vegetables etc. were considered for vegetarian subjects. The graph shows the product of main course and type and quantity of food items by respective groups and should ideally be the same. Ttest for vegetarian and non-vegetarian groups show significant differences (p<0.05) for food intake during lockdown. Further, the standard error of mean for the two groups of vegetarian and non-vegetarian food intake during lockdown show reduction in intake of non-vegetarian items (Figure-2).

Figure 2: Food intake during lockdown
Health and Wellbeing: Self-reported questions on perception of well-being parameters include "energy, pep, vitality", "happy and satisfied personal life", "feel healthy to work", "generally tensed" and "worried about health". However, a question on "feeling in general" is asked which includes overall perception of health. A regression analysis of different predictor well-being parameters that contribute to "feeling in general" is analysed for both before and during lockdown. The result of 121 subjects show an association of dependent variable of "Feeling in General" with a significance of p<0.02, R 2 = 0.51 to predictor variables of "energy, pep, vitality" and "feel healthy to work" with a positive coefficient of 0.305 and 0.374 respectively, during the pandemic situation. Whereas the predictor variables of "energy, pep, vitality", "happy and satisfied personal life", "feel healthy to work" show significant relation p<0.02 with dependent variable of "feeling in general" observed before lockdown with R 2 =0.60 indicating a greater reliability with positive coefficients of predictor variables of 0.501, 0.193, 0.207 respectively . It is expected that "energy, pep or vitality", "happy and satisfied personal life" and "feel healthy to work" are associated with "feeling in general" before lockdown in absence or inexistence of the disease. With emergence of the epidemic and promulgation measure of stayhome the association of "feeling in general" is maintained in "energy, pep or vitality" and "feel healthy to work" however, with a mean change in coefficients of the predictor variables. While there is reduction in coefficient of "energy, pep or vitality" compared with before lockdown, the increase in coefficient for "feel healthy to work" during lockdown could be attributed to improved safe conditions of WfH. Also it is strengthened by the fact that an association of "happy and satisfied personal life" with "feeling in general" is noticed before lockdown (Table-2).

Watching television-TV:
There is significant positive relation with 95% confidence interval and R 2 =0.18 to "Feeling in General" for the news channels of "News updates on COVID-19 cases" with (p<0.05) and "General news updates" with (p<0.01) and increasing trends of 0.269 and 0.311 coefficients respectively (Table-2). There is significant relation to "Happy and satisfied personal life" with (p<0.01) at 95% confidence interval and R 2 =0.14 for channels related to "spirituality" with increasing trend of 0.201 coefficient with dependent variable.

Mode of transport:
The expectations of the people when the lockdown is released show Mode of transport in personal car has a positive coefficient of 0.161 with "Feel healthy to work" with a significance of (p<0.02) with R 2 =0.12 (Table-2).
Built environment and Work from Home (WfH): The average distance of 9.5KM and an average 30 minutes travel by respondents to office/institute have actually saved time and energy that could be contributed to WfH (12). We assessed the relationship of home with WfH in two different aspects. One being the ownership of the house (whether rented, owned or quarters provided by the employer) and the other is the typology of the building (individual house, apartment/group housing and row housing). Group housing is a type of housing consisting of 4-12 tenements in a building whereas apartment has more than 12 tenements in a building. In the 121 samples surveyed, there are three categories of ownership of which 62% of them own the residence, 37.2% stay in rented houses and 0.8% stays in quarters provided by the employer. In typology of building, 52.9% are apartment/group housing, 40.5% are individual/independent houses and 6.6% are of row housing. However, quarters provided by the employer in ownership category and row housing in typology of the building were not considered due to small sample size. Also there are 22 home-based (10 home makers/retired persons and 12 office/businesses operating from home) that were not considered.
The generally available spaces for residential buildings in India are kitchen, living, dining, balcony or sit-out spaces, toilets/washrooms and with more than 90% of them having 1-4 bedrooms (13). Spaces such as living and dining are noisy. Often, living and dining spaces are connected together in India where multiple activities take place. Relatively quieter spaces are the balcony/sit-out used mostly as a micro-garden and as relaxation for short duration, while the quietest is the bedroom. It is important to find a suitable place to work at home. The number of dwellings studied consisting of these spaces are shown in the figure (Yes -available and No -Not available) with few having exclusive spaces viz. store space, home theatre, garage/parking, terrace and back/front yard (Figure 3).
We assessed the response of the participants on WfH and found that people whose homes are of group housing/apartment type that constitute 52.9% have no significant relation, which seemingly reflect unfavourable conditions. As mentioned earlier, group housing is a type of housing consisting of 4-12 tenements in a building whereas apartment has more than 12 tenements in a building.

Figure 3: Spaces in dwellings
Those staying in individual houses (22 respondents) irrespective of the ownership prefer WfH from their bed room space (p<0.05 and R 2 =0.52) with 95% confidence interval and a positive 3.253 coefficient (Table-2). As for the students, those who stay at their own houses (21 samples) prefer balcony/sitout spaces to perform their activities (p<0.05 and R2=0.48 with 95% confidence interval) with a positive coefficient of 1.727 with dependent variable WfH. Interestingly, for the students the association of toilet/wash area with WfH (p<0.05 and R2=0.48, 95% CI) and -2.488 coefficient though negative, reflects its importance during work. It is likely that the toilets/wash areas in institutes those are used by more number of people, specifically in India and during covid19 times is a concern for the students. And it is reasonable to anticipate that the availability of toilet/wash area is negatively associated with WfH compared to that available at the institutes. Moreover, the concern pitches for hygiene required during covid19 for toilets/wash areas at institutes compared for those at home. Therefore, the general living conditions in Indian homes can broadly be categorized under active and passive zones. Activities related to watching TV, family interactions and daily chores of household are performed in active zones that include living, dining and kitchen and are often noisy. Hence the possibility of WfH with no other choice left could happen in bedrooms and sit-outs that are relatively calm and are sufficient in numbers considering the average size of 4members in a family (Figure 4). However, design of spaces that could accommodate the requirements of formal and calm environments for WfH is important during situations of "stay home stay safe".

Discussion
We report an exploratory view of how the built environment was impacted by the world's biggest lockdown following the covid pandemic; rather than take a narrow technical deep view of architecture per se in terms of construction, transmissibility and other micro-environmental factors, we considered the different ways in which people responded at home and for work in their immediate built environment.
The average distance of 9.5KM and an average 30 minutes travel by respondents to office/institute have actually saved time and energy that could be contributed to WfH. Essentially we observed that the major difference entailed by the lockdown was a reduction of time and distance to go to their workplace. In terms of food intake, those who ate only vegetarian food did not experience any change, unlike those who were non-vegetarians, who reduced the intake of meat. This was necessitated both by the cost as well as an (unfounded) fear of transmission through meat. The fear amongst people that wet market places are potential threat of transmission of such diseases, there is a need for transformational change in the way they function. The professionals of built environment could rethink on strategies for location and design of wet market places to enhance quality in the way they function and offer safe and healthy places to people.
To fill the time available on hand during the lockdown, watching television at home was a common pastime. Forced social isolation did not alter the channels watched (movies, sports, educational, spiritual, soap operas, music, environment or news). General news and COVID-19 updates seem to have positive wellbeing along with watching spiritual channels. However, there is a need to consider how design of homes, building construction and materials could support multiple activities of home and work hitherto functioning. Acoustics and Internet of Things amongst others could become integral design considerations for the professionals of built environment.
The unprecedented lockdown led to the family staying at home, and accomplishing all their usual activities in an environment for which it was not originally designed, viz employment work, studies, entertainment and leisure all at once by all the family members. Among those who worked from home, most preferred to work from their bedroom. Students preferred to study outside the house, in balconies or in sit-outs.
Sleep is one of the compromises in the modern world, where people are accused of 'gorging themselves with food and starving themselves of sleep' (14). Here was a situation where there was ample time available for sleep/rest, without the distractions of work or the forced circadian disruptions of shift work. However there doesn't seem to have any effect, but the small sample sizes make it difficult to reach valid conclusions. However, factors including fear of being infected, economic uncertainty could have played a major role. It was a period of forced isolation, not volitional vacation; in addition the period of study could have been too short for any changes to be perceived.
Following the recognition of covid-19 pandemic, attention has focused on built environment trends to lower the risk of transmission by the design of buildings (15), as well as other tactile surfaces such as doorknobs, switches, toilet handles and faucet knobs (16). More broad based concerns about the construction of smart cities which can deal with future pandemics consisted of popularization for health science, improving emergency health systems, and keeping in place multi-industry coordination mechanisms, to deal with pandemics (17). The concept and application of built environment owes its origin to epidemics and pandemics in the past: bubonic plague in the 14th century, yellow fever in the 18th and cholera and small pox in the 19th all resulted in innovations such as broad boulevards, sewer systems, plumbing and urban sprawls (18).
Besides healthy workplaces, telecommuting and online accessibility of various services including telemedicine, distance learning, online shopping and online entertainment are bound to evolve. Houses are not just physical structures, but they are part of a broader social sphere; pandemics disturb the structures and routines that are closely inter-related, which is an interesting macro feature to consider (19). Some of the potential ways covid-19 will impact built environment consist of a shift away from large city offices, a reduced reliance on cars for transport to jobs and development of new forms of public spaces (20).
Ultimately these must lead to rethinking of design, operations, behaviour and maintenance to ensure that first the workplace and thence the economy is less susceptible to disruptions caused by disease (21).
To convert the crisis into an opportunity, one must plan to respond to such unexpected events, re-calibrate transport facilities, the work places to improve spatial distancing, as well as re-design of the environment by fusing blue and green infrastructure (22,23).

Conclusion
The unprecedented lockdown due to COVID-19 pandemic has greatly impacted the behaviours of family staying at home and accomplishing all their usual activities in an environment for which it was not originally designed. The "stay home stay safe" strategy contributed for wellbeing factors of general health, happiness and vitality while keeping away the worry of health and feeling of tensed.
There seems to have some influence of "Energy, pep or vitality and Feel healthy to work". From the coefficients, "Energy, pep or vitality" seems to have increased effect before lock-down compared to during lock-down and for "Feel healthy to work" it seems to have improved during lock-down for safe WfH situation". However, the predictor variable of "Happy, satisfied personal life" is prevalent before lock-down.
In terms of food intake, those who ate only vegetarian food did not experience any change, unlike those who were non-vegetarians, who reduced the intake of meat. This was necessitated both by the cost as well as an (unfounded) fear of transmission through meat. The fear amongst people that wet market places are potential threat of transmission of such diseases, there is a need for transformational change in the way they function. The professionals of built environment could rethink on strategies for location and design of wet market places to enhance quality in the way they function and offer safe and healthy places to people. With ample time to rest there doesn't seem to have any effect on sleep prior lockdown i.e. during normal days and in lockdown.
Average distance of 9.5KM and an average 30 minutes travel to office/institute have actually saved time and energy in contributing to WfH. The relationship of home with WfH by ownership and typology of the building show that those staying in individual houses irrespective of the ownership prefer WfH from their bed room space whereas for the students, those who stay at their own houses prefer balcony/sit-out spaces to perform their activities. However, the general living conditions in Indian homes with family interactions at living, dining and kitchen that are often noisy, design of spaces that could accommodate the requirements of formal and calm environments for WfH is important during situations of "stay home stay safe". There is a need to consider how design of homes, building construction and materials could support multiple activities of home and work hitherto functioning. Acoustics and Internet of Things amongst others could become integral design considerations for the professionals of built environment.
Some of the potential ways covid-19 will impact built environment consist of a shift away from large city offices, mode of transport and development of new forms of public spaces. More broad based concerns about the construction of smart cities can deal with future pandemics with popularization of health science and improving emergency health systems keeping in place multi-industry coordination mechanisms, to deal with pandemics. Besides healthy workplaces, telecommuting and online accessibility of various services including telemedicine, distance learning, online shopping and online entertainment are bound to evolve.

Limitation of the study
Our exploratory study has limitations in having a small sample of subjects along with inherent biases in the recruitment of subjects who had access to internet, were conversant in English and agreed to participate in the study. The method of online questionnaire circulated to the contacts of the authors on social media is adopted from studies under similar situations (8). Nevertheless, it confirms the principles of built environment on well-being and health (24) and hopefully provides an impetus for development based on sound biopsychosocial concepts.