Cohort Profile: Real-Time Insights of COVID-19 in India (RTI COVID-India).

BACKGROUND: The coronavirus disease (COVID) pandemic caused disruption globally and was particularly distressing in low- and middle-income countries such as India. This study aimed to provide population representative estimates of COVID-related outcomes in India over time and characterize how COVID-related changes and impacts differ by key socioeconomic groups across the life course. METHODS: The sample was leveraged from an existing nationally representative study on cognition and dementia in India: Harmonized Diagnostic Assessment of Dementia for the Longitudinal Aging Study in India (LASI-DAD). The wave-1 of LASI-DAD enrolled 4096 older adults aged 60 years and older in 3316 households from 18 states and union territories of India. Out of the 3316 LASI-DAD households, 2704 with valid phone numbers were contacted and invited to participate in the Real-Time Insights COVID-19 in India (RTI COVID-India) study. RTI COVID-India was a bi-monthly phone survey that provided insight into the individual's knowledge, attitudes, and behaviour towards COVID-19 and changes in the household's economic and health conditions throughout the pandemic. The survey was started in May 2020 and 9 rounds of data have been collected. FINDINGS TILL DATE: Out of the 2704 LASI-DAD households with valid phone numbers, 1766 households participated in the RTI COVID-India survey at least once. Participants were in the age range of 18-102 years, 49% were female, 66% resided in rural area. Across all rounds, there was a higher report of infection among respondents aged 60-69 years. There was a greater prevalence of COVID-19 diagnosis reported in urban (23.0%) compared to rural areas (9.8%). Respondents with higher education had a greater prevalence of COVID-19 diagnosis compared to those with lower or no formal education. Highest prevalence of COVID-19 diagnosis was reported from high economic status compared to middle and low economic status households. Comparing education gradients in experiencing COVID-19 symptoms and being diagnosed, we observe an opposite pattern: respondents with no formal schooling reported the highest level of experiencing COVID-19 symptoms, whereas the greatest proportion of the respondents with secondary school or higher education reported being diagnosed with COVID-19. FUTURE PLANS: The study group will analyse the data collected showing the real-time changes throughout the pandemic and will make the data widely available for researchers to conduct further studies.

Measuring time use in rural India: Design and validation of a low-cost survey module.

Time use data facilitate understanding of labor supply, especially for women who often undertake unpaid care and home production. Although assisted diary-based time use surveys are suitable for low-literacy populations, they are costly and rarely used. We create a low-cost, scalable alternative that captures contextually-determined broad time categories; here, allocations across market work, household labor, and leisure. Using fewer categories and larger time intervals takes 33% less time than traditional modules. Field experiments show the module measures average time across the broader categories as well as the traditional approach, particularly for our target female population. The module can also capture multitasking for a specific category of interest. Its shortcomings are short duration activity capture and the need for careful category selection. The module's brevity and low cost make it a viable method to use in household and labor force surveys, facilitating tracking of work and leisure patterns as economies develop.

On Her Own Account: How Strengthening Women's Financial Control Impacts Labor Supply and Gender Norms.

Can increasing control over earnings incentivize a woman to work, and thereby influence norms around gender roles? We randomly varied whether rural Indian women received bank accounts, training in account use, and direct deposit of public sector wages into their own (versus husbands') accounts. Relative to the accounts only group, women who also received direct deposit and training worked more in public and private sector jobs. The private sector result suggests gender norms initially constrained female employment. Three years later, direct deposit and training broadly liberalized women's own work-related norms, and shifted perceptions of community norms.

Trajectories and correlates of poor mental health in India over the course of the COVID-19 pandemic: a nationwide survey.

INTRODUCTION: The COVID-19 pandemic had large impacts on mental health; however, most existing evidence is focused on the initial lockdown period and high-income contexts. By assessing trajectories of mental health symptoms in India over 2 years, we aim to understand the effect of later time periods and pandemic characteristics on mental health in a lower-middle income context. METHODS: We used data from the Real-Time Insights of COVID-19 in India cohort study (N=3709). We used covariate-adjusted linear regression models with generalised estimating equations to assess associations between mental health (Patient Health Questionnaire (PHQ-4) score; range 0-12) and pandemic periods as well as pandemic characteristics (COVID-19 cases and deaths, government stringency, self-reported financial impact, COVID-19 infection in the household) and explored effect modification by age, gender and rural/urban residence. RESULTS: Mental health symptoms dropped immediately following the lockdown period but rose again during the delta and omicron waves. Associations between mental health and later pandemic stages were stronger for adults 45 years of age and older (p<0.001). PHQ-4 scores were significantly associated with all pandemic characteristics considered, including estimated COVID-19 deaths (PHQ-4 difference of 0.10 units; 95% CI 0.06 to 0.13), government stringency index (0.14 units; 95% CI 0.11 to 0.18), self-reported major financial impacts (1.20 units; 95% CI 1.09 to 1.32) and COVID-19 infection in the household (0.36 units; 95% CI 0.23 to 0.50). CONCLUSION: While the lockdown period and associated financial stress had the largest mental health impacts on Indian adults, the effects of the pandemic on mental health persisted over time, especially among middle-aged and older adults. Results highlight the importance of investments in mental health supports and services to address the consequences of cyclical waves of infections and disease burden due to COVID-19 or other emerging pandemics.

Trajectories and correlates of poor mental health in India over the course of the COVID-19 pandemic: a nation-wide survey.

Introduction: The COVID-19 pandemic had large impacts on mental health; however, most existing evidence is focused on the initial lockdown period and high-income contexts. By assessing trajectories of mental health symptoms in India over two years, we aim to understand the effect of later time periods and pandemic characteristics on mental health in a lower-middle income context. Methods: We used data from the Real-Time Insights of COVID-19 in India (RTI COVID-India) cohort study (N=3,662). We used covariate-adjusted linear regression models with generalized estimating equations to assess associations between mental health (PHQ-4 score) and pandemic periods as well as pandemic characteristics (COVID-19 cases and deaths, government stringency, self-reported financial impact, COVID-19 infection in the household) and explored effect modification by age, gender, and rural/urban residence. Results: Mental health symptoms dropped immediately following the lockdown period but rose again during the delta and omicron waves. Associations between mental health and later pandemic stages were stronger for adults 45 years of age and older (p<0.001). PHQ-4 scores were significantly and independently associated with all pandemic characteristics considered, including estimated COVID-19 deaths (PHQ-4 difference of 0.041 SD units; 95% Confidence Interval 0.030 - 0.053), government stringency index (0.060 SD units; 0.048 - 0.072), self-reported major financial impacts (0.45 SD units; 0.41-0.49), and COVID-19 infection in the household (0.11 SD units; 0.07-0.16). Conclusion: While the lockdown period and associated financial stress had the largest mental health impacts on Indian adults, the effects of the pandemic on mental health persisted over time, especially among middle-age and older adults. Results highlight the importance of investments in mental health supports and services to address the consequences of cyclical waves of infections and disease burden due to COVID-19 or other emerging pandemics.

Indian female migrants face greater barriers to post-Covid recovery than males: Evidence from a panel study.

Background: India's abrupt nationwide Covid-19 lockdown internally displaced millions of migrant workers, who returned to distant rural homes. Documenting their labour market reintegration is a critical aspect of understanding the economic costs of the pandemic for India's poor. In a country marked by low and declining female labour force participation, identifying gender gaps in labour market reintegration - as a marker of both women's vulnerability at times of crisis and setbacks in women's agency - is especially important. Yet most studies of pandemic-displaced internal migrants in India are small, rely on highly selected convenience samples, and lack a gender focus. Methods: Beginning in April 2020 we enrolled roughly 4,600 displaced migrants who had, during the lockdown, returned to two of India's poorest states into a cohort observational study which tracked enrolees through July 2021. Survey respondents were randomly selected from the states' official databases of return migrants, with sampling stratified by state and gender. 85% of enrolees (3950) were working prior to the pandemic. Our difference-in-means analysis uses three survey waves conducted in July to August 2020, January to March 2021, and June to July 2021. Our analysis focuses on a balanced panel of 1780 previously working enrolees (the 45% of respondents present in the first wave that also participated in the subsequent two survey rounds). Primary outcomes of interest include labour market re-entry, earnings, and measures of vulnerability by gender. Findings: Before the March 2020 national lockdown, 98% (95% CI [97,99]) of workers were employed in the non-agricultural sector. In July 2020, one month after the end of the lockdown, incomes plummet, with both genders earning roughly 17% of their pre-pandemic incomes. 47% (95% CI [45,49]) were employed in agriculture and 37% (95% CI [35,39]) were unemployed. Remigration is critical to regaining income - by January 2021, male re-migrants report earnings on par with their pre-pandemic incomes, while men remaining in rural areas earn only 23% (95% CI [19,27]) of their pre-pandemic income. Remigration benefits women to a lesser extent - female re-migrants regain no more than 65% (95% CI [57,73]) of their pre-pandemic income at any point. Yet men and women struggle to remigrate throughout - by July 2021, no more than 63% (95% CI [60,66]) of men and 55% (95% CI [51,59]) of women had left their home villages since returning. Gender gaps in income recovery largely reflect higher rates of unemployment among women, both among those remaining in rural areas (9 percentage points (95% CI [6,13]) higher than men across waves) and among those who remigrate (13 percentage points (95% CI [9,17]) higher than men across waves). As a result, we observe gender gaps in well-being: relative to male counterparts, women across waves were 7 percentage points (95% CI [4,10]) more likely to report reduced consumption of essential goods and fared 6 percentage points (95% CI [4,7]) worse on a food insecurity index. Interpretation: Displaced migrants of both genders experienced persistent hardships for over a year after the initial pandemic lockdown. Women fare worse, driven by both lower rates of remigration and lower rates of labour market re-entry both inside and outside home villages. Some women drop out of the labour force entirely, but most unemployed report seeking or being available to work. In short, pandemic-induced labour market displacement has far-reaching, long-term consequences for migrant workers, especially women. Funding: Survey costs were funded by research grants from IZA/FCDO Gender, Growth, and Labour Markets in Low Income Countries Programme, J-PAL Jobs and Opportunity Initiative, and the Evidence-based Measures of Empowerment for Research on Gender Equality (EMERGE) program at University of California San Diego.

Adherence to COVID-19 protective behaviours in India from May to December 2020: evidence from a nationally representative longitudinal survey.

OBJECTIVES: Since the onset of the COVID-19 pandemic, behavioural interventions to reduce disease transmission have been central to public health policy worldwide. Sustaining individual protective behaviour is especially important in low-income and middle-income settings, where health systems have fewer resources and access to vaccination is limited. This study seeks to assess time trends in COVID-19 protective behaviour in India. DESIGN: Nationally representative, panel-based, longitudinal study. SETTING: We conducted a panel survey of Indian households to understand how the adoption of COVID-19 protective behaviours has changed over time. Our data span peaks and valleys of disease transmission over May-December 2020. PARTICIPANTS: Respondents included 3719 adults from 1766 Indian households enrolled in the Harmonised Diagnostic Assessment of Dementia for the Longitudinal Ageing Study in India. ANALYSIS: We used ordinary least squares regression analysis to quantify time trends in protective behaviours. RESULTS: We find a 30.6 percentage point (95% CI (26.7 to 34.5); p<0.01) decline in protective behaviours related to social distancing over the observation period. Mask wearing and handwashing, in contrast, decreased by only 4.3 percentage points (95% CI (0.97 to 7.6); p<0.05) from a high base. Our conclusions are unchanged after adjusting for recorded COVID-19 caseload and nationwide COVID-19 containment policy; we also observe significant declines across socioeconomic strata spanning age, gender, education and urbanicity. CONCLUSION: We argue that these changes reflect, at least in part, 'COVID-19 fatigue,' where adherence to social distancing becomes more difficult over time irrespective of the surrounding disease environment.