Do home quarantine individuals suffer from claustrophobia and anxiety during COVID-19 pandemic?

Abstract The COVID19 pandemic has put people under severe psychological pressure, especially in a country like India that is one of the most populated countries in the world. The objective of the present study is to investigate the association and possible impact of certain factors (gender, age, living status, working status, and location) with claustrophobia and anxiety disorders on home quarantine individuals. A self-reported data was gathered from 684 individuals between the age group of 18 − 60 years of which 63.2% were males and 36.8 % were females. The statistical tools used in the study were correlation, regression, and mediation analysis. The results showed that women and the elderly were more anxious and showed symptoms of claustrophobia. Without exception, mediation analysis showed that gender, location, and age have a direct significant effect on claustrophobia and an indirect effect on anxiety through claustrophobia. The main findings emphasize the adverse psychological effects of claustrophobia and anxiety during the quarantine period and provide crucial information for home quarantine individuals and medical practitioners. Relevance to the Journal The findings of the current study are relevant to a large audience due to COVID-19 situation affected the population at large directly or indirectly. Therefore, it is important to implement the current study findings to overcome psychological issues. Some of the findings are herewith; The current study highlighted the implication of the Quarantine period on the psychological wellbeing of the individuals regarding claustrophobia and anxiety. The findings of the study revealed that gender, age, people living in urban areas, and living alone showed more claustrophobic and anxiety symptoms as compared to their counterparts. The results of the mediation analysis found claustrophobia does affect anxiety levels. The present study findings will apply to individuals and medical practitioners. The causal factors (gender, age, living status, working status, and location) must be taken into consideration to address the claustrophobia and anxiety-related symptoms.


PUBLIC INTEREST STATEMENT
The current study highlighted the implication of the Quarantine period on the psychological well being of the individuals regarding claustrophobia and anxiety. The findings of the study revealed that gender, age, people living in urban areas, and living alone showed more claustrophobic and anxiety symptoms as compared to their counterparts. The results of the mediation analysis found claustrophobia does affect the anxiety levels. The present study findings will apply to individuals and medical practitioners. The causal factors (gender, age, living status, working status, and location) must be taken into consideration to address the claustrophobia and anxietyrelated symptoms. The findings of current study are relevant to large audience due to COVID-19 situation affected the population at large directly or indirectly. Therefore, it is important to implement the current study findings to overcome from psychological issues.

Introduction
The World Health Organization (WHO) has declared the Coronavirus (COVID-19) an international public health emergency. COVID-19 has infected more than 304 million people worldwide, and 5.4 million people have been confirmed dead (World Health Organization, 2022a). Currently, 347,999 people are active in India, and 507,177 deaths have been confirmed by COVID-19 (World Health Organization, 2022b). In addition, the Indian government emphasizes the importance of maintaining physical distance and using masks because of its long incubation period, the virus is easy to spread, and there is no medicine (cure) available (Linton et al., 2020). In India, the Indian government implemented the first lockdown on 25 March 2020, for a period of 21 days (Gettleman & Schultz, 2020). Subsequently, the Indian government extended the lockdown to 30 May 2020, with some relaxations (Ministry of Home Affairs, 2020). Home quarantine is another government preventive measure for those with known/unknown suspected cases in travel history to stop the spread of COVID19 (Ministry of Health and Family Welfare, 2020).
Home quarantine has been used as an effective strategy to prevent the spread of COVID-19 by physically isolating people from others (Flaxman et al., 2020;World Health Organization, 2020b). Although home quarantine is essential to prevent people from contracting COVID-19, this prevention has led to many psychological (Reger et al., 2020;Tull et al., 2020), social, andeconomic (Chen et al., 2011) barriers. Previous studies highlighted that home quarantine in pandemic situations can lead to adverse psychological symptoms, including mood disorders (Yoon et al., 2016), depression (Hawryluck et al., 2004), anxiety (Ferreira et al., 2021), and stress (DiGiovanni et al., 2004), irritability (Lee et al., 2005), insomnia (Lee et al., 2005), anger (Marjanovic et al., 2007), emotional exhaustion (Maunder et al., 2003) reduce social support (Courtet et al., 2020;Reger et al., 2020). A study conducted in the Republic of Ireland highlighted that general anxiety disorder or depression was associated with young age, females, and loss of income during COVID-19 lockdown (Hyland et al., 2020). Another study emphasized the importance of e-learning during quarantine to reduce the prevalence of depression, anxiety, and stress symptoms among the students at Lebanese University (Fawaz & Samaha, 2021). India's population density is particularly high in cities like Delhi (9340 people/km 2 ) (Census of India: Population Density, 2022). During the lockdown, everything came to standstill and people were forced to stay inside the houses, leading lack of personal space at home which further aggravated anxiety among them. At the beginning of the pandemic, work was suspended, followed by quarantine that forced people to live indoors. Therefore, physically and socially quarantined people are likely to suffer from claustrophobia defined as "Quarantine claustrophobia". With the recent sudden outbreak of COVID-19, quarantine claustrophobia is one of the important emotional states that cause anxiety or panic attacks (National Health Service, 2019), and has not yet been evaluated.
Claustrophobia is defined as the fear of narrow or enclosed spaces. It is the most common phobia and is usually classified as anxiety. Claustrophobia was divided into two independent but related fears, called "fear of restraint" and "fear of suffocation" (Radomsky et al., 2006). People with claustrophobia seek out coping skills by avoiding confined spaces. An individual's fear of closed spaces may be in actuality a fear of being trapped in such a way that it averts escape when in danger (Rachman, 1997). During the quarantine period, a person who is unable to contact the outside world for any purpose also shows the same subjective feelings, which is considered to be a manifestation of claustrophobia.
Previous studies have shown that women show more phobias than men (Fredrikson et al., 1996;Lindal & Stefansson, 1993;Marks, 2013). Furthermore, it was found that despite gender differences, most phobias appear after puberty (Marks, 2013). Compared to older people's fears of flying, altitude, and light, younger generations have discovered fear of animals, especially spiders (Fredrikson et al., 1996). One study showed that women and middle-aged people are more likely to be claustrophobic during MRI scans (Dewey et al., 2007). Another study found that the in-curing phobias use of Short-Bore versus open MRI significantly reduced the claustrophobic response, but the claustrophobic response was still higher in women and middle-aged people (Enders et al., 2011). In another study (Pelland et al., 2017), it was found that compared to male cancer patients, women with cancer are more anxious and claustrophobic. More studies have found similar results, but the relationship between gender and age and phobias is still unclear. Generally, people think that claustrophobia develops through traumatic experiences, such as being trapped in a tunnel or elevator. However, some researchers believe that claustrophobia is also related to genetic components (El-Kordi et al., 2013). Another attempt was made to understand the neurotic subjective experience concerning location status. Most of the patients found to have symptoms of phobia came from rural areas (Klemann et al., 1975). Although some studies have revealed various factors related to claustrophobia, more research is still needed to reveal the reasons for differences in location (urban and rural), gender, and age associated with claustrophobia, especially in pandemics situations. The psychological impact of home quarantine is wide and varied, however, health-related information is essential for people in quarantine to maximize their containment effects during the COVID-19 pandemic and minimize the impact on themselves, their families, and related social networks. The purpose of this study is to assess the association and possible impact of the period of quarantine on claustrophobia, which can further lead to personal anxiety in Delhi, India. The novelty of this study is that claustrophobia is a mediating factor between various research variables and anxiety during quarantine. Researchers predicted that quarantined people will experience symptoms related to claustrophobia. Researchers also predicted that there was a significant mediating relationship (claustrophobia) between study factors and anxiety.
H2 (a)-Claustrophobia mediates the relationship between gender and anxiety.
H2 (b)-Claustrophobia mediates the relationship between location and anxiety. H2 (c)-Claustrophobia mediates the relationship between living status and anxiety.
H2 (d)-Claustrophobia mediates the relationship between working status and anxiety.
H2 (e)-Claustrophobia mediates the relationship between age and anxiety.

Design and procedure: -
This study was approved by the ethics committee of the university. Data for this study was collected through an online questionnaire administered to the people who were isolated at home during the COVID19 pandemic. The data of people in home quarantine at a specific time comes from the city administration department in Delhi, India. The main reason for their quarantine was to travel to other states due to certain emergencies. Wiederhold and Wiederhold (2005) in their study, highlighted a strong connection between claustrophobia and agoraphobia as agoraphobia is usually associated with a fear of being alone in an open space, whereas claustrophobia is a fear of being confined in an enclosed space. Thus many people who are afraid of large open spaces also seem to be afraid of small enclosed spaces. Therefore, in the current study, agoraphobia was pre-assessed to rule out people who experienced anxiety solely because of agoraphobia.
The study followed a three-stage method. Participants were first contacted by phone (N = 1032) and asked to complete the declaration of consent and the agoraphobia questionnaire. The study excluded 80 participants who were not interested in the survey and 268 participants with agoraphobia who were classified as mild (78), moderate (85), severe (65), and extreme (48) symptoms. Therefore, the Claustrophobia and Anxiety Disorder survey was only conducted among those who were included in the study (N = 684). This study is cross-sectional because the data were collected at a certain point in time i.e. June 2020. SPSS software was used for the calculation of the correlation, regression, and mediation analysis.

Participants
The present study required 80 participants, according to an a priori power analysis, to detect a small effect size of Cohen's d = 0.25 with 80 % and 0.05 (a two-tailed test was used on the given hypotheses). The effect size estimate of d = 0.25 was also used in previous pre-registered studies using a similar paradigm (Aknin et al., 2020;Hanniball et al., 2019, d's = 0.36, 0.15), as well as recent meta-analyses examining prosocial behavior's effect on well-being (d = 0.28 in Curry et al., 2018). Initially, 1032 people were contacted for the survey, among them, 684 participated in the survey. Two hundred and sixty-eight individuals were found to be agoraphobic and 80 were not interested in the survey. The sample consisted of 684 participants (Table-1), Male: 432(63.2%), and Females: 252 (36.8%). More than half (56.1%) of the sample were either married or living with a partner, while 43.9% were living alone. Around 53.84% of participants were employed, whereas 46.2% were not working. As far as location is concerned, 50.9% of people were staying in urban areas and 49.1% were staying in rural or semi-urban areas. 24.6% of people belonged in the age group of below 18 years, 31% belong to 18-40 years, 32.7% were between the age group of 41-60 years and 11.7% were in the age group of above 60 years.
Study factors such as age, gender, location, living status, and working status were taken as dependent variables, while claustrophobia and anxiety were the independent variables. The proposed model is depicted in Figure 1.

Agoraphobia questionnaire
An agoraphobia questionnaire was developed by Craske et al. (2013). A total of 10 questions about the symptoms of agoraphobia were asked from the individuals. Questions about their thoughts, feelings and behaviors in crowds, public places, using transportation (such as buses, planes, trains), traveling alone or leaving home, etc. were asked from each individual. Each item measured was scored on a 5-point scale (0 = never; 1 = occasionally; 2 = half the time; 3 = most of the time, 4 = all time). The average total score was calculated to determine the severity of a person's agoraphobia based on none (0), mild (1), moderate (2), severe (3), or extreme (4). The scale showed good internal consistency in the current sample (Cronbach's alpha = 0.824).

Claustrophobia questionnaire
The claustrophobia questionnaire developed by Radomsky et al. (2001) was used to assess claustrophobia. The claustrophobia questionnaire consisted of two parts, a total of 26 items, 14 measured the fear of suffocation, and 12 measured the fear of restriction. Participants were asked to use a 5-point Likert scale (0: not at all anxious, 1: lightly anxious, 2: moderately anxious, 3: very anxious, 4: extremely anxious) to rate the degree of restriction and suffocation they experienced. The scale showed good internal consistency in the current sample (Cronbach's alpha = 0.784).

Anxiety questionnaire
The anxiety scale was measured by DASS-Anxiety Scale developed by Lovibond and Lovibond (1995). The questionnaire consisted of 14 items that assessed anxiety symptoms. Items included, "I found it hard to wind down" or "I was aware of dryness of my month" Respondents had to indicate the extent to which they experienced each of the symptoms depicted in the items during the quarantine period on a 4-point Likert-type scale between 0 (Did not apply to me at all), 1 (Applied to me to some degree or some of the time), 2 (Applied to me a considerable degree or a good part of the time), and 3 (Applied to me very much, or most of the time). The internal consistency of this scale was good (Cronbach's alpha = 0.857).

Statistical analyses
As mentioned previously, the purpose of the study was to investigate the impact of home quarantine on claustrophobia and anxiety during COVID-19. The questionnaire was carefully Figure 1. Proposed model. * includes gender, age, location, living status and working statusa, b and c denotes the path reviewed and checked for incompleteness or errors before the responses were entered into the statistical tool. A correlation analysis was performed to determine the association between study factors, claustrophobia, and anxiety. Mediation analysis with the bootstrap method (Preacher & Hayes, 2008) was performed to estimate the indirect influence of the studied factors(for example, gender, living status, location, working status, age) on anxiety through claustrophobia. Bias corrected bootstrapping with 5000 bootstrapped sample was selected for its capability to enhance the power to identify mediation (Fritz & MacKinnon, 2007;Preacher & Hayes, 2008). Hayes process macro for SPSS Model 4 was employed to test the direct and indirect hypothesized relationships (Hayes, 2017). This modeling technique calculates confidence intervals for simultaneous regression analysis and corrects for biases in predicting indirect effects. If the confidence interval does not contain 0, the indirect effect is statistically significant.

Results
The current cross-sectional study was conducted from the single-source data, although it has its limitations. Variance, skewness, and kurtosis were calculated and were within permissible limits, i.e. skewness fall between 3-to +3 and kurtosis acceptable range between +10 and +10 (Brown, 2015). Table 1 demostrates the descriptive statistics and table 2 represents correlation analysis and . The correlation analysis was conducted to identify the factors responsible for higher claustrophobia and anxiety during quarantine period. Working status was insignificantly associated with anxiety (r = −0.01, p > 0.05) and claustrophobia (r = −0.11, p > 0.05). The results also showed a strong positive correlation between gender and claustrophobia(r = -0.274, p < 0.01), gender and anxiety (r = -0.81, p < 0.01) i.e female felt more claustrophobic and anxious as compared to males.In the analysis "male" was coded as 0 and "female" as 1. Location associated positively with claustrophobia and anxiety (r = .199, p < 0.01; r = .287, p < 0.01). Similarly, living status correlated with anxiety only (r = .354, p < 0.01). It was found that age was negatively correlated with claustrophobia and anxiety respectively (r = −.154, p < 0.01; (r = −.664, p < 0.01). In other words, as the age increases the claustrophobia and anxiety decreases. A moderate positive relationship was found between claustrophobia and anxiety (r = 0.34, p < 0.01).
The results of the mediation analysis also revealed that claustrophobia mediates the relationship between few study factors and anxiety in 5000 bootstrapped samples.
The findings revealed that there was a significant mediation of gender, age, and location on anxiety via claustrophobia. Therefore, H2 (a), H2 (b), and H2 (c) were accepted. It was found that gender, location and age had a significant indirect effect on anxiety through claustrophobia, whereas, living status and working status had an insignificant indirect effect on anxiety (Table 3).

Discussion
Current research showed that people in the 14-day quarantine period have a significant impact on their mental health. Although Asmundson and Taylor (2021) found that many of the published studies aimed at addressing PTSD(Post-traumatic Stress disorder) in response to the COVID 19 pandemic might be misleading. Rather, the majority of studies did not include an assessment of Criterion A(DSM-V) events, and the researchers were unable to correlate self-reporting of PTSD symptoms with these events. However, the respondents in the current study suffered from claustrophobia and anxiety due to the actual quarantine of 14 days. As a result, the quarantine period has become a new threat to people as it leads to claustrophobia and anxiety disorders.
Studies have found that compared with men, women are more likely to be affected by quarantine, leading to increased claustrophobia and anxiety disorders. Since women are more susceptible to stress, anxiety will increase, while men engage themselves in solving problems that act as stress relievers. During the quarantine period, as family members were confined at home for a period of time, the workload of women, especially caregiving activities, increased. The gender pattern of time spent on unpaid caregiving tasks was found to be disproportionate. Women spend an average of 3 to 6 hours on unpaid care activities, while men spend an average of half hours to 2 hours (OECD Development Centre, 2014). This becomes worsen when females work in any organization where she is obligated to complete the work-related assignments with household chores, leading to a further rise in anxiety. Through claustrophobia, a small but significant indirect effect was found between gender and anxiety. In other words, claustrophobia mediates the relationship between gender and anxiety during quarantine. The present study also looked at other factors that led to a significant increase in claustrophobia and anxiety during quarantine. Location (urban and rural) has a significant direct effect on anxiety (Shukla & Chouhan, 2020) and claustrophobia, while it has a significant indirect effect via claustrophobia on anxiety. Due to the way of life, urban people were more anxious than rural people. Urban people go for outings more than rural people. Thus, due to inconvenient mobility during quarantine, urban people are more likely to feel suffocated at home.
Living status turned out to be an important factor in the study as it increases anxiety levels. The current study has found that living alone has a significant direct effect on anxiety. Compared with people living with any other members, people living alone are the most affected, showing symptoms of anxiety. One of the important reasons may be that people living alone during the quarantine were unable to adjust their panic emotions, leading to anxiety (Cisler et al., 2010).
In addition, people who were living alone were less involved in other activities due to reduced interest, and the fear of COVID-19 caused more anxiety among them than people who lived with their families. It was also found that people living alone never showed symptoms related to claustrophobia.
It may be surprising that the relationship between working status and anxiety and between working status and claustrophobia was insignificant, while the direct relationship between claustrophobia and anxiety for working individuals was significant. Compared to people who do not work, people who work from home during quarantine experienced symptoms related to claustrophobia. It may be because people are used to working in a huge workplace and roaming freely. However, during the period of isolation, they were prevented from leaving and had to work from home, prompting fears of suffocation.
According to Hayes (2013), if one of the direct effects was significant, the indirect effects will also be significant. Therefore, there may be other mediating factors operational between claustrophobia and anxiety for working individuals. Future researchers can explore the relationship between claustrophobia and anxiety for working individuals, and can use other factors such as personality as mediating factors.
The current study also revealed that with age, anxiety, and claustrophobia decreases. In other words, there was an inverse relationship between age, claustrophobia, and anxiety. Young people are more likely to be anxious because, during isolation, people are afraid of losing their jobs and encounter serious financial problems. Students under the age of 18 are most affected because their studies are severely affected and they are afraid of the uncertainty of the future. During the quarantine period, people in the 18-40 age group were also unable to cope with this situation. They are more anxious than older people who are more experienced in dealing with such situations because they have already faced such difficulties in their life. The results also showed that older people are anxious about restricted mobility. Therefore, the elderly were not so anxious, but due to claustrophobia, that is, restricted mobility, the elderly feel anxious. It is possible that once an individual experiences anxiety during the quarantine period, may experience decremented level of anxiety in the next quarantine period. There must be some mediating factors influencing the results. Therefore, this can be a point of thought for researchers to investigate in the future.
Although many previous studies have reported claustrophobia and anxiety disorders, however, the current study investigates claustrophobia and anxiety disorders in specific situations, namely during quarantine. In addition, it has led to the limited literature on the safety and prevention of infections and their psychological effects on people. Gender and location have been described to influence anxiety through claustrophobia. Anxiety is influenced by gender (male or female) and location whether an individual resides in urban or rural areas. During a pandemic, it is suggested to consider the intercorrelation between gender, location and claustrophobia while treating anxiety. Another important contributor has been identified as claustrophobia as an important mediator of anxiety in home isolation during the pandemic.

Limitation and Future directions
The present study investigated the influence of the quarantine period on the relationship between gender, age, living status, location, and working status on claustrophobia and anxiety. The results indicate that there may be other factors that might have affected the changes in the indirect relationship. Future studies might investigate other factors, such as work from the home workload and fear of COVID-19. The current study also investigated the overall impact of the home quarantine. However, it is also important to investigate the behavioral impact of individuals and their family members who have tested positive for COVID-19. Another limitation of the current study is that it only examines anxiety as a psychological health outcome during the quarantine. Future studies could also investigate the other mental health outcomes of the quarantine period such as depression. The current study examined the impact of study factors influence on anxiety during 14 days quarantine on individuals, yet the effect of longer period vs shorter period quarantine can be investigated in the future. Claustrophobia and anxiety can likewise be impacted by the number of family members dwelling in one specific space under quarantine can be a constraint. One more impediment could be that claustrophobia was taken as a mediating variable, though later on certain other factors, for example, personality traits can be considered as a moderating variable. Cross-sectional data were used in the study, which played a limiting role. Future studies may focus on time-lagged or longitudinal research design. The results cannot be generalized as data were collected from the Delhi region only. Other locations of India can be included in future studies. Another limitation is the data collected from various individuals. Future researchers may wish to replicate the study of a specific age group or specific professionals such as banking, health workers, and the transport sector, as employees of these sectors have continued to provide services that can lead to fear of COVID-19 infection.

Conclusion
COVID-19 has callously affected people all over the world. In other words, COVID-19 may endanger human survival. To prevent this infection, the government has implemented many action plans, such as lockdown and home quarantine, etc. Home quarantine and social distancing are just one way to prevent ourselves from contracting COVID-19. In this difficult period, when human beings are socially isolated during quarantine, ensuring everyone's safety and mental health become crucial.

The Research Group Interests
The research interest of all the authors is in the area of human behavior, they are faculty in engineering and management colleges. The previous research of the authors is in the area of stress, anxiety, and psychological wellbeing of employees. Due to the pandemic, the government of India declared a country-wide lockdown in March 2020, followed by the massive second wave of Covid in 2021. All the authors either experienced it or witnessed the home quarantine among their family members. This led to the idea of doing research on the association and possible impact of certain demographic factors with claustrophobia and anxiety disorder on home quarantine individuals. A similar study can further be conducted in different sectors of the corporate world. Work from home is the new normal; it has its own advantages but at the same time can impact the psychological wellbeing of the employees.

Disclosure statement
No potential conflict of interest was reported by the author(s).