**1. Introduction**

During pandemics, the population's psychological responses to infection play an important role in both the spreading and containment of the disease, influencing the extent to which psychological distress and social disorder occur [1]. This may be partly explained by those emotional states that frequently mark pandemics, such as uncertainty, confusion, and sense of urgency [2]. In the early stages of a pandemic, feelings of uncertainty prevail, due to the fear of becoming infected and not having the right information about the best methods of prevention and management [3–5]. Furthermore, pandemics are associated with various psychosocial stressors, including health threats to oneself and loved ones; significant changes in daily routine, such as restriction in the physical activity behavior (PA) [6–8]; separation from family and friends; shortages of food and medicine; wage loss; social isolation due to quarantine or other social distancing measures; and school closures [9]. Serious economic difficulties can also occur if a family's primary wage earner is unable to work due to illness [1].

**Citation:** Epifanio, M.S.; Andrei, F.; Mancini, G.; Agostini, F.; Piombo, M.A.; Spicuzza, V.; Riolo, M.; Lavanco, G.; Trombini, E.; La Grutta, S. The Impact of COVID-19 Pandemic and Lockdown Measures on Quality of Life among Italian General Population. *J. Clin. Med.* **2021**, *10*, 289. https://doi.org/ 10.3390/jcm10020289

Received: 24 December 2020 Accepted: 11 January 2021 Published: 14 January 2021

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For these reasons, the effects of the current COVID-19 pandemic would be more pronounced, more widespread, and longer-lasting than the purely somatic effects of infection, with serious impairment on peoples' actual and perceived quality of life (QoL). The COVID-19 pandemic that has hit the world in the last 12 months has indeed put a strain on our ability to cope with events and revolutionized our daily habits. In Italy, a state of emergency was declared by the Italian government on 31 January 2020 [10], when two Chinese tourists in Rome tested positive for the SARS-CoV-2. The first case in Italy was recorded in February 2020, and the epidemic rapidly spread, reaching 220 infections on 24 February [11]. The government responded by implementing prevention measures and infection control on 11 March, when the number of infections reached 12,462 and the total deaths were 827. Despite the fact that the infection spread differently between the northern and southern regions of Italy, the increasingly restrictive containment measures led to a total lockdown throughout the country (11 March–3 May 2020). Lockdown measures included the mandatory closure of schools and nonessential commercial activities and industries, in addition to travel restrictions both inside and outside the country. After 3 May, the number of infections dropped below 1221 new cases and many restrictions were gradually eased [12]. On 3 June, freedom of movement across regions and European countries was restored and other nonessential activities reopened.

Most of the early studies on the psychological impact of COVID-19, published at the beginning of the pandemic, have compared the current situation with the SARS epidemic in 2003 [13–16]. These studies highlighted the risk for people with suspected or certain infections to experience uncontrolled fear over a long period, not only in relation to the disease but also to the condition of quarantine. During the previous SARS epidemic, a peak of incidence of many psychiatric disorders, such as depression, anxiety, panic attacks, psychomotorial agitation, and suicide, had been reported. Kwek and colleagues [17] brought out the long-term consequences of the pandemic on health and claimed that SARS impaired significantly both QoL and mental functioning at three months from the acute episode. A small number of additional studies conducted during a previous pandemic also showed the consequences of the pandemic on psychological well-being of infected people, highlighting various factors associated with greater psychological distress, including sociodemographic variables, such as being a woman and middle aged adult or having a lower level of education [3,5]. Moreover, the majority of the studies recently reviewed by Brooks and co-workers [18] reported on the negative psychological effects of quarantine, including symptoms of post-traumatic stress, confusion, and anger. Examples of relevant stressors were a long quarantine period, fear of infection, frustration, boredom, inadequate supplies of personal security systems, inadequate information, financial losses, and social stigma.

This evidence has been further supported by an increasing number of publications on mental health demonstrating higher levels of psychological distress among the population during COVID-19 pandemic [19–22]. For instance, a large Italian study by Rossi and colleagues [19] showed an increase in anxiety and depressive symptoms for people who had lived four weeks of lockdown, and found 37% of the sample with post-traumatic stress symptoms, whereby female gender and younger age were risk factors for worse mental health.

However, while the attention on the consequences of COVID-19 over mental health has been increasing, there is a limited number of international studies on its effects over QoL. Among already published studies, Pieh and co-workers [23] found an average psychological score of the World Health Organization Quality of Life BREF (WHOQOL-BREF) questionnaire significantly lower compared to a study published in 2015 [24]; the study also reported lower scores for younger adults, women, individuals without work, and those with low income. Horesh, Kapel Lev-Ari, and Hasson-Ohayon [25] also reported higher stress levels and lower QoL for women, younger participants, and for people with pre-existing chronic illness. However, to our knowledge, there have been no studies investigating QoL in Italian populations during the COVID-19 pandemic [23,25–28].

In addition to sociodemographic variables, it has been suggested that other factors might influence QoL during pandemics, such as the difficulty in accessing healthcare services [26,27] and social isolation [29]. Van Ballegooijen and colleagues [27] described considerable levels of stress, a lower QoL, and concerns about access to healthcare during the first eight weeks of the COVID-19 lockdown in the Netherlands and Belgium. With respect to the difficulty in accessing healthcare, a Chinese study showed that the relevant index of QoL decreased with increasing age, due to the presence of chronic diseases in this segment of the population [26]. Regarding social isolation, a British study reported lower levels of wellbeing and QoL for people who felt more isolated than usual during lockdown, whereas the level of perceived social support showed significant positive correlations with QoL [29]. Another study from a Chinese sample showed relatively lower levels of physical and psychological domains of QoL but, interestingly, not in the social and environmental domains [28].

These studies highlight that the pandemic situation, including the measures put in place to contain it, involves various aspects of life and health. Monitoring the state of health requires the measurement of indicators capable of grasping the many subjective and functional dimensions of well-being and QoL. Particularly, the assessment of QoL is increasingly often considered as an integral part of any intervention that aims to promote health and wellness. QoL is actually viewed as an overall and multidimensional indicator of general wellbeing. Indeed, the WHO defines QoL as "an individual's perception of their position in life in the context of the culture and value systems in which they live, and in relation to their goals, expectations, standards and concern" (p. 1405) [30]. In measuring QoL, the WHOQOL group takes the subjective dimension strongly into account [31]. The ability to feel a certain well-being, regardless of living conditions, is a subjective variable directly related to other dimensions: genetic variables, personality, and life events. It is a set of factors dynamically interacting with each other in a different way through the life span and across different cultures. QoL is not a simple and linear entity, it is indeed a complex, multidimensional construct that, according to the WHO, includes six domains: physical, psychological, social, level of independence, environment, and spirituality/religions/personal beliefs.

The present study aimed to explore the impact that both the COVID-19 emergency and the resulting restrictive measures had on the perception of QoL among Italian general adult population. Additionally, this study aimed to investigate possible differences in QoL depending on sociodemographic variables, such as sex, age, marital status, occupational status, level of education, and area of residence in Italy, as well as specific factors related to the COVID-19 outbreak (e.g., changes in employment status and location, family members or friends infected with Sars-Cov-2, adherence to control and precautions measures, household size during COVID-19 outbreak). Particular reference will be given to the physical, psychological, social, and environmental domains of QoL as measured by the WHOQOL-BREF.
