key: cord-0893024-b3knqbzp
authors: Stephens, Christine; Breheny, Mary
title: Diverse experiences among older adults in Aotearoa/New Zealand during COVID‐19 lockdown: A qualitative study
date: 2021-10-14
journal: Australas J Ageing
DOI: 10.1111/ajag.12995
sha: 5ad89a50f415bb55c5d410e3e22b4ef37b432ce8
doc_id: 893024
cord_uid: b3knqbzp

OBJECTIVES: There are mixed results from studies of COVID‐19‐related anxiety. We explored older people's perspectives on anxiety and support during lockdown. METHODS: We thematically analysed 730 written comments from older community‐dwelling adults aged 55‐85 years in Aotearoa/New Zealand. RESULTS: Despite some anxiety during lockdown, for those who were retired, working at home or receiving wage subsidies, the experience was very enjoyable. Whether living alone or in households, anxieties were largely ameliorated by a sense of support from family, fellow citizens and government. In contrast, essential workers, those who lost employment and informal carers did not feel sufficient community support to alleviate their anxiety. CONCLUSIONS: Concerns about the plight of older people focus on stereotypes of isolated elders, ignoring the needs of workers and carers. The inductive approach taken to this study provided useful information about the success of supportive measures and highlighted the need to broaden the focus of concern.

Since recognition of the COVID-19 pandemic, health authorities have highlighted the greater risks of mortality for older people who contract the virus. Accordingly, general recommendations for older people 1 included staying at home and avoiding contact with other people. Staying at home means that older people, who are less likely to use online communications, must organise the delivery of groceries and medications, restrict access to health-care centres and maintain a distance from family and friends, which effectively means complete social isolation for those who live alone. Commentators in the UK 2 or the United States 3 warned, early in the pandemic, of the dangers of these restrictions for the health of older people. There was widespread concern about the effects of social isolation on older people's mental health. [4] [5] [6] Some early empirical evidence has supported the fears of increased mental health issues among older people, showing that anxiety and other forms of psychological distress were high during the early stages of the pandemic. High percentages of anxiety and depression were found among people aged over 60 years in China. 6 A more comprehensive population study 7 showed that higher levels of psychological distress were reported by those between 18 and 30 years of age and those older than 60 years. This contrasts with earlier evidence from China that older people reported lower levels of distress than the general population. 8 Findings remain equivocal regarding the special vulnerability of older people to psychological distress. A wide-ranging Internet survey in China 9 showed that, although psychological distress was high, there was no difference between age groups. In the United States, a large population sample 8 reported that older age was associated with less depression and anxiety. The authors concluded that older people are more likely to be resilient and hold fewer unrealistic fears than younger groups. Similarly, a Canadian and US survey 10 found that older adults reported higher emotional well-being than younger adults, although they were subjected to the same COVID-19 stressors.

These differences around older people's vulnerability to stress may reflect the social and cultural context of their pandemic and lockdown experiences. They do highlight the importance of recognising the heterogeneity of older people. 11 Diversity in social class, education, sex, wealth, ethnicity and sexuality means that age in years is not a good indicator of health. Work on the effects of the COVID-19 pandemic points to this heterogeneity: in the early stages of the pandemic, Swedish older adults generally rated their well-being as high as, or higher than, previous years. 12 However, those who worried more reported lower well-being. Among Spanish people during a period of lockdown, resilience among older adults was shown by those with positive self-perceptions of ageing 13 while others 14 reported that, although older adults had higher levels of anxiety about contracting the virus, those who employed proactive coping experienced less COVID-19 stress relative to younger adults. Other factors that have been found to place older adults at higher risk include economic impacts, 15 living rurally 16 and digital exclusion. 17, 18 Recognition of the diversity of older people's social and structural situations and individual resilience means that, while vulnerability is recognised, interventions to support older people in pandemic situations must account for these differences. Bruine de Bruin, 8 suggest that interventions can be targeted to people of all ages, while supporting those who do experience depression and anxiety. Meng et al 6 suggest direct mental health-care interventions, while Hoffman, Webster and Bynum 3 suggest a broader framework for interventions.

To contribute to the development of appropriate support for those experiencing anxiety during lockdown periods, we explore the perspectives of older people themselves. The early survey research on the effects of lockdown during the COVID-19 pandemic has been based on assumptions about the detrimental effects on older people. This study takes an inductive approach to utilise older people's own accounts of their experiences. The study took place in Aotearoa/ New Zealand (NZ), a small island nation in the southwestern Pacific Ocean. The first case of COVID-19 was reported in February 2020, and as the virus spread through the community, a national state of emergency was declared in March, followed by lockdown two days later. The entire population was to remain in their homes and associate only with immediate household members. Any travel beyond the home, except for exercise in the immediate vicinity or trips to grocery shops or health-care facilities, was banned. All nonessential businesses, schools and services were closed. Designated essential workers were permitted to work under strict protocols governing social distancing. A public health system tested contacts of all cases and promoted clear public health messages about the regulations and health behaviour. Government financial assistance was available for employers, businesses and individuals. The Prime Minister and her ministers and officials communicated daily with the public about the measures, cases and deaths, while promoting a sense of common national purpose which was to eliminate the virus from NZ. 19 

To answer the research question about older people's perspectives during the COVID-19, we employed a qualitative analysis of written comments on a national questionnaire survey. Participants were respondents to the 2020 wave of the Health, Work and Retirement Study of older community-dwelling adults who were initially randomly selected from the New Zealand Electoral Roll and had agreed to participate in the biennial longitudinal

The findings of this paper have important implications for government policy affecting the care and support of community-dwelling older people during pandemic responses. Institutional support from government leaders and agencies supports the well-being of older people during lockdown. Current policy focuses on vulnerability in relation to age alone, but these findings support calls for a broader policy framework that accounts for the diversity of circumstances among older people.

Recognition of the diversity of older people's individual, social and structural situations means that interventions to support older people in pandemic situations must account for these differences. While vulnerability to illness and isolation due to age is recognised, people should not be targeted on the basis of age alone. Interventions to support older people must include recognition of other vulnerable situations such as those of workers and informal caregivers.

survey (see Ref. 20) . The 2020 cohort of n = 4,000 is aged 55-85 years and includes representation of those of Māori descent. The questionnaire was designed to capture quantitative information regarding the social participation, behavioural, work, caregiving, housing and demographic predictors of social, mental and physical health of community-dwelling older people. The survey was conducted three weeks after lockdown was eased.

The back page of the questionnaire was blank with a header noting: 'We are interested in hearing about your thoughts and experiences on any of the topics in the survey. Please use this space to write any comments you may have, including any regarding the COVID-19 pandemic'. These procedures were approved by Massey University Human Ethics Committee [application reference # SOA 20/07].

Participants in this study were 730 survey respondents who commented on their COVID-19 experiences on the back of the questionnaire. Some respondents wrote one or two sentences, while others wrote lengthy commentaries. Age groups were as follows: 55-59 (119), 60-64 (178), 65-69 (174), 70-74 (122), 75+ (137) including 236 males and 475 females. Of these, 172 were in full-time employment, 162 in part-time employment, 13 unemployed and seeking work, 23 unable to work and 304 retired (56 other or missing). There were 159 living alone.

We took a realist descriptive semantic approach to the present analysis; focussing on a description of participant experiences in terms of the ideas and meanings explicitly stated by those participants. The orientation was inductive in that the meanings were derived from the data. We used a thematic analysis (TA) of these unstructured data to provide a broad overview of the shared perspectives and experiences of respondents. 21 The version of TA we drew upon offers the researcher analytic tools to make sense of data which has been gathered using a wide range of different research designs and data collection methods while offering the potential for interpretative analysis. 22 Following this approach, all responses were coded with NVivo software using the method of constant comparison 23 to identify all explicitly stated ideas, experiences and feelings about lockdown. The coded extracts were then analysed to identify the main themes and interpret their shared meanings. Both authors participated in coding, identifying and interpreting the themes.

Due to the size of the data set, there were many themes covered in the accounts from many different perspectives. Our approach to the findings reported here was to choose themes (whether addressed by many or few writers) that were pertinent to our research question about support needed by older people during lockdown.

From this analysis, we identified 3 themes that reflected the experiences of our participants: 'Strain and Worry', 'Enjoyment' and 'Community Support'. In the first part of the results section, we describe these three themes separately. In the second section, we describe two important aspects of the expression of these themes. First, that two or three of these themes could be experienced by the same people either across time or at the same time. Second, that these combinations depended upon the particular circumstances of the writer. This final important point speaks to the diversity of older people's situations which shape their experiences of the same events. These results are described below with illustrative extracts.

Many participants reported experiencing strains around the lockdown, including concerns about isolation from family members and friends, or difficulties with shopping and accessing medical services. For example, participants wrote:

Had to be isolated from people, and distancing was put in order. Threat of no sanitizers or towels, toilet paper, or flour was stress in itself. Shelves were emptied, as was milk and some goods. The lines were quite longreaching in the New World, right back to T. street, sometimes.

Found Covid19 hard. Needed contact with other people apart from husband. Missed socializing.

Those over 70 years old often expressed resentment about being singled out as vulnerable and told to stay at home. This participant describes how this changed her own perceptions of self:

Until Covid19, never did my age be of concern. I never felt or considered myself old. Covid19 came along and told me 'you are old, be careful'. Now I avoid large gatherings, stay my distance in stores, wash my hands countless times daily, frequently spray furniture, wipe down surfaces, door handle, etc All because now I have to admit that I am indeed old.

There was a great deal of worry about these circumstances expressed using words like anxiety, nervousness, anger, sadness, terror, stress and fear. Anxiety was attributed to personal vulnerability to the illness, worry about self, children or everybody, about losing their job and about unknown futures for themselves, family and the world. Some described becoming anxious as they stayed in place:

I had lots of plans and things to do during the lock-down, but after a day or two, I became restless, lethargic, and quite anxious. I felt lonely and started to miss physical touch at times, like a 'skin hunger'. I had weird dreams as well. A few participants also reported experiencing serious mental health issues which included recognition of anxiety disorders needing treatment or the exacerbation of previous mental health issues.

Despite the focus in the early literature on anxiety and mental health issues, a great many accounts in this sample were also about enjoying the lockdown time. In general, respondents described their enjoyment of a time for personal reflection, catching up on garden and home chores and hobbies, and quality time with family members. People also rejoiced in lack of noise, quiet roads for walks and bicycle rides. They described a time of 'calm and peace' or 'a time of contentment', with several harking back to a more ideal past as in this example: A great productive time at home bottling fruit, making relish, harvesting fruit and vegetables and planting seeds for winter veges. A lovely quiet time without traffic noise and machinery operating. It was a real winding down time which reminded me of life in the '70's. Lots of sharing with neighbours and friends with excess produce, etc. Great to be able to Facetime with grand-children and other friends. The pace of life was wonderful and the air on the country road I walked every day was so clean-until level 3 when some people went back to work and rubbish on the roadside started to appear again.

Several others also reported getting on better with their neighbours (albeit at a distance) and a general feeling of warm conviviality. These included stories of people waving and greeting from a distance or sharing regular evening drinks with neighbours that they had not done before. The 81-year-old participant in the following example describes how she enjoyed a more general sense of support that was gained by this new sense of community:

The Covid19 pandemic isolated a lot of whānau [family], the elderly stayed in their 'bubble'. The 3 months was mind-bobbling. The panic of buying foods, toiletries, etc aside brought out changes in mankind, everyone helping one another with so much kindness and a freely received, freely given attitude. People reaching out, bonding, sharing, the help is still going strong in our community. I thank our Heavenly Father for his gracious love and blessings.

People who told these enjoyment stories often mentioned the importance of support from their family, friends, local organisations, and the government and associated agencies.

Not all older people in the age group of our survey required personal support; in fact, many were carers for others. However, for some older people, family was an important source of support for the practical aspects of life that government advice made it difficult to access. These examples show how immediate and wider family provided support for their elders:

My family decided that my wife and I should be in lock-down the week before anyone else. My granddaughter, who just passed her stage one of her licence, decided to do our shopping for us.

During the Covid-19 pandemic quarantine, we agreed that my son do all our supermarket shopping to avoid me standing in long queues. Our Tuhoe Iwi [tribe] delivered groceries for 5 weeks and meat only the following weeks, which we are still receiving.

Older people who lived alone generally said that they did not change their daily lives and some, like this respondent, found additional benefits including more attention from family, support from community organisations and support from the whole country:

I was surprised at how well I coped for an 83-year-old. My 2 children contacted me more than usual, but I was able to assure them that I am used to living alone and am very independent in my normal life. Once I had hooked into having groceries delivered from the supermarket, I was fine. … I was most impressed by the fact that 3 separate organisations phoned to check if I was alright. More friends and family phoned a lot to see if I needed anything. I didn't imagine I would catch the virus-(rightly or wrongly). I had a warm and proud feeling as to how our fellow countrymen behaved and coped with the difficulties of lock-down.

Although there was some criticism of government actions, a great majority of the commentators praised the government decisions. One form of government support was clear daily communications which were much appreciated:

Updates at 1pm each day was excellent. Felt connected with whole of New Zealand and information was given calmly and informatively. Definitely helped with living alone although I had good contact with family, updates made me feel part of 5 million whānau.

People enjoyed both the leadership style and additional economic support targeted to those on New Zealand Superannuation (pension scheme) or other benefits. The following quote captures the tone of appreciation for both these aspects of government support which impacted the well-being of older people and their family members:

We (my husband and I) were very grateful to the government for the extra winter energy payment we received during the pandemic. It meant we used the clothes dryer and heater more during the lock-down. …We looked forward to the daily news updates on the pandemic and thought Jacinda Ardern [NZ Prime minister] and Dr Ashley Bloomfield [NZ Director-General of Health] were calm and reassuring. It wasn't a hardship for us.

We felt very well cared for. Our grandson also received the wage subsidy, which he was very grateful for.

In regard to other forms of support, people also described their personal resilience. Some remembered the polio epidemic (when they were home-schooled) or more recent earthquake or other disasters that they have survived. Others wrote about the support that they received from their religious faith. There was also a great deal of pride expressed in the efforts of New Zealanders together in this most recent disaster, summarised by:

Living through Covid-19 has been stressful, but due to the current status I am so impressed with our New Zealand team of 5 million.

People's fears were often alleviated by a sense of personal resilience and support. They described support from family and friends, from all New Zealanders, and a strong sense of being cared for by the government and NGOs.

It is important to note that the main themes we identified were not isolated in individual accounts. Themes may be contradictory in meaning and thematic analysis can additionally point to more nuanced constructions in the data. 24 The three themes of 'strain and worry', 'enjoyment', and 'community support' were interwoven within many of the accounts provided by our participants. Some people who wrote about enjoying lockdown also expressed anxiety or a sense of support, or all three. Some of those who reported anxiety also described the aspects that they enjoyed, or a shift from worry through a sense of support, to enjoyment of the lockdown, as in this brief example:

I was anxious, initially, about contracting Covid-19. I respect and appreciate the way the government handled the situation in NZ. …It was so relaxing to have the 7 weeks at home and 'smell the roses'.

Another participant typically described difficulties and gratitude for community support:

The Covid-19 pandemic has been a trying time for over-70s, and taking the government advice to stay home made it a bit difficult to get our groceries-but we are very grateful to the government for making the decision to stop the community spread of the virus. The increase of the subsidy of our power costs allowance has made a huge difference in that we turn on our heating without worrying about paying the bill.

In this third example, the participant herself notes the apparent contradictions in expressing enjoyment and worry together, while showing gratitude (qualified) for government support:

Overall, I quite enjoyed the restrictions of lock-down and had marvellous support from family and loads of contact with friends. I missed cuddles and sleepovers with my grandkids though, although they kept in touch well and would come round and blow kisses though the window. Although it may sound contradictory to my first comment, I have been continuing to be hugely concerned about the pandemic and how the world has handled it and have experienced anxiety for the first time. The world's future is uncertain, and these pandemics and extremes will continue to affect us all, I believe. Thank goodness for good leadership (on the whole) in NZ, and decisive actions.

One of the important factors that shaped the combination of themes in these accounts was the person's own circumstances. Identifying the differences between people points to the importance of the diverse situations across the older population.

Lockdown was enjoyable for older people who were retired, able to work from home or supported by government wage subsidies. Like many, the following writers were aware that enjoying lockdown was a privilege and expressed awareness of and concern for those who were in more difficult situations: I loved it. I think I will rewrite that… I LOVED IT!!. …I was very aware that others were not so fortunate, but selfishly, for me, it was bliss. :) -oh yes, and … I was paid throughout.

We were well cared for by the management of W---Retirement Village and also the government. Being retired, the Covid-19 pandemic did not really affect us as those in the workforce. We are very aware and concerned for those who have lost income and employment.

Many older people are in paid work and, for those in our sample who were deemed essential workers or threatened with job loss, the time was often stressful and worrying with no alleviating sense of support or enjoyment. Many of those who became anxious were not older people confined to the house, but were essential workers, as in these examples:

Because I am an essential worker, the Covid-19 period was an intensely busy time and extremely hectic. Since the return to work, I have struggled to keep up with the workload…The managers seem not to hear my concerns and I expect it will end badly. Sadly.

As a front-line worker, ie nurse at GP practice, I have worked all the way through. My colleagues and I are exhausted and need a break, but now we are at level 1, we find ourselves busier than ever…Very stressful.

Working in aged care has been extremely stressful during the Covid-19 pandemic and the risk still provides a lot of anxiety and stress.

Being single and with no children, I felt very anxious about losing my job during Covid-19. Suddenly I felt I had no real connections to people or any purpose/meaning for being alive. I became sick and depressed.

Others were also anxious about the loss of their jobs. COVID-19-related job loss often meant sudden retirement because of the difficulties in regaining employment or retraining in older age. People told stories of job losses at the border, at airports or in other affected organisations as in this account:

There is some chance that in the next 2-3 months the organisation I work for may have to restructure. This is due to the impact of Covid-19. If I should lose my job as a result of this, it would have negative consequences. My job is important to me.

While our participants did often note that they were lucky to be retired, and concern for workers, there was less awareness of the situation of many older people who were caring for others such as children, grandchildren or spouses. The difficulties for these people included the loss of social network support and being left alone with the caree as in this account:

…I found the lock-down stages at level 3 and 4 quite hard to accept. NB This is tied in with the fact that currently my wife and I are starting to go through early stages of assessment to see if she is starting to suffer from dementia. With just the two of us in lock-down, this added to some problems of how I felt.

The most poignant stories were of difficulties experienced since nursing homes enforced more stringent distancing requirement. These stories came from men and women who were separated from their spouses: I live alone in my own home and I feed my wife a midday meal every day in the rest home where she has lived for 9 years with advanced dementia. During the Covid-19 lockdown, I was not allowed to visit her for about 2 months. I talked to her several times each week when the rest home staff facilitated a video link.

Another respondent described in more detail the very detrimental effects of the separation on the physical and mental well-being of her husband. These stories of difficulties provide stark contrasts to the many accounts of relaxing, exercising and social support, enjoyed by those who were physically and financially well off.

In summary, older people in New Zealand did express worry and anxiety for themselves and for others during the period of lockdown in the pandemic. However, for those who were retired, able to work at home or eligible for wage subsidies, the experience was also very enjoyable. Our analysis shows that for these older people, whether living alone or in household groups, anxieties were largely ameliorated by a sense of being supported. Those who did not feel sufficient support to alleviate their anxiety were in particular situations: essential workers, those who lost employment and those who were caring for dependent others.

For the first group, our findings highlight the importance of strong government guidance and support. First, older people appreciated the material support shown by wage and heating subsidies swiftly provided (for them and their wider families), and the support for a range of home contact and support services provided by local authorities and NGOs. Second, the cohesive leadership provided by the government, which included daily information updates and clear consistent messages, led to a sense of security and social cohesion. This was reflected in the consistent repetition of catch phrases from those messages (such as 'team of 5 million' or 'be kind'). This leadership was supported by Māori and Pacific Island leaders and politicians of different political persuasion. So, for a time, the country did express a strong sense of unity, which in turn supported those who may have felt more helpless. A Dutch study 25 found that a decline in trust in societal institutions during lockdown was associated with increasing mental health problems. Although the authors suggest that institutions could focus on facilitating meaningful contact with kin, our results suggest that, while family support is also important, it is the institutions themselves that can provide a strong sense of social support.

Our data have highlighted inequalities in the experiences of support during lockdown. Several authors (eg, Ref. 1, 26) have pointed to the effects of ageism in constructing older people as disposable or subject to extreme isolation. Drawing on a broad community-dwelling sample of older people has shown that relying on stereotypes of all older people as retired and physically or mentally vulnerable, we ignore the diversity of older people and neglect other kinds of stressful situations. Older people who are currently employed may require more focussed concern. Older workers (employed people aged 55 years and over) were expected to comprise around 25% per cent of all employed people in New Zealand by 2020 27 so this is a significant group.

The plight of workers also includes those unpaid older workers who care for others. The number of informal caregivers has increased in New Zealand in line with the ageing population, and the proportion of caregivers in older age groups increases at a faster rate than in the general population. 28 The present data highlighted the distress of caregivers who were separated from their carees by the lockdown and the negative consequences for those who were being cared for. Discussions of the needs of isolated older people ignore the growing number of older people actively engaged in caring and paid work. Many participants in our study did both.

A strength of this study is the inductive approach which allowed older people to tell their own stories. No specific questions were posed in the invitation to write accounts, and people highlighted the aspects of the COVID-19 experience that were important to them. Thus, we were able to observe that the stories of anxiety were mixed with accounts of support and highlight the anxieties of those older people who do not fit into the stereotyped category of the lonely isolated older person and whose experiences were more stressful. The approach also limits our findings. The sample is not representative, and many other aspects of lockdown experiences may have been missed. Furthermore, the nature of the data (brief accounts written in a prescribed space on the back of a questionnaire) meant that, although we had many respondents addressing the same themes, these topics were not addressed in depth.

What this analysis does show is the diversity in older people's experiences. Assumptions about the detrimental mental health effects of isolation do result in the treatment of older people as a homogenous group of vulnerable elders, while neglecting the needs of specific groups such as workers or carers. As all countries refine their epidemiological and medical responses, the response to the needs of older citizens should be broadened to include the diversity of older adults' situations and experiences.

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No conflicts of interest to declare.

https://orcid. org/0000-0003-1325-3579