Psychological Wellbeing and Psychological Distress in the Elderly during the COVID-19 Pandemic

INTRODUCTION

In Indonesia, the COVID-19 pandemic began in March 2020 and is still ongoing as of April 2022. The government has taken various measures to overcome the its effects, including implementing PSBB (large-scale social restrictions), transitional PSBB, and PPKM (enforcement of restrictions on community activities) (up to four-level). Despite all measures taken, the incidence of COVID-19 remains high in Indonesia.

There are three significant impacts of the COVID-19 pandemic that were felt globally: the economic impact (massive layoffs and reduced salaries), the environmental impact (industrial closures, tourism, etc.), and the psychological impact (increased fear of death, loneliness, and issues related to future security) [1]. Despite causing a severe economic downturn, the environmental effects of the COVID-19 pandemic were rather positive due to reduced levels of pollution across the globe [1, 2]. The psychological impact of the pandemic, in turn, is of particular concern to many researchers, especially in the social and health sciences. Many studies report that the COVID-19 pandemic has had a negative impact on mental health [2–11], triggering anxiety, stress, depression [12–19], loneliness, and worry [20–23]. In addition, a study of 157,213 participants living in America concluded that calm, happiness, and optimism decreased during the COVID-19 pandemic [3].

Studying the state of mental health during the COVID-19 pandemic has become highly relevant and important, especially amongst the elderly population. The elderly population is deemed to be the most vulnerable to the effects of the pandemic [24]. It has been shown that more than 80% of the deaths caused by COVID-19 in America were among people over the age of 65 years (CDC COVID-19 Response Team, 2020). Those who are aged 60 had the highest level of confirmed deaths compared to other age groups. Even in Indonesia, the number of COVID-19 deaths as of 5 November 2021 had reached 143,534, including the elderly population (https://covid19.go.id/peta-sebaran-covid19).

The higher the mortality, the more worried the population seems to be. This is evidenced in research reports indicating high rates of anxiety in the elderly with comorbidities such as hypertension, heart disease, and diabetes mellitus [26]. Other studies report that increased rates of mental health problems were caused by social isolation, impacting their bio-psycho-social vulnerability [27]. In particular, Lumbantoruan et al., 2021 defined that social isolation leads to loneliness, which increases the risk of depression, anxiety disorders, and suicide, especially among elderly patients living in nursing homes. Similar results were reported by Stolz et al., who interviewed 557 participants aged 60 years and over, showing that loneliness increased during the lockdown. Another factor that affects the mental health of the elderly is an attachment to God. Individuals believe that their closeness to God will provide a sense of security and help them in times of difficulty [29]. Homan [30] and Kent et al. [31] demonstrated that there is a link between attachment to God and mental health. Individuals with a secure attachment to God can treat themselves with kindness and care, especially when facing severe problems.

Although there are studies examining the effect of the COVID-19 pandemic on the mental health of the elderly, this research topic has barely been studied in the context of Indonesia. The specific purpose of this research is to examine the mental health status of the elderly during the COVID-19 pandemic in Indonesia during the implementation of the four-level PPKM system and the factors that affect their mental health, such as loneliness and attachment to God.

METHOD

Study design

A sequential explanatory form of mixed-method approach was adopted for this study. Using this approach allowed the combination of quantitative and qualitative elements in a sequential manner and the building of subsequent phases of the research on what had previously been determined. In particular, the researchers first conducted quantitative research, analyzed the results, and then explained them in more detail using qualitative research [32].

Sampling

Incidental sampling was chosen as a sampling strategy for this study. Participants in this study found it difficult to communicate well, so the selection of participants was based on communication skills. Interviews were conducted with the elderly participants who had extreme high and low mental health status, as based on the survey.

Recruitment

We recruited participants by spreading the recruitment link online. We approached colleagues, friends, and psychology students who have elderly family members and asked them to act as guides when completing the questionnaires. Each participant signed a consent form before completing the questionnaire.

Procedure

We used Google Forms to share the above link with colleagues, friends, and psychology students. An online format was chosen to minimize any risk of spreading the COVID-19 virus. After the data was collected, we analyzed the data using mental health level categorization. The data collected was also used to determine potential participants for the planned interviews. Interviews were conducted by psychology students whom we had befriended beforehand.

Measurement

Mental Health Inventory (MHI)

MHI-5 was chosen as a data collection tool to measure the mental health status of the elderly. The MHI-5 is a shortened version of the 38-item based on fundamental theory [34], then expanded to five items [35]. This measurement tool reveals two important aspects: psychological well-being (2 items) and psychological distress (3 items). The MHI-5 has a reliability value of 0.67.

Attachment to God

Attachment to God was measured using the Muslim Spiritual Attachment Scale (M-SAS) developed by Miner et al., which includes 16 items arranged based on four factors: Proximity, Positive model of God, Positive Model of Self, and Separation Protest [36]. Each factor of the M-SAS Scale consists of four items. The M-SAS has a reliability of 0.62.

Loneliness

Loneliness was measured using the University of California, Los Angeles (UCLA) Loneliness Scale 6, also known as ULS-6. The ULS-6 measuring instrument was developed by Hudiyana et al. [37]. The ULS-6 measuring instrument has shown good quality in terms of measuring loneliness in cross-cultural studies and has been tested in three countries, namely Indonesia, Germany, and America. ULS-6 has a reliability of 0.89.

Guide Interview

In-depth interviews were used as a data collection tool. The interview guide was developed following Veit and Ware [34], indicating that mental health is measured based on two opposing dimensions. The positive dimension is represented by psychological well-being and the negative dimension by psychological distress. The interview guide is shown in Table 1.

Table 1. Interview Guide

Data analysis

Data from two different approaches was analyzed separately following the guidance offered by Creswell and Creswell [32]. The analysis was completed via three steps. Firstly, quantitative data was analyzed using JAMOVI to categorize it and create correlations between variables and perform regression analyses. Secondly, qualitative data was analyzed via the content analysis. Content analysis includes several steps such as coding of the interview transcript, merging codes into categories, and developing themes [37]. Thirdly, quantitative and qualitative results were integrated.

RESULTS

Participants

Overall, 82 elderly individuals with an age range of 60 to 90 years old were recruited for the purposes of the quantitative part of this study. The majority of participants were women (73.2%). Quantitative sample characteristics are shown in Table 2.

Table 2. Quantitative sample characteristics

Further, nine elderly participants with very low (three participants) and very high (six participants) mental health status categories were invited to the qualitative interviews. This was done to examine the differences in the groups’ responses and capture diverse perspectives. Qualitative sample characteristics are presented in Table 3.

Table 3. Qualitative sample characteristics

Quantitative result

Intercorrelation between variables

According to the results of correlation analysis, the mental health variable has a correlation with loneliness (R=-0.447, with a significance of <.001). This indicates a negative correlation between mental health and loneliness. This means that the higher the loneliness in the elderly, the lower or worse their mental health. On the other hand, the lower the loneliness in the elderly, the higher or better their mental health. The correlation between attachment to God and mental health did not show the expected results as no significant correlation was found. No significant results were found with regard to the relationship between loneliness and attachment to God (Appendix A).

Regression Analysis

Based on the regression analysis, there is a significant effect of loneliness on mental health (R²=0.20; p <0.001). However, the effect is relatively small. The magnitude of the influence of loneliness on mental health is 20%, while other factors influence the remaining 80% (Table 4).

Table 4. Regression analysis results

Qualitative result

We deepen the results of quantitative research with qualitative methods. The results of the interviews can be described according to two major themes, namely psychological distress and psychological well-being.

Psychological distress

Based on the results of interviews with nine elderly individuals, it was found that limited activities (not being able to recite the Qur’an together, visiting neighbors, etc.), being anxious and suspicious of others who may have tested positive for COVID-19 and being unable to visit or be visited by children and grandchildren made the elderly unhappy during the COVID-19 pandemic. Religious activities can be one of the ways to avoid and prevent the elderly from experiencing such sadness, which included prayer, reading the Qur’an, and Dzikr. The elderly also mentioned other activities such as going to the fields or doing productive activities at home. Furthermore, using telecommunications equipment to make voice or video calls with family members who are far away and communicating with children and grandchildren at home were mentioned as useful to avoiding psychological distress. Some example quotations are presented below:

“To avoid feeling sad, I pray, read the Qur’an and do more dzikr”

(Female, 73 years)

“When I feel sad, I pray, recite and pray and do dhikr so that my heart feels joy”

(Female, 65 years)

“…by doing activities in the kitchen and around the yard”

(Female, 63 years)

Psychological well-being

Based on the results of interviews conducted with nine elderly people, what makes them happy and how to prevent from being sad could be evaluated. Doing activities such as going to the fields, making coffee, and selling crackers were all mentioned as helping to maintain psychological well-being. Otherwise, avoiding suspicion (some people tend to hide their positive COVID-19 diagnoses to avoid suspicion), staying connected online with family members, playing with grandchildren, and being cared for were specified as making the elderly happy. Some example quotations are presented below:

“Feel peaceful when you go to the rice fields”

(Male, 61 years)

“Can still communicate with other family members even through the internet”

(Male, 62 years)

“…carry out commercial activities such as selling crackers and making ground coffee”

(Female, 63 years)

Based on the results of interviews with nine elderly people related to psychological distress and psychological well-being, the flow of themes found in the interviews is shown in Figure 1. It can be seen that elderly individuals could feel sad (part of psychological distress) for various reasons such as limited activities, being unable to meet distant family members, and a suspicion of being among people affected by the COVID-19 virus, then coping with these could be themed into three forms to relieve sadness. The first form of coping includes pursuing productive activities as a form of diversion. The second form of coping is performing religious activities, including prayer, reading the Qur’an, and dhikr. The third form of coping is communication activities, such as making voice or video calls with smartphones, communicating with family members at home, and diverting communication about COVID-19. Coping strategies create happy feelings such as healthy family members, being close to children and grandchildren at home and far away, feeling cared for, and not feeling suspicious in communication with neighbors.

Figure 1. Qualitative research results.

DISCUSSION

Main findings

Based on the results of the quantitative research, mental health is only affected by loneliness. Qualitative results showed that reduced activity, not being able to meet children and grandchildren, and not being able to recite the Qur’an were amongst the main factors triggering sadness among the elderly during the COVID-19 pandemic. Furthermore, we defined that elderly people use productive activities, religious activities, and communication as their main coping strategies.

Strengths and limitations

This study has two main strengths. Firstly, to our knowledge, it is the first study to explore the mental health status among elderly individuals in Indonesia. Secondly, the results of this study can be used as the basis for understanding mental health in the elderly to take further appropriate action.

The results of our study have several limitations. The research sample was defined using non-probability sampling with an accidental sampling technique, so the conclusions drawn are difficult to generalize. The absence of additional training in conducting interviews with the elderly led to difficulties during the interview process, which may have influenced the results.

Comparison with the existing literature

The results of this study generally confirm that psychological distancing causes problems such as feeling lonely [38], especially amongst adults who cannot use technology [39]. Similar results were found among elderly people in Europe who reported a higher loneliness due to physical distancing during the pandemic [40]. Although other studies confirm that loneliness in the elderly occurs only in those with multiple physical and mental health diagnoses, it is associated with reduced loneliness in those with larger social networks [41].

No correlation between attachment to God and mental health was confirmed in this study. In contrast, another study noted that there was an effect of attachment to God on mental health [30, 31]. According to the qualitative data results, in order to cope with loneliness, elderly individuals use worship-related practices, showing their attachment to God. Therefore, we suspect that attachment to God might well be a moderating variable, while religious coping is a mediator between loneliness and mental health.

Implications for future research

We suggest the following implications for future research. Firstly, the attachment to God variable may need to be reviewed using different approaches. Such studies might confirm why Attachment to God has no relationship with mental health status (or indeed otherwise). Secondly, the religiosity variable can be studied further and compared with the attachment to God variable. Finally, considering that Indonesia is known to be a religious country, exploring certain religious concepts could be helpful to a description of how religious concepts influence mental health.

CONCLUSION

This study confirms that the loneliness caused by lockdown is a factor in mental health issues among the elderly population, whereas attachment to God has no apparent effect. The results show that reduced activity, inability to meet children and grandchildren, and inability to recite the Qur’an are the main factors triggering sadness among the elderly during the COVID-19 pandemic. Furthermore, we defined that elderly people use productive and religious activities and communication as their main coping strategies. The implications of this research can be used as a basis or reference for maintaining the mental health of the elderly during the pandemic. The results of the study should be interpreted in light of its limitations with regard to the number of participants and other variables that may have an impact on mental health.

1. Hiscott J, Alexandridi M, Muscolini M, Tassone E, Palermo E, Soultsioti M, Zevini A. The global impact of the coronavirus pandemic. Cytokine Growth Factor Rev. 2020 Jun;53:1–9. doi: 10.1016/j.cytogfr.2020.05.010.
2. Loh HC, Looi I, Ch’ng ASH, Goh KW, Ming LC, Ang KH. Positive global environmental impacts of the COVID-19 pandemic lockdown: a review. GeoJournal. 2021 Jul 23:1–13. doi: 10.1007/s10708-021-10475-6.
3. Yarrington JS, Lasser J, Garcia D, Vargas JH, Couto DD, Marafon T, Craske MG, Niles AN. Impact of the COVID-19 Pandemic on Mental Health among 157,213 Americans. J Affect Disord. 2021 May 1;286:64–70. doi: 10.1016/j.jad.2021.02.056.
4. Pan K-Y, Kok AAL, Eikelenboom M, Horsfall M, Jörg F, Luteijn RA, Rhebergen D, Oppen Pv, Giltay EJ, Penninx BWJH. The mental health impact of the COVID-19 pandemic on people with and without depressive, anxiety, or obsessive-compulsive disorders: a longitudinal study of three Dutch case-control cohorts. The Lancet Psychiatry. 2021;8(2):121–129. doi: 10.1016/s2215-0366(20)30491-0.
5. Johnson S, Dalton-Locke C, Vera San Juan N, Foye U, Oram S, Papamichail A, Landau S, Rowan Olive R, Jeynes T, Shah P, et al. Impact on mental health care and on mental health service users of the COVID-19 pandemic: a mixed methods survey of UK mental health care staff. Soc Psychiatry Psychiatr Epidemiol. 2021 Jan;56(1):25–37. doi: 10.1007/s00127-020-01927-4.
6. Boden M, Zimmerman L, Azevedo KJ, Ruzek JI, Gala S, Abdel Magid HS, Cohen N, Walser R, Mahtani ND, Hoggatt KJ, et al. Addressing the mental health impact of COVID-19 through population health. Clin Psychol Rev. 2021 Apr;85:102006. doi: 10.1016/j.cpr.2021.102006.
7. Thome J, Deloyer J, Coogan AN, Bailey-Rodriguez D, da Cruz ESOAB, Faltraco F, Grima C, Gudjonsson SO, Hanon C, Holly M, et al. The impact of the early phase of the COVID-19 pandemic on mental-health services in Europe. World J Biol Psychiatry. 2021 Sep;22(7):516–525. doi: 10.1080/15622975.2020.1844290.
8. Wang Y, Shi L, Que J, Lu Q, Liu L, Lu Z, Xu Y, Liu J, Sun Y, Meng S, et al. The impact of quarantine on mental health status among general population in China during the COVID-19 pandemic. Mol Psychiatry. 2021 Sep;26(9):4813–4822. doi: 10.1038/s41380-021-01019-y.
9. Kola L, Kohrt BA, Hanlon C, Naslund JA, Sikander S, Balaji M, Benjet C, Cheung EYL, Eaton J, Gonsalves P, et al. COVID-19 mental health impact and responses in low-income and middle-income countries: reimagining global mental health. Lancet Psychiatry. 2021 Jun;8(6):535–550. doi: 10.1016/S2215-0366(21)00025-0.
10. Ravens-Sieberer U, Kaman A, Erhart M, Devine J, Schlack R, Otto C. Impact of the COVID-19 pandemic on quality of life and mental health in children and adolescents in Germany. Eur Child Adolesc Psychiatry. 2021 Jan 25. doi: 10.1007/s00787-021-01726-5.
11. Herdian H, Qingrong C. Mental Health in the elderly during the Pandemic in Indonesia. J Clin Dev Psychol. 2021;3(2):1–9.
12. Dozois DJA. Anxiety and depression in Canada during the COVID-19 pandemic: A national survey. Can Psychol. 2021;62(1):136–142.
13. Turna J, Zhang J, Lamberti N, Patterson B, Simpson W, Francisco AP, Bergmann CG, Ameringen MV. Anxiety, depression and stress during the COVID-19 pandemic: Results from a cross-sectional survey. J Psychiatr Res. 2021 May;137:96–103. doi: 10.1016/j.jpsychires.2021.02.059.
14. Varma P, Junge M, Meaklim H, Jackson ML. Younger people are more vulnerable to stress, anxiety and depression during COVID-19 pandemic: A global cross-sectional survey. Prog Neuropsychopharmacol Biol Psychiatry. 2021 Jul 13;109:110236. doi: 10.1016/j.pnpbp.2020.110236.
15. Ozamiz-Etxebarria N, Idoiaga Mondragon N, Bueno-Notivol J, Pérez-Moreno M, Santabárbara J. Prevalence of Anxiety, Depression, and Stress among Teachers during the COVID-19 Pandemic: A Rapid Systematic Review with Meta-Analysis. 2021;11(9):1172.
16. Hawes MT, Szenczy AK, Klein DN, Hajcak G, Nelson BD. Increases in depression and anxiety symptoms in adolescents and young adults during the COVID-19 pandemic. Psychol Med. 2021 Jan 13:1–9. doi: 10.1017/S0033291720005358.
17. Faisal RA, Jobe MC, Ahmed O, Sharker T. Mental Health Status, Anxiety, and Depression Levels of Bangladeshi University Students During the COVID-19 Pandemic. Int J Ment Health Addict. 2021 Jan 4:1–16. doi: 10.1007/s11469-020-00458-y.
18. Bareeqa SB, Ahmed SI, Samar SS, Yasin W, Zehra S, Monese GM, Gouthro RV. Prevalence of depression, anxiety and stress in china during COVID-19 pandemic: A systematic review with meta-analysis. Int J Psychiatry Med. 2021 Jul;56(4):210–227. doi: 10.1177/0091217420978005.
19. Kibbey MM, Fedorenko EJ, Farris SG. Anxiety, depression, and health anxiety in undergraduate students living in initial US outbreak “hotspot” during COVID-19 pandemic. Cogn Behav Ther. 2021 Sep;50(5):409–421. doi: 10.1080/16506073.2020.1853805.
20. Heinberg LJ, Steffen K. Social Isolation and Loneliness During the COVID-19 Pandemic: Impact on Weight. Curr Obes Rep. 2021 Sep;10(3):365–370. doi: 10.1007/s13679-021-00447-9.
21. Varga TV, Bu F, Dissing AS, Elsenburg LK, Bustamante JJH, Matta J, van Zon SKR, Brouwer S, Bultmann U, Fancourt D, et al. Loneliness, worries, anxiety, and precautionary behaviours in response to the COVID-19 pandemic: A longitudinal analysis of 200,000 Western and Northern Europeans. Lancet Reg Health Eur. 2021 Mar;2:100020. doi: 10.1016/j.lanepe.2020.100020.
22. Hansen T, Nilsen TS, Yu B, Knapstad M, Skogen JC, Vedaa O, Nes RB. Locked and lonely? A longitudinal assessment of loneliness before and during the COVID-19 pandemic in Norway. Scand J Public Health. 2021 Nov;49(7):766–773. doi: 10.1177/1403494821993711.
23. Wickens CM, McDonald AJ, Elton-Marshall T, Wells S, Nigatu YT, Jankowicz D, Hamilton HA. Loneliness in the COVID-19 pandemic: Associations with age, gender and their interaction. J Psychiatr Res. 2021 Apr;136:103–108. doi: 10.1016/j.jpsychires.2021.01.047.
24. Pradana AA, Casman C, Nur’aini N. Pengaruh kebijakan social distancing pada wabah COVID-19 terhadap kelompok rentan di Indonesia. J Kebijak Kesehat Indones JKKI. 2020;9(2):61–67.
25. Team CC-R. Severe Outcomes Among Patients with Coronavirus Disease 2019 (COVID-19) — United States, February 12-March 16, 2020. MMWR Morb Mortal Wkly Rep. 2020 Mar 27;69(12):343–346. doi: 10.15585/mmwr.mm6912e2.
26. Tobing C, Wulandari ISM. Tingkat Kecemasan bagi Lansia yang Memiliki Penyakit Penyerta Ditengah Situasi Pandemik Covid-19 di Kecamatan Parongpong, Bandung Barat. Community Publ Nurs. 2021 April;9(2):135–142.
27. Lumbantoruan M, Sirait A, Aritonang J. Kajian Kecemasan Lansia Di Masa Pandemi Covid 19. Ahmar Metastasis Health Journal. 2021;1(2):43–48. doi: 10.53770/amhj.v1i2.48.
28. Stolz E, Mayerl H, Freidl W. The impact of COVID-19 restriction measures on loneliness among older adults in Austria. Eur J Public Health. 2021 Feb 1;31(1):44–49. doi: 10.1093/eurpub/ckaa238.
29. Bonab BG, Namini ASY. The Relationship between Attachment to God and Reliance on God. Procedia — Social and Behavioral Sciences. 2010;5:1098–1104. doi: 10.1016/j.sbspro.2010.07.242.
30. Homan KJ. A mediation model linking attachment to God, self-compassion, and mental health. Ment Health Relig Cult. 2014;17(10):977–989.
31. Kent BV, Bradshaw M, Uecker JE. Forgiveness, Attachment to God, and Mental Health Outcomes in Older U.S. Adults: A Longitudinal Study. Res Aging. 2018 Jun;40(5):456–479. doi: 10.1177/0164027517706984.
32. Creswell JW, Creswell JD. Research Design Qualitative, Quantitative, and Mixed Methods Approaches. USA: SAGE Publications; 2017.
33. Veit CT, Ware JE, Jr. The structure of psychological distress and well-being in general populations. J Consult Clin Psychol. 1983 Oct;51(5):730–742. doi: 10.1037//0022-006x.51.5.730.
34. Berwick DM, Murphy JM, Goldman PA, Ware JE, Jr., Barsky AJ, Weinstein MC. Performance of a five-item mental health screening test. Med Care. 1991 Feb;29(2):169–176. doi: 10.1097/00005650-199102000-00008.
35. Miner MH, Ghobary-Bonab B, Dowson MN. Development of a Measure of Attachment to God for Muslims. Rev Relig Res. 2017;59:183–206.
36. Hudiyana J, Lincoln TM, Hartanto S, Shadiqi MA, Milla MN, Muluk H, Jaya ES. How Universal Is a Construct of Loneliness? Measurement Invariance of the UCLA Loneliness Scale in Indonesia, Germany, and the United States. Assessment. 2021 Jul 23:10731911211034564. doi: 10.1177/10731911211034564.
37. Miles MB, Huberman AM. Analisis data kualitatif jakarta: Universitas Indonesia. Jakarta: UI press; 1992.
38. Miller ED. Loneliness in the Era of COVID-19. Front Psychol. 2020;11:2219. doi: 10.3389/fpsyg.2020.02219.
39. Dahlberg L. Loneliness during the COVID-19 pandemic. Aging Ment Health. 2021 Jul;25(7):1161–1164. doi: 10.1080/13607863.2021.1875195.
40. Cohn-Schwartz E, Vitman-Schorr A, Khalaila R. Physical distancing is related to fewer electronic and in-person contacts and to increased loneliness during the COVID-19 pandemic among older Europeans. Qual Life Res. 2022 Apr;31(4):1033–1042. doi: 10.1007/s11136-021-02949-4.
41. Rumas R, Shamblaw AL, Jagtap S, Best MW. Predictors and consequences of loneliness during the COVID-19 Pandemic. Psychiatry Res. 2021 Jun;300:113934. doi: 10.1016/j.psychres.2021.113934.