key: cord-0975398-t8fibijc
authors: Yang, Qing; Wang, Yuxin; Tian, Chong; Chen, Yuan; Mao, Jing
title: The Experiences of Community‐dwelling older adults during the COVID‐19 Lockdown in Wuhan: A qualitative study
date: 2021-07-14
journal: J Adv Nurs
DOI: 10.1111/jan.14978
sha: 26c1c2d655a208f7dc228d7af9a54bc5710df283
doc_id: 975398
cord_uid: t8fibijc

AIMS: To explore the experiences of community‐dwelling older adults in Wuhan during the coronavirus disease 2019 lockdown. DESIGN: An empirical phenomenological approach was used to conduct a qualitative study. METHODS: We performed semi‐structured, in‐depth telephone interviews between July 24 and August 2, 2020. A purposive sample of 18 participants (≥65 years old) who lived in Wuhan during the lockdown was recruited, including both infected and uninfected people. Data summarization and theme categories refinement were performed following Colaizzi's phenomenological approach. RESULTS: Four main theme categories emerged. First, the ‘Challenges’ posed by the epidemic. Older adults were challenged with barriers in seeing a doctor and daily life inconveniences. And they experienced negative emotions, whether infected or not. The second domain was ‘multi‐dimensional support’, which helped older people went through the difficult period. The third domain was ‘resilience amid challenges’. Although they experienced physical and psychological distress, most of them could self‐adjust and achieve transcendence from the unique experience. Lastly, the remaining impact after the epidemic affected older adults. Some still had mental burdens, while others thought they have benefited from the quarantine time (e.g. regular diet, learning new skills). CONCLUSION: The epidemic and lockdown of the city brought significant physical and mental challenges to community‐dwelling older adults. Active adaptation and multifaceted support helped them through this period. However, the mental burdens after the epidemic still require attention. These experiences would provide guidelines for the protection of vulnerable populations during public health emergencies. IMPACT: The results of the study suggested that certain social dynamics and individual behaviours helped the elderly to better cope with the stressful lockdown period. The findings in this study provided guidelines on how to reduce the negative effects on older adults during the pandemic and enlighten studies concerning the well‐being of older adults or other vulnerable people in future crises.

The Coronavirus disease 2019 has rapidly spread worldwide (Zhu et al., 2020) , infecting more than 140 million individuals and causing 3,003,794 deaths until (World Health Organization & COVID-19 outbreak situation, 2021 . Among all the people worldwide facing this pandemic, older adults suffered the most.

Older adults are at higher risk of infection, deterioration and death from COVID-19 than young people Zhou et al., 2020) . The United Nations also warned of a looming mental health crisis due to the COVID-19 pandemic and asserted that older adults are prone to more psychological instabilities (United Nations Policy Brief, 2020) . To prevent infection, the government introduced physical distancing policies and older adults were constrained from visiting family members and friends, leading to a state of social isolation, which could further propose a negative impact on mental and physical health in older adults, such as anxiety, depression, disability, chronic diseases, physical inactivity, increased risk of Alzheimer's disease and mortality (Brooks et al., 2020; Nicholson, 2012) .

With the continuously expanding ageing society (Abbatecola & Antonelli-Incalzi, 2020), older adults should be paid special attention under the pandemic (Landi et al., 2020) . Low immune function, comorbidities (e.g. hypertension, diabetes, frailty) and cognitive decline contributed to COVID-19-related high risk among older people (Cunha et al., 2020; Wu & McGoogan, 2020; Zhou et al., 2020) . Meanwhile, many countries (e.g. China, Italy, Spain) adopted lockdown policies to curb the spread of COVID-19 (Chinazzi et al., 2020) , which also caused much inconvenience and distress for older adults (Gaur et al., 2020; Pan et al., 2020) .

People were not allowed to have outdoor activities as before. What is even more alarming is the second wave of the pandemic. Many countries in Europe showed exponential growth in new cases in October, 2020 (World Health Organization & WHO COVID-19 Dashboard, 2021) .

Ireland, Spain, Germany, France and the United Kingdom (Scotland) have announced a national lockdown. A prolonged quarantine period and minimum social contacts would bring more challenges to older adults (Busby, 2020; Moradian et al., 2021) . Comprehending older adults' conditions would be a basis for practical interventions to guarantee their well-being.

Most previous studies focused on specific psychological and physical symptoms or risk factors, and objective descriptions were used (Bergman et al., 2020; Robb et al., 2020) . Little is known about older adults' real-life experiences during the COVID-19 pandemic, which might be complicated and underestimated due to the complexity of daily lives. Meanwhile, why did some older adults cope well during the epidemic? How did they recover from the adversity and become stronger? Many problems were raised without solutions proposed. Exploration of these issues would provide ideas for the welfare of older adults during the crisis.

Wuhan, Hubei, China, the first epicentre of the COVID-19 pandemic, has experienced outbreaks and stringent lockdown (social distancing, traffic restriction, strict stay-at-home policy) (National and 'leaving no one unattended' policy were adopted on the country level. Medical services were reorganized and 42,000 healthcare workers were dispatched to help Wuhan. The government also undertook all medical expenses for COVID-19 treatment to relieve the financial worries of patients infected with COVID-19. Moreover, communities in Wuhan have taken much responsibility during the lockdown. The community system in China is the basic unit that provides residents with living services (Chen et al., 2013) . Social workers in the community have the responsibility to integrate resources and coordinate social relations in the community and help those in need. And communities enforced the quarantine policy and supported every resident in the face of COVID-19 as all residential communities in Wuhan were locked down.

The epidemic in Wuhan is under control now, but regular epidemic prevention and control measures are implemented to prevent relapses. Community-dwelling older adults in Wuhan faced various challenges throughout the whole epidemic and lockdown period and their experiences were unprecedented. Every aspect of their life changed dramatically in terms of food, transportation and getting medical support. A comprehensive understanding of older adults' experiences in the epidemic is needed to guide further support for older adults in this post-epidemic period and develop better antiepidemic programmes preparing for future crises.

Our research aimed to explore the details and understand the experiences of community-dwelling older adults in Wuhan during the COVID-19 lockdown to provide guidelines for other cities K E Y W O R D S coronavirus infection, experience, lockdown, nursing, older adults, Wuhan challenged with COVID-19 and for similar challenges to human society in the future.

We used an empirical phenomenological approach to conduct a qualitative study. Semi-structured in-depth telephone interviews were used to explore the experiences of older community-dwellers during the COVID-19 lockdown in Wuhan. The focus of phenomenological research was to describe the commonalities of experiences across the older population. We followed the Standards for Reporting Qualitative Research guidelines (SRQR) and the consolidated criteria for reporting on qualitative research (COREQ) throughout this study (O Brien et al., 2014; Tong et al., 2007) .

Community-dwelling older adults in Wuhan were chosen as study objects. Eligible participants included older community-dwellers who were 65 years old and above and spent the whole COVID-19 epidemic and lockdown period (January 23-April 8, 2020) in Wuhan.

Exclusion criteria were: (a) cannot communicate and (b) unwilling or refuse to participate. Participants were recruited using purposive and snowball sampling. Firstly, we purposely selected older adults with different infection histories regarding COVID-19 and living statuses (e.g. were infected with COVID-19 or not, lived with family members or alone, lived in different districts in Wuhan). Then, we used the initially recruited participants as informants to locate more older adults that met our inclusion criteria to enlarge the study population. The sample size was decided by data saturation and recruitment ended when no new themes emerged. Twenty-two older adults were approached. Eighteen people consented to be interviewed, and four declined due to their health conditions (e.g. fatigue). Seven participants were known to the research team members before, and others were approached through snowball sampling.

Our team reviewed relevant literature and consulted two geriatric experts' opinions (a geriatric nursing specialist and a geriatric medical professor) to formulate a semi-structured interview guide.

Then we conducted a pilot test with three older adults to adjust and determine the final interview guide. At the beginning of the interviews, the participants' social-demographic information and infection history were collected. The interview guide covered three main categories: (a) Experiences and feelings (medical services, food, transportation and entertainment) during the epidemic, (b) Ways to cope with the challenges and (c) Feelings after the epidemic. The open-ended questions and probes in the guide were flexible to allow the interviewer to explore relevant issues as they emerged. The telephone interview guide is presented in Table 1 .

In total, 18 individual in-depth telephone interviews were conducted from July 24 to August 2, 2020. The interviewers (YQ, WYX) had the experience of qualitative research and conducted the interviews following the interview guide. The telephone interviews were adopted because social distancing was encouraged in Wuhan. They also ensured a greater level of anonymity and privacy, allowing the participants to be more comfortable sharing personal feelings. Prior to the interviews, we had contacted the older adults first to explain our study purpose, provided information on the whole interview process and obtained informed consent. The interviews were scheduled at a time convenient to the participants. Interviews were conducted in Mandarin or Wuhan dialect. Each interview lasted between 11-105 minutes and was audio-recorded. Thematic redundancy was achieved at the 16th interview, and two more interviews were further conducted to confirm data saturation. Detailed field notes were written during and immediately after the interviews to inform data analysis. If the participants showed negative emotions (anxiety, depression, panic) during the interviews, the interviewer would provide psychological support and offer time to rest before continuing.

The audio-recordings were transcribed verbatim within 24 h of the interviews and then reviewed by the interviewer for accuracy.

For older adults who only speak the Wuhan dialect (n = 6), one researcher, who is a Wuhan local, ensured the transcripts possessed the original meanings of the dialect. The interviews, original transcriptions and data analysis were in Chinese. Theme categories and quotations were determined after discussions of the team. All quotations were translated into English and translated back by two researchers to ensure that meaning was retained.

The study protocol was approved by the Ethics Committee of Tongji Medical College, Huazhong University of Science and Technology (S184). All participants gave oral informed consent before interviews, and all dialogues were audio-recorded. The aims of the study were clearly explained to all participants, and they were assured of the anonymity and confidentiality of their responses. Confidentiality was guaranteed by using numbers instead of names (e.g. N1, N2) and eliminating identifying information from the transcriptions. The data were only used for academic research. The recordings and relevant notes were safeguarded by the principal investigator. It was clarified to the participants that their participation was voluntary, and they could withdraw from the study at any time.

Data analysis was initiated alongside data collection. We utilized Colaizzi's phenomenological method to analyse the transcripts (Colaizzi, 1978 

The Consolidated Criteria for Reporting Q ualitative Research (COREQ ) was rigorously followed. We strictly carried out the sampling strategy to ensure a maximum variation of the data set. Concurrent data analysis ensured that the emerging themes were probed in the following interviews to explore the themes in greater depth. All participants were interviewed using the same interview guide. An audit trail was created to document all decisions made throughout the study.

We enrolled ten females and eight males between 65 and 82 years old. Seven older adults had been infected with COVID-19. The participants' characteristics are summarized in Table 2 .

We Table 3 .

Gender ( 

An empirical phenomenological approach was applied to understand the experiences of community-dwelling older adults during the COVID-19 lockdown in Wuhan. We refined four themes from their experiences: challenges posed by COVID-19, multi-dimensional support, resilience amid challenges and impact after COVID-19.

As one of the most vulnerable groups in the COVID-19 epidemic, older adults in our study faced challenges in nearly every aspect of their lives, including difficulties seeking medical help, inconveniences in daily lives and psychogenic diseases. It was reported that older adults expressed more negative emotions during the COVID-19

crisis (Reger et al., 2020; Shevlin et al., 2020; Wong et al., 2020 ).

An epidemiological study reported that the prevalence of anxiety symptoms among Chinese older people during the epidemic was twice as high as before the epidemic (Wang, Qi, et al., 2020) . Suicidal ideation was also reported among Chinese older adults (Wand et al., 2020) . Meanwhile, mental pressure and psychogenic disease were observed in other study populations or different crises (Cheng et al., 2004; Hamm et al., 2020; Li et al., 2020) . These data suggested that both material help and psychological help are needed during public crises.

In line with previous findings, support was seen as a key determinant for older adults to overcome difficulties (Dolovich et al., 2019; EclinicalMedicine, 2020) . Family and mobile internet were the two most often mentioned themes in our study. Our study also highlighted the resilience of older adults. The restrictions during the epidemic reduced interpersonal interactions and seriously affected their way of living. However, older people found ways to cope and adapt in the lockdown period, and in a few cases, they even thrived. Some of them made a regular schedule and continued their activities, such as walking and Tai Chi at home.

Some, who were inactive in the past, started exercises to fight COVID-19. Although studies have shown that some older adults had blind optimism for COVID-19 (Pu & Wang, 2020) , most of them strictly followed lockdown policies and implemented personal protection measures. Older adults also learned to use smartphone apps to entertain themselves, communicate with others and buy goods.

According to the online data released via a smartphone app, the number of middle-aged and older users increased by 237% during the epidemic (Yang, 2020) . The resilience and the ability to continue learning exhibited in older adults suggested that besides help from others, empowering themselves might generate a better effect.

Older adults were reported to be at higher risk of mental health problems after the pandemic (Banerjee, 2020 

There are several limitations in this study. Firstly, data collection was conducted after the lockdown was relieved. Therefore, we could only reach the COVID-19 survivors in our study population, which prevented us from hearing the voices of those who lost their lives fighting the COVID-19. Secondly, the participants were asked to recall their past experiences, which could have ambiguity or miss some important points. Also, in the telephone interviews, we could not catch the nonverbal information. Moreover, the purposive and snowball sample strategy could limit the representativeness of our study population. And the Chinese cultural setting of this study could impede the generalizability of our study findings.

This study explored the experiences of community-dwelling older adults in Wuhan during the COVID-19 lockdown. Although being challenged in every aspect of daily lives, older adults in our study showed amazing resilience and adapted to the situation. We believe that the 'family culture' helped them and other Wuhan citizens to look out for each other and get through difficult times.

The results of the study suggest that certain social dynamics and individual behaviours helped the elderly to better cope with the stressful quarantine period. The findings of the study not only help to better understand the experiences of older adults but also provide guidelines on how to reduce the negative effects on the older adults during the COVID-19 pandemic and enlighten studies concerning the well-being of older adults or other vulnerable people in future crises.

The authors thank all the older adults who participated in the study.

No conflict of interest has been declared by the authors.

All authors have agreed on the final version and meet at least one of the following criteria (recommended by the ICMJE*): 1) substantial contributions to conception and design, acquisition of data or analysis and interpretation of data; 2) drafting the article or revising it critically for important intellectual content. Study concept and design: All authors. Acquisition of data: Y.Q., W.Y.X., T.C., C.Y. Analysis and interpretation of data: Y.Q., W.Y.X., T.C., C.Y. Drafting of the manuscript: Y.Q., W.Y.X., T.C. Critical revision of the manuscript for important intellectual content: All authors.

The data that support the findings of this study are available from the corresponding author upon reasonable request.

The peer review history for this article is available at https://publo ns.com/publo n/10.1111/jan.14978. 

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