key: cord-0977107-dofxce08 authors: Kremers, Evi M.; Janssen, Jeroen H. M.; Nieuwboer, Minke S.; Olde Rikkert, Marcel G. M.; Peeters, G. M. E. E. (Geeske) title: The psychosocial adaptability of independently living older adults to COVID‐19 related social isolation in the Netherlands: A qualitative study date: 2021-05-24 journal: Health Soc Care Community DOI: 10.1111/hsc.13436 sha: 9e13ccbd4a4105b147963f5cabece4560ce9ac0d doc_id: 977107 cord_uid: dofxce08 Since coronavirus disease 2019 (COVID‐19) entered the Netherlands, the older adults (aged 70 or above) were recommended to isolate themselves, resulting in less social contact and possibly increased loneliness. The aim of this qualitative study was to explore independently living older adults’ perceptions of social and emotional well‐being during the COVID‐19‐related self‐isolation, and their motivation to expand their social network in the future. Semi‐structured phone interviews were held with 20 community‐dwelling adults (age range 56–87; 55% female) between April and June 2020 in the Netherlands. The interviews were audio recorded and transcribed verbatim. Open coding process was applied to identify categories and themes. Participants said to use more digital technologies to maintain contacts and adapt to the government measurements. Most participants missed the lack of social contacts, while some participants had no problems with the reduced social contacts. The emotional well‐being of most participants did not change. Some participants felt unpleasant or mentioned that the mood of other people had changed. Participants were not motivated to expand their social network because of existing strong networks. The relatively vital community‐dwelling older adults in this study were able to adapt to the government recommendations for self‐isolation with limited negative impact on their socio‐emotional well‐being. social contact and stay at home. Furthermore, several public places were closed to prevent the spread of the disease. Most clubs and services, including those that specifically serve older adults, stopped their activities. For many older adults, these measures meant that their daily schedule changed, because they were no longer able to go grocery shopping, look after grandchildren or participate in voluntary work. As a result, there was an involuntary increase in social isolation. Before the pandemic, two million adults (31.2%) aged 45 years and older felt (somewhat) alone in the Dutch population (Data from webpages CBS, 2019). It is therefore important to understand the impact of isolation measures on older adults' perceived loneliness and well-being. With the ageing of society, more and more senior adults are experiencing loneliness or are at risk of social isolation (Yanguas et al., 2018) . Social distancing has a negative impact on loneliness and social isolation (Armitage & Nellums, 2020; Banerjee & Rai, 2020; Hwang et al., 2020) . Loneliness is defined as the unpleasant experience that occurs when a person's network of social relationships is deficient in some important way, either quantitatively or qualitatively (De Jong Gierveld, 1998) , whereas social isolation is the objective lack of contacts and interactions with a person, family or friends (Fakoya et al., 2020) . Both social isolation and loneliness are associated with negative psychological and physical outcomes (Menec et al., 2019; Yanguas et al., 2018) , so it is likely that the COVID-19 measures led to a change in older adults' social well-being (Krendl & Perry, 2020) . However, it is still unclear how community-dwelling older adults have experienced this. Furthermore, the mandatory isolation affects older adults' social network (Smith et al., 2020; Williams et al., 2020) . Therefore, we were also interested in people's perceptions on changing their social network post-isolation. The aim of this qualitative study was to explore the perceptions around social and emotional well-being during self-isolation and social distancing imposed by the government measures in response to the COVID-19 outbreak among adults of 50 years and older. The key questions were: (a) 'What is the impact of the COVID-19 outbreak on the social contacts of the participants?' (b) 'What is the impact of mandatory isolation, during the COVID-19 outbreak, on the motivation of participants to enlarge their social network in the future?' and (c) 'What is the impact of mandatory isolation, during the COVID-19 outbreak, on the participants' feelings towards social isolation and social loneliness?' 2 | ME THODS A qualitative research design with semi-structured telephone interviews was used. The Consolidated Criteria for Reporting Qualitative Research were applied to ensure methodological quality (Tong et al., 2007) . The interviews were administered from 29 April 2020 until 25 June 2020 in Nijmegen and vicinity, in the east of the Netherlands. Participants were recruited through local newspaper and website advertisement, 'Netwerk 100' (the regional network aimed at improving the care for and well-being of frail older adults), and the personal network of the researchers, participants and co-workers not involved in the study. Researchers who reached out to their personal network were not involved in the data collection. Inclusion criteria were Dutch-speaking and being aged 50 years or older. Exclusion criteria were a decreased mental capacity and/or problems with vision or hearing that limit participation in a phone interview (even when using hearing or visual aids). Participants were approached over the phone or through e-mail to provide information about the study and to arrange a date and time for a telephone interview. Prior to the interview, participants received further information, a questionnaire and the informed consent form by postal mail or e-mail. The study was reviewed by the research ethics committee of the Radboud university medical centre and was judged as not being • Population ageing leads to an increase in number of older adults who experience loneliness. • The COVID-19-related social isolation measures have led to more social isolation and loneliness among frail Dutch older adults. • The relatively vital community-dwelling older adults in The Netherlands have generally not experienced a change in their emotional well-being. • The psychosocial adaptability of relatively vital community-dwelling older adults to a decrease in physical contacts is generally very good. • The older adults in this sample feel no need to expand their social network after COVID-19-related isolation measures will be lifted. Open-ended questions relating to the well-being and the social contacts of the participants during the corona pandemic were used Sample characteristics were described with descriptive statistics. The program Atlas.ti (version 8.4.24) was used to analyse the interview data. The analysis of the transcripts was performed according to the grounded theory approach of open, axial and selective coding (Glaser et al., 1968; Williams, 2019) and consisted of three steps. First, the open coding process of the first three transcripts was conducted by two coders separately, and discussed face to face to reach agreement on the codes. Second, to improve validity, the two coders each independently coded half of the transcripts and checked the coding for the remaining transcripts. Third, a codebook was written containing all the codes and definitions. The final codes were categorised on paper. These categories were grouped to form themes. In total, 20 participants were recruited (n = 5 through advertisement, n = 4 through 'Netwerk 100', n = 5 through the network of researchers, n = 2 through the network of participants, n = 3 through the network of co-workers uninvolved in the study and for n = 1, it is unknown how this participant was recruited). The mean age of the study sample was 72 years (range 56-87) and 11 participants were female. Sixteen participants were classified as not lonely and 40.0% had a social network of more than 20 persons. Additionally, 55.0% of the participants lived independently and with a partner. Two participants (10.0%) were classified as frail. On average, the sample score showed low levels of frailty (M = 0.07) ( Table 1) . The qualitative data analysis revealed three themes: (a) 'Social behaviour during the COVID-19 outbreak', (b) 'Emotional behaviour during the COVID-19 outbreak' and (c) 'Motivation to expand the social network'. Table 2 shows the themes, categories, codes and quotes. In the next section, the categories will be evaluated per theme. Participants tried to keep in contact with their relatives in different ways, for example, by phone calls, postcards or e-mail. They also expressed that there was more digital contact (e.g. WhatsApp Messenger and video calls) during the social isolation (quote 1). Some participants experienced little change in social contacts (quote 2). But, one participant was explicitly called by a relative who said that they must look after each other (quote 3). Nearly all participants indicated that everybody was in the same situation (quote 5). They adapted to the situation by finding ways to maintain their social contacts within the boundaries of the social distancing measures, for example, by receiving guests in their garden so there was more space to keep distance (quote 7) and by avoiding crowded places (quote 6). On the one hand, participants were hindered in daily activities which felt as if the naturalness of their usual lives was gone (quote 8). On the other hand, participants filled their time with other activities, such as house chores (quote 9). Participants saw their family and friends less, and spontaneous contact was gone (quote 10), but this was generally not perceived as a problem (quote 11). Others said that this situation was difficult for everyone as they missed physical contact with relatives and they were looking forward to cessation of the social isolation and distancing measures (quote 13). Participants described their emotional state during the COVID-19 lockdown as either calm, unchanged or unpleasant. Most participants indicated that the lockdown did not change their emotional well-being (quotes 15 and 16). These participants described this period as calm (quote 14). However, some participants experienced negative feelings during the lockdown. They said that they felt more dreary and more emotional, or were affected by the stories of lonely people living in nursing homes (quotes 17-20). Interestingly, some participants noted a change in the mood of other people. While some participants noted a short temper in other people, other participants commented that people were generally more supportive and friendly (quotes 21). None of the participants felt a need to expand their social network after the isolation measures are lifted. The main reason was that they felt that their current networks were sufficiently large and strong. Moreover, they felt that expansion of their network would make it difficult to maintain contact with everyone or that the experience of the lockdown made participants appreciate social contact more. Rather than expanding their networks, they felt it was more important to strengthen the bond with existing contacts (quotes 22 and 23). Participants pointed out, however, that they could imagine that in older adults who do feel lonely, the strict government-imposed isolation measures could potentially lead to either an increase in motivation to expand their networks (quote 24) or a decrease in interest to expand their networks (quote 25). This study aimed to explore the impact of the government-imposed measures in response to the COVID-19 outbreak on fit older adults' emotional and social well-being, and their motivation to expand their social network. This group of relatively vital and well-educated community-dwelling older adults, generally felt minimally emotionally affected by the measures despite the substantial impact on their daily and social lives. However, they did note changes in the socioemotional well-being of others. Despite the substantial impact of social isolation and social distancing on participants' daily lives and social activities, most participants felt minimally emotionally impacted. This was partly due to their creativity in finding ways to maintain social contact and fill their day, for example, through the use of digital technology and welcoming visitors to their garden where they were able to maintain distance. The use of internet is associated with reduced TA B L E 1 Characteristics of subjects aged 50+ participating in interviews on COVID-19-related changes in social contacts I14 (F) (18) Sense of something lacking, that you are actually forced to be inside, that you can't go your own way anymore. I15 (F) (19) It is just awful, because you hear miserable stories about loneliness and people who say: 'I don't want to live anymore', 'I don't want to take a pill, but I can't live like this', you know. Yes, so it is intense, yes, it is intense. I20 (M) (20) Yes, in the beginning you think it is not that bad, it will be over soon, but in the long term it does make you feel more dreary. I6 (M) (21) We cycle a lot and then you see that there are people who have a short temper. We have the impression that this has increased, that more people are having a low tolerance. loneliness and increased social support (Chopik, 2016) . Older adults acknowledge the benefits of technology to improve social relationships and make communication easier (Chopik, 2016) . Some older adults already use technology to prevent the feeling of loneliness (Vošner et al., 2016) . Another coping strategy was to keep themselves busy to avoid thinking about the risks and fear associated with the virus and feel less emotionally affected (Brooke & Clark, 2020) . Moreover, most participants were acceptive of the situation as they felt 'in it together' and adapted to the situation. These findings were in contrast with reports in the Dutch media which were dominated by the sad stories of isolated older adults in nursing homes. Besides, preliminary results in the Dutch population also show an increase in perceived loneliness due to the Covid-19 isolation measures (van Tilburg et al., 2020) . The strong contrast of perceived loneliness is likely explained by the differences in health and resilience between these groups. While the media focused on frail older adults in nursing homes who often were unable to understand the situation due to cognitive decline, the current sample was generally vital and socially well connected. Although we did not measure resilience in this study, the responses of participants are illustrative of their abilities to adapt to the changed situation (Chen, 2020) . Although the questions asked about participants' own experiences, many participants indicated that they believed that the impact of the measures was greater for others. These views were based on what they saw in their frail peers with small networks, and was reinforced by the negative reporting in the media. However, there is still a stigma to admitting the feeling of loneliness as a result of which older adults might not always dare to admit this feeling (Rokach, 2012) . Therefore, it is easier to talk about others than about themselves as being lonely. Participants experienced the reduced social and physical contact with close relatives as difficult. Social isolation and disconnectedness are associated with perceived loneliness, which can cause mental health issues such as depressive symptoms and anxiety (Newman & Zainal, 2020; Taylor et al., 2018; Wu, 2020) . This may partly explain why, particularly for older adults, it is difficult to continue to adhere to the measures despite awareness of COVID-19 and potential consequences (Betsch, 2020) . The lockdown experience did not motivate participants to expand their social networks. Most participants were satisfied with their existing social network, to which they felt a sufficiently close emotional connection despite the physical distance. Rather than wanting to expand their network, they became more appreciative of the contacts they had, and aware of the importance of investing in these relationships. Furthermore, some participants mentioned that maintaining good contact with their existing social network was time consuming. They mentioned that if their social network expanded further, it would be hard to keep this up. These findings coincide with previous literature that found that for older adults, the quality of contacts is more important than the quantity for their experienced social loneliness and well-being (Bruine de Bruin et al., 2020; Green et al., 2001) . A strength of this study is the timing. The interviews were held at the end of the first peak in COVID-19 infections in the Netherlands and during the third and fourth month of self-isolation and social distancing. This means that participants had experienced the lockdown situation for 2-4 months at the time of the interview. Thus, they had had some time to adjust to the situation, but were also still experiencing it. This study ties with a similar study performed in the United Kingdom which also aimed to explore the experiences of older adults (aged 70 or above) during the COVID-19 isolation and showed some similarity in results (Brooke & Clark, 2020) . Another strength is that the interviews were held over the phone. Research has shown that people prefer phone interviews over faceto-face interviews, as it offers privacy (Sturges & Hanrahan, 2004) , is more anonymous and creates a safe environment to provide honest answers. Lack of personal contact could potentially also lower the threshold for false answers; however, we did not get the impression that this was an issue, as participants appeared very open and hon- est. An important limitation that needs to be taken into account is the limited representativeness of the sample. The sample is representative of relatively vital and highly educated community-dwelling older adults who were living with a partner. As discussed above, the experiences of frail older adults with smaller networks may have been very different. However, after the first 16 participants were interviewed and it appeared that saturation was achieved, we purposively recruited four additional participants with lower levels of education and/or smaller networks and found similar results. Future research should target frailer older adults who live alone or have smaller social networks. In conclusion, this group of vital and well-connected communitydwelling older adults experienced minimal socio-emotional problems due to the government-imposed measures in response to the COVID-19 outbreak. The measures had a great impact on their daily lives and they missed physical contact with close relatives, but they accepted the situation and adapted to it. Rather than feeling a need to expand their networks, participants felt a need to strengthen existing contacts. These experiences of this group of vital and wellconnected older adults probably differ from those of frailer older adults with smaller social networks who have seriously increased feelings of loneliness. We would like to thank the participants for generously sharing their experiences with us. This research received funding from the Netherlands Organisation for Scientific Research (NWO), grant number 645.003.002, and is part of the Social Health Games project in collaboration with Games for Health and Cooperation Dela. The authors declare to have no conflict of interest. Olde Rikkert https://orcid COVID-19 and the consequences of isolating the elderly. 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