Background
In late 2019, the world faced the challenge of a novel coronavirus labelled SARS-CoV-2, which caused severe respiratory illness. During the first months of 2020, the virus spread rapidly, and in March 2020, the World Health Organization (WHO) declared the outbreak a pandemic (WHO, 2020). Early on, advanced age was one of the primary risk factors for death caused by SARS-CoV-2 (Rothan and Byrareddy, Reference Rothan and Byrareddy2020). Compared to most countries, Sweden chose a different strategy to minimise the consequences of the SARS-CoV-2 outbreak, specifically during the COVID-19 pandemic. Instead of implementing a general lockdown, Swedish authorities recommended strict hand hygiene and social distancing. However, for 1.6 million people aged 70 and older in Sweden, the recommendations were stricter, including voluntary quarantine and social distancing outside the household (Public Health Agency of Sweden, 2020).
It has been hypothesised that the recommendations on social distancing might be a major concern for public health (Armitage and Nellums, Reference Armitage and Nellums2020) since previous research has shown that perceived isolation increases the risk of depression and anxiety in older people (Santini et al., Reference Santini, Jose, Cornwell, Koyanagi, Nielsen, Hinrichsen, Meilstrup, Madsen and Koushede2020). The recommendations, aimed at limiting the spread of the virus, required older adults to change their behaviour substantially. Maintaining such behaviours can be very challenging and can be influenced by factors such as social pressure, level of self-regulation and personal resources (Kwasnicka et al., Reference Kwasnicka, Dombrowski, White and Sniehotta2016).
During 2020 and 2021, there has been extensive publication on the mental health effects of the COVID-19 pandemic. Most of these publications consist of quantitative reports on self-reported worry, depression and the impact of social distancing concerning COVID-19. While many of these indicate a decrease in wellbeing among older adults (Hyland et al., Reference Hyland, Shevlin, McBride, Murphy, Karatzias, Bentall, Martinez and Vallières2020; Robb et al., Reference Robb, de Jager, Ahmadi-Abhari, Giannakopoulou, Udeh-Momoh, McKeand, Price, Car, Majeed, Ward and Middleton2020; Arpino et al., Reference Arpino, Pasqualini, Bordone and Solé-Auró2021), other prevailing aspects have also been revealed. In a rapid review of 135 studies conducted by Lebrasseur et al. (Reference Lebrasseur, Fortin-Bédard, Lettre, Raymond, Bussières, Lapierre, Faieta, Vincent, Duchesne, Ouellet, Gagnon, Tourigny, Lamontagne and Routhier2021), the majority (N = 120) reported that older adults experienced fewer psychological symptoms compared to other age groups (N = 6 studies reported worsened psychological health and N = 4 studies showed no differences). For instance, a recent Swedish study by Kivi et al. (Reference Kivi, Hansson and Bjälkebring2021) (N = 1,071, aged 65–71) reported no difference in wellbeing between 2020 and the previous five years, indicating that wellbeing remained stable (in terms of life satisfaction and loneliness) or even increased (in terms of self-rated health and financial satisfaction) in 2020 compared to earlier years. Similar results were shown in qualitative studies (Knepple Carney et al., Reference Knepple Carney, Graf, Hudson and Wilson2020; McKinlay et al., Reference McKinlay, Fancourt and Burton2020), suggesting that many older adults demonstrated resilience to COVID-19 restrictions despite initial concerns in society about potential mental health consequences. As proposed by Fuller and Huseth-Zosel (Reference Fuller and Huseth-Zosel2021), one possible explanation for this resilience is that older adults possess unique coping abilities due to their life experiences.
Coping, which is a process that occurs in response to a stressful event, involves how individuals detect, appraise, deal with and learn from such encounters (Skinner and Zimmer-Gembeckv, Reference Skinner, Zimmer-Gembeck and Friedman2016). The ability to cope may directly influence an individual's quality of life (van Leeuwen et al., Reference van Leeuwen, van Loon, van Nes, Bosmans, de Vet, Ket, Widdershoven and Ostelo2019), and the relationship between mental health and coping is a well-established area of research (Folkman et al., Reference Folkman, Lazarus, Dunkel-Schetter, DeLongis and Gruen1986; DeLongis et al., Reference DeLongis, Folkman and Lazarus1988; Weber and Laux, Reference Weber and Laux1990). Gunther (Reference Gunther1994) suggests that mental health can even be defined in terms of the ability to cope successfully, though the meaning of ‘successful’ must also be defined. There are various categories of coping strategies that have been established. The most recognised categories are problem-solving coping (such as attempting to solve the problem and time management) and emotional coping (such as avoiding the problem, distracting oneself and substance use) (Folkman and Lazarus, Reference Folkman and Lazarus1980, Reference Folkman, Lazarus, Stein, Leventhal and Trabasso1990; Blum and Silver, Reference Blum, Silver and Ramachandran2012). Critics of the problem-focused versus emotion-focused coping framework argue that these two dimensions overlap and may reflect both types of functions (Dubow and Rubinlicht, Reference Dubow and Rubinlicht2011). Individuals may also engage in proactive coping, which is defined as the processes by which people anticipate or detect potential stressors and take action in advance to mitigate their impact (Aspinwall and Taylor, Reference Aspinwall and Taylor1997). Proactive coping involves building resources and acquiring skills to assess the changing environment accurately (Blum and Silver, Reference Blum, Silver and Ramachandran2012). However, coping does not exist in isolation and may be influenced by a person's personality (Vollrath, Reference Vollrath2001; Carver and Connor-Smith, Reference Carver and Connor-Smith2010) as well as contextual factors (Shing et al., Reference Shing, Jayawickreme and Waugh2016). Optimism and neuroticism are two well-known personality traits that can influence our coping resources. Optimistic individuals, who are open to new experiences, positively motivated and goal-directed, are more likely to experience successful ageing and cope effectively with life challenges (Aldwin et al., Reference Aldwin, Sutton, Chiara and Spiro1996). On the other hand, neuroticism, characterised by emotional instability and negative emotions, is often associated with passive and ineffective coping mechanisms, including more emotion-focused strategies (Watson and Hubbard, Reference Watson and Hubbard1996), as well as inefficient escape-avoidance strategies such as wishful thinking and self-blame (Bolger, Reference Bolger1990). Contextual coping has received significant attention in research on disasters and crises in recent years. Contextual coping suggests that the demands individuals experience in relation to stressors during crises partly depend on the characteristics of the specific situation. Therefore, different coping strategies may emerge depending on the type and phase of a disaster (Shing et al., Reference Shing, Jayawickreme and Waugh2016). According to Shing et al. (Reference Shing, Jayawickreme and Waugh2016), after an initial disaster, individuals may experience an overwhelming emotional response that can be or feels threatening. To cope with this, the review by Shing et al. (Reference Shing, Jayawickreme and Waugh2016) suggests that positive distraction is an expected coping strategy. Between the initial impact of the disaster and its termination, the demands can transition into ongoing and uncontrollable stress, which can be managed by using adjustment and acceptance as coping strategies. The choice of coping strategy appears to depend on the type of disaster (man-made or natural) and the level of loss included.
Research on age differences in coping strategies encompasses two currents: a developmental interpretation and a contextual interpretation. The developmental interpretation focuses on inherent, stage-related changes in the ways people cope as they age. The contextual interpretation suggests that differences in coping arise from the inherent changes with age and the challenges that individuals must cope with (Folkman et al., Reference Folkman, Lazarus, Pimley and Novacek1987). The developmental interpretation suggests that older adults may appraise problems as less stressful due to their greater range of experience, which enables them to develop more coping resources (Aldwin et al., Reference Aldwin, Sutton, Chiara and Spiro1996). Folkman et al. (Reference Folkman, Lazarus, Pimley and Novacek1987) suggest that age differences exist in both hassles and coping, supporting the developmental interpretation. However, it is important to also consider the contextual interpretation (Folkman et al., Reference Folkman, Lazarus, Pimley and Novacek1987). On the other hand, findings from McCrae (Reference McCrae1989) indicated that age had a limited influence on coping behaviour in a community-dwelling sample. Instead, McCrae (Reference McCrae1989) suggests that coping responses are, to some extent, influenced by consistent individual characteristics. More recent research on the SARS outbreak suggests that older adults may excel in emotional regulation during a crisis compared to their younger counterparts. They tend to exhibit less anger and demonstrate adaptive coping strategies that can be adjusted to changing circumstances (Yeung and Fung, Reference Yeung and Fung2007).
A few recent studies have been published in the qualitative research literature on coping strategies during the COVID-19 pandemic. In Fuller and Huseth-Zosel's (Reference Fuller and Huseth-Zosel2021) study conducted in the United States of America, 76 older adults (aged 70–97) were interviewed. The study revealed coping strategies that emerged in the early weeks of the pandemic, including staying busy, seeking social support and maintaining a positive mindset. Similarly, McKinlay et al. (Reference McKinlay, Fancourt and Burton2020) found that older adults in the United Kingdom (UK) (N = 20, aged 72–93) relied on their regular coping skills and life experiences to navigate the challenges posed by the COVID-19 pandemic. Finally, Verhage et al. (Reference Verhage, Thielman, de Kock and Lindenberg2021) conducted interviews with 59 older adults (aged 54–95) in the Netherlands. The study found that older adults perceived the crisis as difficult to comprehend, and despite filling their lives with activities, they experienced a sense of loss or lack of purpose. To regain a sense of control, they employed coping strategies such as self-enhancing comparisons, acceptance and distraction.
In conclusion, the ongoing COVID-19 pandemic is believed to impact individuals' mental health due to factors such as isolation and concern about the virus (Zhang and Ma, Reference Zhang and Ma2020). Older adults, in particular, have faced significant challenges with forced and voluntary isolation (Hyland et al., Reference Hyland, Shevlin, McBride, Murphy, Karatzias, Bentall, Martinez and Vallières2020; Robb et al., Reference Robb, de Jager, Ahmadi-Abhari, Giannakopoulou, Udeh-Momoh, McKeand, Price, Car, Majeed, Ward and Middleton2020; Arpino et al., Reference Arpino, Pasqualini, Bordone and Solé-Auró2021). However, it has been suggested that older adults may possess unique skills to cope with situations (Fuller and Huseth-Zosel, Reference Fuller and Huseth-Zosel2021). Another intriguing aspect is how worries may change over time during a crisis.
Therefore, the aim of this study is to explore the coping strategies employed by adults aged 70 and older in Sweden during the COVID-19 pandemic.
Methods
To our knowledge, this is the first qualitative study conducted in Sweden that specifically focuses on the coping behaviour of older adults during the COVID-19 pandemic. The study was conducted by the first and second authors (LB and JG) through telephone interviews conducted in two phases. The first phase involved interviews conducted in April and May 2020 with a sample size of 41 participants (N = 41), while the second phase consisted of follow-up interviews conducted in November and December 2020 with a sample size of nine participants (N = 9). The current study adheres to the COnsolidated criteria for REporting Qualitative research (COREQ) checklist (Tong et al., Reference Tong, Sainsbury and Craig2007), which is a 32-item checklist designed to assist authors in reporting interviews and focus groups. The checklist covers domains such as ‘research team and reflexivity’, ‘study design’ and ‘analysis and findings’.
Context
At the time of the first data collection, Sweden did not enforce a general lockdown but instead relied on urging the population to use common sense. The authorities recommended strict hand hygiene and social distancing measures for the general population. However, for individuals at higher risk, specifically, those aged 70 and over, the recommendations were stringent. They were advised to voluntarily quarantine themselves and avoid all social interactions outside their households (Public Health Agency of Sweden, 2020). During the second phase of data collection, additional restrictions were implemented, affecting the general population and not solely adults over the age of 70.
The study
This interview study was conducted as part of a larger research project that also involved collecting data through a questionnaire. The questionnaire, completed by a total of 1,854 participants (N = 1,854), included inquiries regarding mental health status, risk perception and compliance with recommendations. The purpose of conducting the interviews was to delve deeper into these aspects and gain a more comprehensive understanding. Detailed findings from the questionnaire can be found in the publication by the authors (Gustavsson and Beckman, Reference Gustavsson and Beckman2020).
Participants and recruitment
The inclusion criteria for this study were adults aged 70 years and older who were residing in Sweden. Participants were invited to take part in either a questionnaire, an interview or both. Recruitment took place in April and May 2020, targeting both men and women between the ages of 70 and 84. Recruitment efforts included social media advertisements on platforms like Facebook and dissemination of information through a pensioners' organisation's semi-weekly information letter. Snowball sampling was initially utilised, wherein participants were asked if they knew anyone who would be interested in participating and, if so, to pass on the contact information. Additionally, respondents who completed the questionnaire had the option to provide their contact details to express their interest in participating in the interview study. Out of the 1,854 respondents who completed the questionnaire, approximately 1,200 individuals left their contact information. We contacted these individuals in chronological order, reaching out via social media, the questionnaire, text messages or via email to inquire if they were willing to participate in an interview and, if so, to schedule a suitable date. Some participants also granted permission to be contacted through the snowball sampling method, wherein individuals who were already interviewed suggested potential participants for the study.
To ensure a greater variation in our sample, we employed a specific selection criterion. From the initial sample of 1,200, we identified the first six individuals who had indicated a high degree of feeling anxious about the COVID-19 situation in the questionnaire and had given their consent to be contacted for an interview. However, we found that little additional information emerged from this sub-group, and their coping strategies did not significantly differ from the rest of the sample. For the second phase of interviews conducted in November and December 2020, we selected a sub-sample of nine individuals (N = 9) from the first phase group. The participants for this follow-up were randomly drawn from the initial sample. The aim of this phase was to investigate potential changes in coping strategies over time. We reached out to these nine individuals, and all of them agreed to participate in a second interview.
Socio-demographic information
Our sample consisted of 33 per cent men and a total of 27 per cent of the participants lived alone. We asked whether they had access to a garden, and the results showed that less than 20 per cent lived in housing without a garden, i.e. apartments. This question indicated whether they could go outside in their own garden or if their isolation was confined to their sole apartment. Participants were also asked to rate their health on a scale of 1 to 10, and the results ranged from 6 to 10, with a mean of 8.5. One-third of the participants lived in a major city or suburb, another third in a smaller city and the remaining third in the countryside. Examples of professions included teachers, nurses, academics, farmers, entrepreneurs, bankers and social workers. One-third of the participants were still working to some extent.
Procedure and interviews
The study was approved by the Swedish Ethical Review Authority. We used a semi-structured interview guide for in-depth telephone interviews, which lasted approximately 30–60 minutes each. Only the interviewer and participant were present during the interviews. Informed consent was obtained and recorded at the beginning of the interview. The interview guide encompassed four main areas of content: perception of recommendations, information, risk, and wellbeing and mental health, all in relation to the COVID-19 pandemic. The initial question asked participants to describe how their lives were affected by the current situation. Subsequently, we inquired about their mental health status and wellbeing, such as asking: ‘How has your mental health status and wellbeing been affected by the situation?’ We did not specifically ask for coping strategies; instead, we allowed the participants to discuss freely how they managed the situation. The interview guide was pilot tested on two persons in the target population. The transcripts were not shared with the participants prior to or after the analysis. Participants were offered the opportunity to receive the study results following publication.
Analysis
The data were transcribed verbatim in Swedish and analysed using qualitative content analysis, following the approach outlined by Graneheim and Lundman (Reference Graneheim and Lundman2004). All interviews were analysed simultaneously, starting with reading the transcripts to gain an understanding of the content. In the first step, both authors identified the units of meaning, which could be sentences, phrases or words related to the study's aim. In the second step, these meaning-bearing units were condensed and shortened while preserving the essence of their message. In the third step, each condensed text section was assigned a code representing its content, such as discrete objects, events or phenomena. The codes were interpreted in the context of the study. The codes were continuously compared to identify both differences and similarities in the data, leading to the fourth step, where the codes were grouped into sub-categories that captured the latent content of the text (Graneheim and Lundman, Reference Graneheim and Lundman2004). Subsequently, the sub-categories were combined to form five categories that constituted a theme. To enhance the analysis, relevant and illuminating quotes were included. The categories and quotes were translated into English with the assistance of a native speaker. The software NVivo 12 was utilised for the analysis.
Research team and reflexivity
The authors, LB and JG, are both women and approach the study from a public health perspective. LB is an associate professor in public health science, specialising in mental health research. JG, on the other hand, is an assistant professor in risk sciences, focusing on research related to older adults. Additionally, JG is a registered nurse with extensive experience in working with older people. Both authors have prior experience in qualitative research.
Results
The theme was conceptualised as ‘Feeling quite alright’. The categories identified were: Ways of handling information, Positive view on the situation, Using life experiences, Keeping busy and New online encounters. Each category consisted of two or three sub-categories, as shown in Table 1.
Table 1. Categories and sub-categories for the theme ‘Feeling quite alright’
Feeling quite alright
The overarching theme ‘Feeling quite alright’ illustrates how the interviewees experienced their mental health in relation to the current situation. Overall, they expressed a sense of ease, focusing on staying calm and taking each day as it comes. For some, the pandemic, and the resulting restrictions did not impact their mental health. While they acknowledged it as a ‘strange year’, it was often perceived as the most challenging period they had encountered. Some even mentioned enjoying a less-stressful life. One participant suggested that wellbeing might be influenced by one's personality, i.e. how easily a person is being affected:
Interviewer: Are you worried?
Informant: No, no. Not for me, personally. No, I'm actually not at all, but … I'm very lucky because I'm kind of … I have a kind of basic sense of security that isn't disturbed by these kinds of things. (IP1.1)
On the other hand, others were emotionally affected by the current situation, and even if they did not feel genuine panic or actual depression, they described it as ‘boring times’. Some described themselves as ‘paralysed’, and as in the quote below, they felt ‘sad’ and ‘fragile’:
I feel a little more fragile, I must say. I can get a little more … sad about things I did not care so much about before. (IP9.1)
This might indicate that the situation was a little overwhelming for them, and some experienced more vulnerability than before. Furthermore, there were concerns about the virus, and the thought of getting infected and the risk of dying from COVID-19 seemed like a terrible outcome.
Follow-up interviews indicated that negative mental health consequences seemed to decrease even further during the first six or seven months of the pandemic. Everything felt easier during the summer of 2020 when the number of infections was low. However, it became stressful again when the situation worsened in October. At this stage, the situation was no longer novel and had become the new normal.
Although they handled the situation well, all participants talked about missing social contacts, which had an impact on their wellbeing. The social aspect, or lack of social contact, was a central component of this situation. The absence of social contact with friends and family, especially grandchildren, was particularly challenging for them:
I'm quite used to being alone, but it's different when one can't see friends, children and grandchildren. (IP12.1)
In the beginning, it was easy, but as time went by, it became more difficult. However, this loneliness was somewhat alleviated for those who lived with someone with whom they could share the situation. In the follow-up interviews conducted seven months later, the same person mentioned earlier highlighted the longing for their grandchildren and expressed their feelings of loneliness:
I am very involved with my grandchildren, so it is sad; it is grief. It's not like I'm sitting at home and burying myself, it is grief in my heart, but it's not like I'm sitting here crying every day. (IP12.2)
The last quote illustrates how the participants express their sadness about not being able to see their grandchildren, but they also emphasised that despite this, they are not completely devastated. In other words, they still feel quite all right.
Ways of handling information
The first category within the overarching theme is Ways of handling information, which encompasses various aspects of managing and utilising the constant influx of information about COVID-19 to which the participants were exposed. In the early stages of the pandemic, it was evident that the participants actively sought out information to stay informed about the situation. However, shortly after the initial phase, when fewer new updates were being presented, a shift occurred, and the opposite approach emerged. The first sub-category, Controlling the information flow, became a coping strategy for some. They felt overwhelmed by the information from the media and authorities, and they needed to distance themselves and limit the amount of information and news they consumed:
It feels like, to feel good, you have to start shutting down a bit, I think. (LB7)
In the follow-up interviews, participants continued to stay updated with news and information, but they had implemented strategies to limit the flow. For instance, they would check the news once a day and attend the authorities' press conferences twice a week.
Another sub-category was Increasing knowledge, which involved actively seeing facts and acquiring new information about the virus. One example was watching tutorial videos on the internet that demonstrated techniques to strengthen the lungs in case of a coronavirus infection:
I also saw this when I Googled how you could exercise your lungs and do it in advance only for preventative purposes but also when you start to get sick. So that the lungs do not become so stressed. There is an excellent video that I saw on a Facebook page because a colleague posted it, and I think they could show it a little now and then on TV [television], actually. (IP8.1)
A third sub-category was Following advice from experts. All participants believed that they were adhering to the recommendations, although some had their own interpretations of the advice. Nonetheless, following the advice had a calming effect and helped alleviate concerns about contracting the virus. One woman expressed this sentiment:
I wash my hands, wear gloves outside, wash my hands again if I have been outdoors, and go to the store at times intended for us [older people]. So I do not think I expose myself. (IP4.1)
It felt reassuring to have something tangible to hold on to during times of uncertainty, and the act of handwashing became a recurring symbol of the pandemic in the interviews.
Positive view of the situation
A Positive view of the situation is evident among the participants, as they did not become overly distressed by the circumstances. Instead, they approached each day with a mindset of taking things one at a time. They recognised the importance of not allowing themselves to become too depressed about something beyond their control. Two sub-categories emerged from this positive outlook: Accepting the situation and Positive thinking.
A predominant coping strategy observed among the participants was Accepting the situation. This involved adopting a day-by-day approach and gradually establishing new routines to alleviate the challenges. The prevailing belief was that this difficult phase would eventually come to an end. Adapting to the recommended guidelines appeared acceptable to them. When asked about the process of adjusting to the new situation, one participant expressed the following sentiment:
The process, if I'm to return to it, there was nothing more to it; we adapted slowly to the circumstances. (IP16.1)
They perceived there were no other alternatives than to adapt, as one participant said:
It's just to accept it; if you want to take others into account and take your wellbeing into account, then you have to accept it. We still have the freedom to go out, to be out and about, so to speak. (JG12.1)
In this quote, the participant empathises with the freedom Swedish citizens still had compared to other countries, where isolation was not voluntary. The participants emphasise that there is nothing to complain about, just accept the situation.
When we conducted the follow-up interviews seven months later, the view remained consistent. The same participant reiterated during the follow-up interviews:
In some way, you can only take one day at a time and accept it; it is what it is. I can't influence it; I can only do what I can for myself. (IP12.2)
Despite the situation, a rather optimistic view emerged. Positive thinking was a way of approaching the situation, and whining did not help. One participant expressed this perspective during the interviews:
It does not get better because you are depressed, rather the opposite. (IP11.2)
This perspective continued to prevail in the second wave of interviews. Participants believed there was no point in worrying or being afraid because the pandemic was beyond their control. Some even mentioned feeling an expectation of being miserable, which they defied. The dominant sentiment was that they had everything they needed and nothing to complain about.
Using life experiences
Using life experiences includes the ability to draw upon and relate to other, sometimes more challenging, situations. These experiences could also be personal or work-related, such as having knowledge of how the virus is transmitted, which made the situation more manageable. This category consists of two sub-categories: Experience-based and Knowledge-based.
It was evident that previous experiences (Experience-based) influenced their perception of the current situation. Having gone through more difficult circumstances in life seemed to contribute to a calmer outlook regarding the pandemic. Experiences of living in a developing country or having endured serious illness made it easier for them to put things into perspective. They recognised that there were greater concerns in the world to worry about:
There are, of course, other things that are so awful, things that I have always cared about. For example, the environment, which we have fought for since the 1970s when we were young ourselves. Energy issues and nuclear power and the atomic bomb and peace issues, armaments and militarism, and such issues. This always makes me worry. But this, that is happening now, is what it is – it doesn't worry me so much more. (IP8.1)
There was also a perception that age played a role, as older individuals who had already experienced numerous positive and negative situations found it easier to relate and remain calm.
Participants with a background in medical science, such as nursing or a pharmacy, expressed that their knowledge (Knowledge-based) and ability to interpret the information helped them navigate the situation more effectively. One participant, who had worked as a nurse, felt confident in her understanding of how the virus was transmitted:
I have worked in health care, so I know, unlike my partner, how the infection spreads. (IP07.1)
Keeping busy
To fill the day with activities that made the time pass and kept thoughts of the ongoing pandemic at bay, participants relied on habits, routines and engaging in pleasant activities. This category comprised two sub-categories: Maintaining routines and Doing pleasant things.
Right from the start of practising social distancing, creating and maintaining routines was crucial. One example of such a routine was participating in regular activities like following along with the daily 20-minute easy physical exercise TV show (a popular Swedish TV show that quickly gained popularity). One participant expressed:
Yes, what should I say; I wake up, eat breakfast, exercise, and then have a cup of coffee. Trying to find a structure. It is when you have as much time as you like, you can always do everything later, then nothing gets done, then I eat lunch, then I go out. But I like the mealtimes; it is the food and exercise that are the regular routines. That's how it is. (IP21.1)
As time passed, the significance of habits became increasingly evident, and during the follow-up interviews seven months later, the same individual continued to emphasise the importance of routines, despite having undergone a major operation:
I follow a physical activity programme. I used to follow [the 20-minute easy physical exercise TV show], but I can no longer do that [because of an operation]. I have my own training programme, which I do three times a day, and I like to have something to do. (IP21.2)
Organising daily routines and adhering to them served as a means of coping with boredom.
Additionally, engaging in activities that were pleasant and ‘cosy’ contributed to increasing wellbeing. These activities reminded them of normalcy and the reality that existed prior to the pandemic:
It's nice to see some old things [on TV] that you think are warm and cosy. It's a sense of normality that I think we all need in this whole mess. (IP07.1)
A desire for positive news was also expressed to counterbalance the abundance of negative information. Engaging in various activities brought joy, such as pursuing hobbies, acquiring a pet dog, taking walks and using the time to repair things around the house.
Furthermore, buying groceries and cooking played a significant role during isolation. Maintaining the activity of grocery shopping became important when other options were limited. The act of preparing delicious meals and indulging in a glass of wine on a weeknight was also mentioned.
New online encounters
New online encounters describes how online tools could fill gaps created by following recommendations. The current situation prompted or even compelled individuals to push their boundaries and adapt to new methods of socialising and online shopping. This category was further divided into two sub-categories: Filling the need for social interactions and Using online services.
There was a strong desire and longing for social interactions, and this need was partially fulfilled through walks with friends and family. Another crucial tool for staying connected was various digital video solutions. For some, this was the first experience with these tools, which they learned and utilised to communicate with their grandchildren.
Additionally, there was a newfound need for assistance with tasks such as shopping, particularly compared to before the pandemic. When older adults were advised against going to grocery stores, many turned to the internet as an alternative. One participant expressed:
But now I can, you see (laughs), with a little guidance. I had never done this before … But now I think it's really fun so now I can shop every day. (IP41.1)
For many, this was their initial experience with online services, which they regarded as positive and helpful. It is likely that these services will continue to be a part of their lives even after the pandemic.
Discussion
In this study, we sought to explore how older adults managed a stressful situation – the COVID-19 pandemic. Our results contribute to the literature on older adults' coping strategies during a crisis and the current public debate on vulnerability among older adults. As far as we know, this is the first Swedish study on the topic. Since the aim was not to validate any specific questionnaire but rather to let the participants speak freely about their situation, qualitative methods were the natural choice of method.
There has been concern about decreased wellbeing among older adults during the pandemic due to the potential negative effects of social distancing. In the public debate, older adults have been portrayed as vulnerable during the pandemic, which may be true in relation to their physical status. However, previous literature, as well as our results, show that older adults have a strong ability to cope with stressful situations, sometimes even better than the younger population (Yeung and Fung, Reference Yeung and Fung2007; Knepple Carney et al., Reference Knepple Carney, Graf, Hudson and Wilson2020; McKinlay et al., Reference McKinlay, Fancourt and Burton2020). They are physically vulnerable but resilient in regard to the situation. In this study, most participants' mental health was not severely affected by the situation, perhaps due to the unique coping skills that older adults have been shown to possess (Fuller and Huseth-Zosel, Reference Fuller and Huseth-Zosel2021). Interestingly, the participant's perception of the situation and their worry about the pandemic seemed almost unchanged during the seven months between the data collection periods. We expected the participant's mental health to deteriorate, primarily due to the prolonged period of social distancing. As some participants said in the beginning, ‘I don't know how to manage if this continues much longer’. However, when we conducted the second phase of interviews, the vaccine was within reach, which probably eased the situation as they could see the end of living with the restrictions.
Most of our results, such as Following advice from experts (Gerhold, Reference Gerhold2020; Verhage et al., Reference Verhage, Thielman, de Kock and Lindenberg2021), Accepting the situation (Van Leeuwen et al., Reference van Leeuwen, van Loon, van Nes, Bosmans, de Vet, Ket, Widdershoven and Ostelo2019; Vannini et al., Reference Vannini, Gagliardi, Kuppe, Dossett, Donovan, Gatchel, Quiroz, Premnath, Amariglio, Sperling and Marshall2021; Verhage et al., Reference Verhage, Thielman, de Kock and Lindenberg2021), Doing pleasant things (van Leeuwen et al., Reference van Leeuwen, van Loon, van Nes, Bosmans, de Vet, Ket, Widdershoven and Ostelo2019; Whitehead and Torossian, Reference Whitehead and Torossian2020), Maintaining routines (Justo-Alonso et al., Reference Justo-Alonso, García-Dantas, González-Vázquez, Sánchez-Martín and del Rio-Casanova2020), Social interactions, Positive view on the situation (van Leeuwen et al., Reference van Leeuwen, van Loon, van Nes, Bosmans, de Vet, Ket, Widdershoven and Ostelo2019; Fuller and Huseth-Zosel, Reference Fuller and Huseth-Zosel2021; Vannini et al., Reference Vannini, Gagliardi, Kuppe, Dossett, Donovan, Gatchel, Quiroz, Premnath, Amariglio, Sperling and Marshall2021) and Using life experiences (McKinlay et al., Reference McKinlay, Fancourt and Burton2020), can be supported by previous literature on coping among older adults during COVID-19. These strategies also align with factors contributing to the overall quality of life among older adults in general (van Leeuwen et al., Reference van Leeuwen, van Loon, van Nes, Bosmans, de Vet, Ket, Widdershoven and Ostelo2019). One category that is less clearly identified in the literature is Controlling the information flow, specifically restricting exposure to news about the pandemic. This behaviour can be seen as an active way to remove the stressor (Folkman et al., Reference Folkman, Lazarus, Dunkel-Schetter, DeLongis and Gruen1986), possibly due to the prolonged duration of the pandemic, as initially, the behaviour was predominantly focused on consuming all available information. Overall, these strategies can be viewed as emotion-focused, which have been suggested to be particularly utilised by older adults during crises (Yeung and Fung, Reference Yeung and Fung2007; Shing et al., Reference Shing, Jayawickreme and Waugh2016). However, this may also be because there are limited problem-solving actions that can be taken during a pandemic; thus, accepting the situation becomes crucial (Verhage et al., Reference Verhage, Thielman, de Kock and Lindenberg2021). Nevertheless, as argued by Verhage et al. (Reference Verhage, Thielman, de Kock and Lindenberg2021), the measures taken to reduce the risk of infection, such as following advice, can be seen as both a problem-focused and emotion-focused strategies.
The category Using life experiences indicates that individuals draw upon their past experiences, including the ability to contextualise the current situation. Throughout their lifetime, the participants in our study have encountered various challenging situations, such as financial crises, the Cold War, nuclear accidents and personal crises, among others. Therefore, the current context must be understood in the context of their extensive life experiences, particularly when comparing our results to the experiences of younger individuals. It has long been argued that older adults tend to cope more effectively than younger adults (Diehl et al., Reference Diehl, Coyle and Labouvie-Vief1996).
New online encounters could be understood within the coping strategy of ‘positive reappraisal’, where individuals create positive meaning by focusing on personal growth. The participants embraced this opportunity and learned new things, experiencing personal development (Folkman and Lazarus, Reference Folkman, Lazarus, Stein, Leventhal and Trabasso1990). However, the motivation for going online could also simply be to stay in touch with relatives. Lebrasseur et al. (Reference Lebrasseur, Fortin-Bédard, Lettre, Raymond, Bussières, Lapierre, Faieta, Vincent, Duchesne, Ouellet, Gagnon, Tourigny, Lamontagne and Routhier2021) highlight the importance of maintaining social connections, preserving family ties, and ensuring the ability to give and receive help among older adults during a pandemic. Therefore, enhancing accessibility to communication technologies and providing digital tool training can facilitate social interactions despite the isolation and protective measures, thereby reducing stress (Strutt et al., Reference Strutt, Johnco, Chen, Muir, Maurice, Dawes, Siette, Botelho, Hillebrandt and Wuthrich2021). Another aspect of technology mentioned by our participants was the ability to purchase groceries online, which increased their sense of safety while practising social distancing. According to our participants, their children and grandchildren were their primary sources of education on new technologies. This raises the question of whether older adults would consider seeking external help and education if it were offered. Furthermore, it is important to note that our results may not fully reflect the absolute reality, as we may not have captured individuals from lower socio-economic status (SES) groups. Many older adults cannot afford to own a tablet or computer, nor do they have sufficient social support, which reduces their opportunities for active engagement on the internet.
The role of SES in coping is complex. While vulnerable groups, such as those facing economic instability and chronic diseases, are more exposed to stressors compared to non-vulnerable, it appears that the ability to be flexible in coping is what ultimately matters. For instance, Atal and Cheng (Reference Atal and Cheng2016) discovered that within a low SES group, participants with higher coping flexibility reported significantly better health-related quality of life than those with lower coping flexibility. However, SES has also been associated with different coping skills. Ouwehand et al. (Reference Ouwehand, de Ridder and Bensing2009) found that higher income and educational levels predicted the use of more proactive coping strategies to manage problems associated with ageing. It is also plausible to consider that lower SES groups have more prior experiences with hardship, which could contribute to their coping abilities. Additionally, as stated by Shing et al. (Reference Shing, Jayawickreme and Waugh2016), the type of coping employed may depend on the specific disaster and the level of loss involved.
Thus, this raises the question for our study: are the results only applicable to older adults with a stable economy who also perceive themselves as healthy? While SES may not be the sole determining factor for coping ability, we do believe that higher SES groups have better conditions to manage a pandemic in the long term, thanks to factors such as a stable economy. However, it is important to acknowledge that cultural differences might play a bigger role in how individuals cope with the pandemic. Despite whether Sweden handled the situation differently, we are observing similar results from other countries, which leads us to believe that our findings could be applicable and relevant to other countries and communities.
When the objective is to maintain good health, one particularly interesting strategy during a pandemic is proactive coping (Aspinwall and Taylor, Reference Aspinwall and Taylor1997). This approach involves having sufficient resources, which may have been accumulated throughout one's life, to build resilience and be prepared. The participants we encountered in our study were generally in good health and had favourable conditions, including stable life circumstances and relatively high SES. Proactive coping entails problem-solving rather than avoidance. We discovered that participants, at least initially, sought information about the pandemic through news sources and the internet. Additionally, they were actively following advice as a preventive measure against contracting the virus. Lastly, increased knowledge was a prominent proactive behaviour aimed at minimising the potential consequences of infection.
Strengths and limitations
The study's main strengths lie in the extensive number of interviews conducted, encompassing both men and women from diverse regions in Sweden, including both rural and urban areas, conducted during the initial period of the pandemic, capturing feelings and experiences in the moment of a novel and potentially frightening situation, Additionally, follow-up interviews were conducted approximately seven months later, providing valuable firsthand accounts from the population most vulnerable to the virus. However, certain limitations should be acknowledged. Firstly, conducting telephone interviews may not be optimal, particularly for this age group, which may experience an increased level of impaired hearing compared to other age groups. Natural pauses become scarce and forced, and the absence of visual cues may hinder deep conversations, particularly when discussing wellbeing and mental health. Face-to-face interviews would have been preferred, but due to the imposed restrictions at the time, telephone interviews were the only viable option. Fortunately, telephone interviews may increase respondents' feelings of anonymity, potentially leading to increased relaxation and openness, thereby mitigating interviewer effects (Sturges and Hanrahan, Reference Sturges and Hanrahan2004). Secondly, when interpreting the results, it is important to recognise that pandemic restrictions varied across different countries, and the pandemic itself had varying degrees of impact. Nevertheless, the confirmation of our findings in international studies supports the potential transferability to other Western settings. Thirdly, our participants exhibit homogeneity in terms of SES and living conditions. Therefore, caution should be exercised when generalising the results to poorer and other vulnerable older populations, as they may face different circumstances for maintaining their wellbeing. For instance, a Swedish report suggests that the situation might be different for those living in nursing homes (von Berens et al., Reference von Berens, Mainow, Johansson and Sonde2021). However, as discussed earlier, SES and coping skills are influenced by a complex interplay of factors, necessitating caution in drawing conclusions regarding the role of SES in individuals' coping abilities. Lastly, it is important to note that mental health issues, particularly among men in this age group, may be considered taboo or unaccustomed to open discussion (Karlsson et al., Reference Karlsson, Hammar and Kerstis2021). To address this and obtain a broader range of participant perspectives, we purposefully recruited six individuals who expressed high levels of concern and worry. From a personality perspective, they may have contributed to a more stressed (neurotic) outlook on the pandemic and employed alternative coping strategies, such as avoidance and less-positive thinking (Carver and Connor-Smith, Reference Carver and Connor-Smith2010). Overall, it is crucial to acknowledge that this study, along with the literature referenced, primarily represents a Western country perspective.
Conclusions and implications
In conclusion, this study highlights the diverse array of coping strategies used by older adults during the pandemic. Despite the public debate and widespread apprehension regarding the wellbeing of older adults in relation to social isolation, our findings shed light on their resourcefulness. It appears that their previous life experiences and unique coping skills may provide an explanation for their resilience. When developing interventions aimed at promoting the health of older adults, it is crucial to bear this in mind. Empowering them by nurturing their capabilities, rather than merely managing or eliminating risks, should be the goal.
We can leverage current knowledge when strategising interventions to alleviate mental health issues. The significance of social interactions was evident, and a societal challenge lies in sustaining these interactions amid an ongoing pandemic. As suggested by Lebrasseur et al. (Reference Lebrasseur, Fortin-Bédard, Lettre, Raymond, Bussières, Lapierre, Faieta, Vincent, Duchesne, Ouellet, Gagnon, Tourigny, Lamontagne and Routhier2021), one approach is to provide digital tool education. We observe that engaging online assists older adults in coping with the situation by facilitating social interactions, shopping and carrying out other tasks. However, it is important to acknowledge that older adults are not a homogeneous group, and vulnerable sub-groups within the older adult population, who already experience decreased wellbeing, reported amplified difficulties compared to pre-pandemic times (Kivi et al., Reference Kivi, Hansson and Bjälkebring2021; Lebrasseur et al., Reference Lebrasseur, Fortin-Bédard, Lettre, Raymond, Bussières, Lapierre, Faieta, Vincent, Duchesne, Ouellet, Gagnon, Tourigny, Lamontagne and Routhier2021).
Financial support
This work was supported by the Swedish Civil Contingencies Agency (grant number 2020-03635).
Ethical standards
The study was approved by the Swedish Ethical Review Authority (2020-01600).
Open access
