Agency and Mental Health Among Peruvian Older Adults During the COVID-19 Lockdown

Abstract

Objectives

To explore the experiences of older Peruvian adults living in urban areas of Lima under lockdown due to the National COVID-19 Emergency, this study analyzes how older adults (aged 60 and older) exercise agency while also living with the negative impacts of coronavirus disease 2019 (COVID-19) and related control measures.

Methods

Between August and December 2020, our research team conducted a telephone-based, qualitative study, in which we undertook semistructured interviews with a purposive sample of low-income older adults living with chronic multimorbidities and limited resources. Forty older adults, 24 women and 16 men, with a mean age of 72 years, participated in the study. For data analysis, we employed thematic analysis with a predominantly inductive approach.

Results

Older adults demonstrated several forms of agency to regulate emotions, maintain crucial bonds, foster social relationships, and seek economic and food security. Older adults experienced entertainment and support by caring for pets, undertaking farm work, and practicing their religious beliefs. For several participants and their families, quarantine was an opportunity to strengthen family relationships and learn new technologies. Older adults and their families reorganized themselves to assume new roles and perform activities that improved self-worth and confidence, thereby improving their well-being and mental health.

Discussion

Peruvian older adults exerted agency in different ways to respond to and sustain their mental health during the COVID-19 lockdown. Policymakers should value and recognize the agency of older adults when planning future health responses.

Background and Objectives

A few days after the first confirmed case of coronavirus disease 2019 (COVID-19) in Peru, the government initiated national quarantine measures that ended up becoming one of the Latin American region’s strictest and longest-lasting (Arredondo-Bastidas, 2021). Quarantine measures included mandatory social isolation, suspension of freedoms of assembly and transit. These actions sought to reduce virus transmission, shield the health system from overuse, and protect individuals considered at higher risk of mortality due to COVID-19 infection (Consejo de Ministros, 2020). Government policy designated adults 65 years and older a vulnerable population and mandated that they adhere to stay-at-home orders, even after such restrictive measures began to ease for younger people. From mid-March to mid-November 2020, older adults were required to remain at home; allowed exceptions included medical emergencies or the older adults’ circumstances were such that no other person could provision food or satisfy other basic needs. Beginning in October 2020, Government rules allowed for 60 min of walking outdoors, three times per week.

International and local organizations indicated that the lack of physical activity, fear of acquiring COVID-19, lack of intellectual stimulation, and digital exclusion resulting from the COVID-19 emergency severely affected older adults’ mental health (Ministerio de Salud, 2020; Naciones Unidas, 2020). In response, some researchers in Latin America focused on measuring the presence of negative mental health symptoms such as stress, anxiety, or depression using online surveys (Antiporta et al., 2021; Herrera et al., 2021; Ruiz-Frutos et al., 2021). However, while quantifying disorders or negative symptoms is highly valuable, this approach only tells part of the story. These methods do not readily allow visualization and understanding of the different ways that older adults adapted to the new circumstances produced by the COVID-19 pandemic.

In response, we conducted a qualitative study to explore the impact of lockdown restrictions on the mental health of older adults. We conducted a qualitative interview-based study to give centrality to how older adults themselves describe their lockdown experiences. Narratives and stories provide an invaluable way of understanding people’s experiences.

When we read our interviews, we realized that study participants had shared lockdown experiences with our research team that seemed characterized by adaptation and agency practices enacted in the context of once-in-a-lifetime pandemic hardship. Thus, for this manuscript, we aim to describe and analyze those lived experiences using an agency framework.

Agency theory enabled us to perceive how older adults exercised capabilities that contradicted national government and press portrayals of them as frail and vulnerable. The COVID-19 pandemic has exacerbated ageism by homogenizing older adults and disproportionately emphasizing their vulnerability to COVID-19 in comparison with other high-risk groups (Angulo-Giraldo et al., 2020; Ayalon et al., 2020; Morrow-Howell et al., 2020; Reynolds, 2020).

By providing evidence of older adults’ agency during COVID-19, we offer policymakers and health professionals reasons to work with older adults to develop health interventions that will take into account their lived experiences. Such an approach to policy would recognize older adult agency and respond to their needs and strengths.

Theoretical Framework

The World Health Organization (WHO) defines mental health as “a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community” (World Health Organization, 2018). In this conceptualization, agency is intrinsically linked to mental health because this capability directly concerns one’s ability to respond effectively to life’s challenges, including those produced by an event like the COVID-19 pandemic and the mobility restrictions it imposed (Caballero, 2021).

While there are different approaches to agency, we adopted Bandura’s (2018) social psychology perspective, which recognizes “human functioning as a product of intrapersonal influences, the behavior individuals engage in, and the environmental forces that impinge on them. Because personal influences play an influential role in the casual mix, people have a hand in shaping events and the courses their lives take” (p. 130). From this point of view, people individually and collectively develop, adapt, and change intentionally, influencing their functioning and life circumstances. This implies that an individual and his/her group, family, community, or society, can proactively organize, self-reflect, and self-regulate to sustain wellness (Bandura, 2006, 2018). Agency is also related to meaningful participation, being part of a group and in decision-making processes and negotiation while recruiting resources emerging from within the individual (emotions, values, thoughts, expectations), from their family, community, and their environmental conditions (material, economic, and political; Kabeer, 1999).

Adopting a social cognitive approach for agency implies a focus that is slightly more on the individual side, but without neglecting collective functioning or the cultural, social, and economic environment. We deliberately analyzed the study participants’ individual narratives, as well as their descriptions of their experiences and representations. Bandura (2006, 2018) describes three core properties of agency: forethought, self-reactiveness, and self-reflectiveness. Together, these three properties frame adaptation behaviors in terms of how individuals and groups guide themselves by visualizing goals and potential outcomes (forethought); how they self-regulate in the process (self-reactiveness); and finally how they examine their own thoughts, actions, and capabilities (self-reflectiveness). Examination of one’s own thoughts, actions, capabilities, and broad functioning would be the most advanced agentic characteristic, because unless older adults believe they can produce certain desired effects by their actions, they have little incentive to act or to persevere in the face of difficulties.

Method

Research Design and Methods

Study design and setting

We conducted this qualitative study remotely by phone and recruited participants from two urban districts located in South Lima (San Juan de Miraflores and Villa El Salvador). These two districts largely consist of low- and middle-income households whose members had migrated (mainly from the Andes) from the rural countryside to urban settlements during the early 1960s (Miranda et al., 2012; Rodríguez Vignoli, 2004).

Study participants

Participants (60 years and older) were recruited from a database built over the previous 2 years (2018–2020). The database was a product of the Global Excellence for Chronic Obstructive Pulmonary Disease Outcomes Study (Siddharthan et al., 2022), that included a random community sample of 3,500 participants (40 years and older), stratified by age and sex.

For this qualitative study, we purposively sampled 40 people 60 years of age and older (24 female and 16 male), with a wide range of characteristics to ensure maximum variability of experiences. We excluded from the research anyone who had participated in a recent qualitative study led by our research group (Flores-Flores et al., 2020) and who did not have a mobile or home phone number registered in the research database. Subsequently, we sampled men and women with and without chronic noncommunicable diseases, and from two age sets (60–75 years old and 75 and older).

Data collection

Older adults were approached and invited to participate via telephone by a research team member. Trained interviewers conducted in-depth interviews that lasted 40 to 70 min on average and were conducted in the local language (Spanish). We audio-recorded all the interviews using a phone app Cube ACR. The multidisciplinary research team, that included social and biomedical researchers, developed the interview guide to capture the impact of COVID-19 and lockdown on mental health. The interview guide included topics based on the broad concept of mental health as defined by the WHO. Thus, we developed questions about feelings, thoughts, behaviors related to participants’ economic circumstances, employment situation, interaction, and any supportive collaboration with family and members of their community, coping activities, and adaptations. We gave particular attention to changes participants experienced (impact) during the lockdown. The interview guide with probing questions can be found in Supplementary Material. We pilot-tested the interview guide prior to data collection.

Data analysis

Our study adapts a reflective thematic analysis developed by Braun and Clarke (2006, 2019), which employs a constructivist and experiential orientation to data interpretation. To ensure reflexivity throughout each stage of the study, we held regular meetings to share our codes and themes, to review memos and research notes, and to thoroughly discuss the varied assumptions, interpretations, and conclusions that had emerged from the members of our multidisciplinary team. We adopted a predominantly inductive approach utilizing open-coding and respondent-based meanings. To organize, interpret and ensure that our open-coding strategy would produce themes that responded to our research questions, we applied Bandura’s agency framework. Specifically, we focused on situations in which research participants related how they had demonstrated agency despite circumstances and conditions produced and sometimes worsened by Peru’s extended periods of national quarantine and lockdown. We used the MAXQDA software (VERBI GmbH, Berlin, Germany, Version 18.2) to manage and organize the data.

Ethics

We obtained ethical approval for this research from Institutional Review Boards from A.B. PRISMA (Lima, Peru), Universidad de San Martin de Porres (Lima, Peru), and University College London (London, United Kingdom). Informed consent was obtained orally from the participants. Consent provided authorization to use quotes from interviews in academic publications. Confidentiality of the data was assured during analysis by using only codes instead of personal identifiers and by storing identifiers in a password-protected, locked online folder. In this manuscript, we agreed to use pseudonyms when referring to study participants.

Interviewers were trained to properly handle sensitive matters during the interviews. Some of the strategies used in moments of distress were to pause the interview, allow the participant to recover, or reschedule the conversation. Finally, participants received a token of appreciation for their time and collaboration with the research project, which consisted of a basket with food supplies equivalent to 15 U.S. dollars. It was delivered according to local safety guidelines during the national COVID-19 emergency.

Results

Most of the participants lived with their families in multigenerational households. Their mean age was 72.1 ± 8.2 years. Typically, a house is split into floors that accommodate the different adult children and their own families. Usually, the owner of the house was an older adult of the first generation of Andean migrants. Table 1 describes the characteristics of the sample.

Table 1.

Characteristics of the Study Sample

	Total (n = 40)	Youngest old (60–75) [n = 23]	Middle and oldest old (75+) [n = 17]
Sex
Female	24 (60)	12 (52)	12 (71)
Male	16 (40)	11 (48)	5 (29)
Total in house	4.3 ± 2.1	4.3 ± 2.1	4.4 ± 2.2
Education, years	7.4 ± 4.7	9.3 ± 3.5	4.8 ± 5
Education classified
No education	16 (40)	3 (13)	13 (76)
Primary school	8 (20)	7 (30)	1 (6)
High school	13 (33)	11 (48)	2 (12)
Any higher education	3 (8)	2 (9)	1 (6)
PHQ-9 sum (n = 32)	4.6 ± 5.9	4.9 ± 7.2	4.3 ± 4.3
Depression symptoms (n = 32)
None–mild (PHQ-9 ≤9)	27 (84)	13 (81)	14 (88)
Moderate–severe (PHQ-9 ≥10)	5 (16)	3 (19)	2 (13)
BAI sum	6.5 ± 6.8	6.9 ± 7.2	5.9 ± 6.3
Anxiety symptoms
Mild (BAI ≤15)	37 (93)	21 (91)	16 (94)
Moderate–severe (BAI ≥16)	3 (8)	2 (9)	1 (6)
District
SJM	22 (55)	16 (70)	6 (35)
VES	18 (45)	7 (30)	11 (65)
Comorbidities
None	13 (33)	8 (35)	5 (29)
One	17 (43)	8 (35)	9 (53)
Two or more	10 (25)	7 (30)	3 (18)
Frailty	5 (13)	3 (13)	2 (12)
Insurance
No insurance	13 (33)	8 (35)	5 (29)
EsSalud	9 (23)	4 (17)	5 (29)
SIS	18 (45)	11 (48)	7 (41)

Notes: BAI = Beck Anxiety Inventory; PHQ-9 = Patient Health Questionnaire-9; SIS = Seguro Integral de Salud; SJM = San Juan de Miraflores; VES = Villa El Salvador. Comorbidities (diseases included: hypertension, chronic heart disease, diabetes, tuberculosis, asthma, chronic obstructive pulmonary disease, emphysema, arthritis, lung cancer, and psychosis).

In this manuscript, we focus on positive adaptations undertaken by study participants to lockdown conditions. As a result, we use agency constructs to explain these findings. Thus, we divided the results below into two general categories that encompass how agential action supports mental health: (1) self-regulation of emotions, stress management, and maintenance of a positive state of mind; and (2) maintenance and restoration of social bonds and relationships with family and friends.

Self-Regulation of Emotions and Stress

The COVID-19 pandemic and quarantine modified older adults’ everyday routines, which among other emotional responses, caused stress and fear. Because most older adults worked in informal jobs (e.g., street vendor, carpenter, janitor, cleaner), most of our study participants experienced loss of income because quarantine rules did not allow them to leave their homes.

Study participants used several ways of emotional self-regulation in addition to undertaking specific methods for effectively coping with their new and adverse realities. They would perform activities at home that would provide them with a sense of “normality” and offer distraction from stressful thoughts and events conjured by the pandemic. The activities mentioned by study participants were linked to leisure such as listening to music, reading newspapers, watching TV, dancing, or even learning new hobbies such as searching YouTube to find fun videos or information.

Well, I think people are too desperate sometimes. The best thing is to wait, for me, I can’t be without music, I like music, all by myself, I’m cleaning at home I put on the music, when I’m alone. I’m dancing, cleaning like that, and that is the best thing, I think, to forget about it, not to get too dramatic and just move on with the disease (COVID-19). (Consuelo, 78 years old)

... for example, I didn’t use YouTube before, it bored me, now she [her daughter] tells me: “mom, go to YouTube, look at all the information you want”. There I get distracted looking at everything about diseases, I like to listen to those things, there I am looking at everything that they say. (Dolores, 64 years old)

Well, basically when I try to control myself is that I, (…) what I like to do now is to clean the house or paint, I have even been painting the doors, I have been painting my furniture, with a machine I have been sanding, [doing that I] totally forgot about, I even think I’ve forgotten about the pandemic. (Juan, 68 years old)

A second form of emotional self-regulation was related to caring for pets and domesticated animals. Older adults’ household configurations often included animals that were considered significant others by the participants. Their presence seemed to support older adults’ agency because they contributed to transforming their homes into positive environments, supporting well-being and mental health. For example, when we asked a female participant what she did to reduce the sadness of having her family away, she mentioned that taking care of her pets and farm animals, even cooking meals for them, became important activities for emotional self-regulation:

Well, at home I try to cook, I have cats, dogs, I have some hens, I amuse myself with that, I try to cook for the kittens, I cook for the dog, for my hens, I have four hens and a rooster he’s called ‘Flaco’. (Bertha, 74 years old)

In a similar emotional statement, Julia also explained how the activities and relationship with her animals at home, talking and laughing with them, were helpful as a self-regulation mechanism:

Well, at the beginning I still felt sad, as I told you, there are days I get a little sad, but today I’m fine. Sometimes, every two, three weeks, one day like that I get very sad, upset, but as the specialists say, no, you have to control your worries, so I’m doing that effort, well.

Interviewer: And how, what do you do to better control your emotions ...?

Well sometimes to control my emotions I laugh, I laugh, I make jokes, I have a few little animals, chickens, rabbits, with them I talk, I try to laugh a lot … (Julia, 64 years old)

A third form of emotional and stress regulation was related to the role of religious faith. Older adults enacted faith through praying, which helped them remain hopeful and strong during the lockdown. Significantly, faith-reinforcing activities also help lend order and meaning to pandemic situations otherwise often experienced as frightening and uncertain.

thank God, He has lifted me up morally, physically, spiritually, if I hadn’t trusted the Lord, I don’t know [what would have happened to me]. (Luz, 61 years old)

Family members’ self-reflections narrated their sense that being together helps confirm that everyone is well, thereby relieving a potential source of stress and producing calm and stillness.

Interviewer: What allows you to be stronger, feel calmer…?

The tranquility/peacefulness of my house, of my home; of my family, that everyone is OK. We always communicate, hey how are you, all good, all calm, then it gives you a little more strength. (Alan, 64 years old)

Another very specific, yet complex way of dealing with anxiety during the quarantine emergency, was to avoid the news, especially sensationalistic media reports. Doing so allowed study participants to avoid exposure to information about death and crises in other families that might affect them as well. Choosing not to consume potentially harmful information showed emotional self-awareness.

Sometimes I don’t want to remember because it hurts. [It hurts] to see the people, the hospitals, people dying every day, so many people and there was no room [in the hospitals]. We would turn on the TV and felt sick ... (Carla, 64 years old)

I tell him because when you are still, or you are sitting down, or you are just watching television, or you have your cell phone in your hand, at least it makes me nervous, I cannot be more than half an hour, an hour so, there if it starts to make me nervous, no. (Natalia, 69 years old)

Older adults in our study seized opportunities to make and execute plans. They also governed themselves and regulated their emotions during quarantine to produce calm daily environments that they could enjoy by themselves and with others. Such actions show one of the ways in which study participants would show agency.

Social Bonds and Relationships

Sustaining bonds and relationships with family and friends during quarantine was an important activity that supported mental health. Quarantine provided some of the families to which older adults belonged with opportunities to spend more time together and therefore to strengthen interpersonal bonds and relationships with one another:

We have known each other a little more during lockdown because when they[adult children] were children you know what they want, what they do, what their thoughts are, but when they are adults, not anymore, not anymore because each one comes to have their own family, so they no longer share with us, then this pandemic has enclosed us, it has brought us back, we have been integrated into the family. (Miguel, 69 years old)

I am satisfied now together with my children, and there is one important thing for me; we [previously] have never been together, there has never been that union between the family, right? So, [now] I have been able to feel that family union, talk with my children sometimes (about) anything. (Julia, 64 years old)

The need to instantiate family bonds without face-to-face contact encouraged older adults to learn how to use messaging services such as WhatsApp. Notably, prior to the pandemic, only 23.4% of older adults in Peru reported regularly accessing internet services (Instituto Nacional de Estadística e Informática, 2021). Consequently, learning how to use internet-enabled devices presented study participants with a challenging process that showed adaptation to the “new normal” and one of the ways that they maintained significant social relationships:

Now they have united through the WhatsApp system, they have become closer. All my family, they communicate [through WhatsApp], they are so far away, my sisters are in Italy, but I talk to them almost every day. It has improved a lot during this pandemic, not only for me but many people and above all, the older adults I think they are having something special (...) I didn’t even know how to use it, I just answered and tapped [the screen] to talk, today I am learning to use it better, I can send messages, the links that the church sends me, I also send [messages] to Italy (...) that is why I say thanks to this pandemic for me no, for me it has given me many benefits, you understand me. (Pedro, 81 years old)

The COVID-19 pandemic caused an economic crisis in most Peruvian families (Jaramillo & Ñopo, 2020) and sustaining social bonds and family relationships surged in importance for economic and food security. Our study participants further indicated that kinship links and friendships were also fundamental for generating and sustaining their health. Older adults who previously had lived independently found themselves in quarantine conditions needing to often ask their children for things that they were accustomed to provide by themselves. These circumstances, for many older adults caused anxiety.

Many of the multigenerational households in which older adults lived reorganized themselves during quarantine to address economic and food crises. Reorganization occurred around a logic and mutual support. Older adults would undertake household activities such as cooking, caring for grandchildren, or cleaning the home, while adult children would perform activities that would require leaving home such as provisioning for food, paying bills, or other tasks. Due to financial constraints, each family member needed to share food to ensure everyone was able to eat.

He [my son] brought me five kg of rice, a bottle of oil, sugar, my younger daughter [brought] as much as she was able with her money. She brought the chicken, legumes, and that’s how we got by; because my husband did not work, because at start of quarantine, they[company] fired him. (Maria, 64 years old)

Several study participants contributed to their families through undertaking productive and therefore meaningful activities. Some assumed new household chores. For instance, Roberto began crafting wooden objects for his children and grandchildren and painted the walls of the family house, among other activities:

And from there [lockdown] I started to make some cell phone holders out of wood, right? I cut it into strips (...) and I put it together and put the cell phone there. My grandchildren, who live on the third floor, I also made them [furniture] for their computer. I’ve done quite a few, [since] I had nothing to do. I just didn’t realize it (...) [My wife would tell me]: ‘hey, don’t you get tired? sit down to watch television [with me]’ (...) but from then on, I was going to do my thing. I’ve done quite a few [furniture] for my siblings, I’ve given away, not for profit, no, but for the purpose of doing, of giving a present to my siblings. (Roberto, 81 years old)

The desire to continue being active and productive through undertaking chores or domestic activities intended to achieve more than sustaining social bonds and generating income. Study participants linked such activities to their own self-worth and confidence, which in turn contributed to their self-esteem. Following their pre-pandemic routines (e.g., harvesting, knitting) and performing productive activities during quarantine provided an important sense of normalcy for older adults, which enabled them to regulate their emotions and helped them to avoid succumbing to quarantine worries and stresses.

Right now, imagine, everything has changed, we can no longer go out, we can’t talk with the family. I do worry, but the only thing I take refuge in is that I knit. I’m knitting, and lately I’m going out; the woman [neighbor] has a company, she dedicated to weaving, exporting. … Sometimes she keeps my clothes [to sell later] for me, then this is great joy for me. (Julia, 64 years old)

Discussion

Older adults demonstrated agency through regulating their emotions, maintaining crucial kinship bonds, fostering social relationships, and supporting domestic productivity along with economic and food security activities. To regulate their emotions and distract themselves from negative thoughts and feelings, older adults maintained or started new leisure activities, found entertainment and comfort in caring for pets and farm animals, through religious practices and by actively avoiding negative media reports about COVID-19. For several research participants and their families, quarantine was an opportunity for strengthening family relationships, learning how to use new internet technologies for communicating with relatives who lived at a distance. Older adults and their families reorganized themselves around new household roles and tasks. They also undertook activities that improved their self-worth and confidence, which ultimately improved their well-being and mental health.

Similar to our approach, Renkens et al. (2022) used an agency framework to explore adaptation in emergency-disaster situations. Renkens et al. noted that among refugees, resilience and grief are not limited to passive suffering but also involve actively enduring. As a result, agency in decision making does not necessarily translate into an externally observable behavior. Two decades later, Chang et al. (2020) observe that policymakers may find it difficult to measure older adults’ adaptions to adverse circumstances, which may foster and reinforce preexisting perspectives about older adults’ lack of agency. Lind et al. (2021) questioned whether older adults were indeed the most vulnerable populations during COVID-19 lockdowns by highlighting older adults’ psychological strengths. Specifically, the authors observed that older adults would reflect upon their lives by “taking the long view” and by attempting to connect with and guide subsequent generations through selectively adapting and sharing personal memories about past adverse situations that could be perceived as similar to shared, present circumstances.

We used the concept of agency and not resilience as the latter is usually described as the ability to recover to an original or previous condition (Promislow et al., 2022), and because agency tends to emphasize individuals’ intrinsic capacity for ongoing adaptation. In some frameworks, resilience means coping with external challenges (Woo, 2019), whereas agency captures the multidimensional ways humans adapt to dynamic social and structural circumstances. This article highlights older adults’ agency in the context of negative, COVID-19 quarantine-generated circumstances.

One aspect of the lockdown several older adults reported was an improvement in relationships with relatives. One participant stated that the pandemic “brought them back” into the family, which suggests previously he had not felt included. While multigenerational households existed before the pandemic, the attitudes of younger generations toward their older relatives changed during quarantine. Whether feelings of connectedness will continue after lockdown ends remains unknown. Regardless, we must ask how Peru could retain some of the positive and integrative practices that emerged in quarantine as effective methods for addressing loneliness and social isolation among older adults.

Our study results strongly suggest that people who make policy during emergency or disaster situations ought not perceive older adults as passive victims who need to be taken care of and protected. Although in our research, older adults’ agency cannot be separated from their social context, their health needs should be understood as arising from more than their biological age. Their experiences and voices should be incorporated into how local and national institutions organize future responses to societal and public health emergencies. Additionally, recognizing older adults’ agency accords with the UN Decade of Healthy Aging (2021–2030) platform that emphasizes the need to change how we think, feel, and act toward older age and aging in order to combat ageist policies (World Health Organization, 2020). Older adults are active agents who adapted to dynamic and changing circumstances to continue contributing to their families and communities. Furthermore, we conclude that promoting an agency perspective among local health and social providers would improve mental health interventions so that they would recognize and foster older adults’ capabilities rather than focus mainly on older adults’ limitations. Finally, in alignment with the Lancet Commission on Global Mental Health, researchers should not only consider negative symptoms, or the binary presence or absence of a disorder, but also understand mental health as a continuum (Patel et al., 2018). We encourage mental health researchers to include positive dimensions of mental health such as agency, resilience, and self-efficacy when evaluating the impact of mental health interventions.

A strength of our research is that data collection was purposive using a recently collected data set that contained social and clinical characteristics of participants. However, while we attempted to reach older adults with varied characteristics and from low-income settings, we did not include older adults with severe disabilities or those without telephone access. Finally, because participants in this study resided in low-income urban areas of Lima, the quarantine experiences and coping strategies of rurally resident older adults could be expected to be different.

Conclusion

While we recognize the heterogeneity of their experiences, older Peruvian adults exercised agency in different ways to respond to and to support their mental health during the COVID-19 lockdown in low-income urban areas of Lima. By regulating their emotions, maintaining crucial kinship bonds, fostering social relationships, learning new technology-based ways of communicating, and supporting domestic productivity along with economic and food security activities, older Peruvian adults utilized their capacity for agency to adapt to lockdown restrictions in ways that policymakers and health leaders ought to give greater attention.

Funding

The parent GECo (Global Excellence in Chronic Obstructive Pulmonary Disease Outcomes) study was supported by the UK Medical Research Council (MR/P008984/1, PI: J. R. Hurst) under the Global Alliance for Chronic Disease. The present qualitative study was funded by the Medical Research Council (MRC) and the National Institute for Health Research (NIHR; project reference: MR/V028650/1) using UK aid from the UK Government to support global health research. The views expressed in this publication are those of the authors and not necessarily those of the MRC, NIHR, or the UK Government. O. Flores-Flores is supported by the Fogarty International Center and National Institute of Mental Health of the National Institutes of Health (NIH), United States under Award Number K43TW011586. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Conflict of Interest

The authors declare that they do not have conflict of interest.

Data Availability

The data used or analyzed during the current study are available from the corresponding author on reasonable request.