The psychosocial effects of the COVID-19 pandemic on Turkish older adults: is there a difference between males and females?

Abstract

Background

The COVID-19 pandemic has seriously affected older adults’ social lives, physical activity, and cognitive functions. Additionally, the lockdowns have disrupted regular healthcare for patients with chronic illnesses or needing acute care. Furthermore, the pandemic has negatively affected different psychosocial influences in each country due to the various cultural characteristics, technology, health system, and financial opportunities. This study aimed to investigate the effects of COVID-19 on mood, social participation, and healthcare use in older adults living in Turkey.

Methods

A cross-sectional study was conducted during the third wave of the COVID-19 pandemic (March-December 2021) in three medical centers in Turkey. Patients aged 60 + years without significant cognitive impairment were recruited by mail or at hospital admissions. Information on demographics, pandemic-related distancing measures, healthcare use, lifestyle, symptoms of anxiety, depression, and social participation were assessed.

Results

A total of 343 participants were included in the study. Women had a higher rate of hypertension, symptoms of anxiety, depression, and fatigue compared to men (p < 0.05). Since the start of the pandemic, only 22.4% of non-acute healthcare appointments were conducted face-to-face. Time spent with family and friends, hope for the future, and physical activity decreased. At the same time, the experience of loneliness, the number of meals and unhealthy snacks, and the use of digital services increased. Women were also more concerned about getting coronavirus infection, transmitting the virus to others, and being discriminated against because of the infection (p < 0.05).

Conclusions

These pandemic days have had a significant psychosocial impact on Turkish older adults, especially women. As a strategy of the health care policy, easy access and follow-up to the health system should be provided, and the necessary support should be procured to minimize the detrimental effects of the pandemic on older people.

Background

The coronavirus disease (COVID-19) pandemic has had severe adverse health, psychosocial, and lifestyle consequences for older adults worldwide [1–3]. Beyond disease-related mortality and morbidity, older adults have also had to deal with challenges due to the measures taken to contain the pandemic, such as social distancing, limitations to public gatherings, and travel restrictions [4]. Additionally, the lockdowns have disrupted access to both routine and emergency healthcare facilities for chronically ill elderly patients or those in need of acute care [5, 6]. Moreover, these individuals, who were sensitive to isolation measures, had to struggle with varying degrees of physical inactivity, unhealthy diet, loneliness, and mental/cognitive deficiencies, depending on the sociocultural characteristics of the countries, the use of technology, and financial means [4, 7].

In this landscape, the World-Wide FINGERS (WW-FINGERS) global network of multidomain lifestyle intervention trials for dementia risk reduction and prevention [8] of the direct and indirect impact of the pandemic on lifestyle, management of chronic conditions and psychosocial factors relevant to brain health in older adults [4, 9]. The WORLD-WIDE-FINGERS-SARS-COV-2 survey aimed to measure the effects of the pandemic on older adults to inform the adaptation of strategies for dementia risk reduction and prevention in the pandemic and post-pandemic landscape. The survey has been implemented in over 20 countries, including Turkey.

The older adults in Turkey were instructed to stay home under quarantine-like conditions to protect them during the first three waves of the COVID-19 pandemic. Considering Turkey’s cultural, health, and economic diversity, it is important to evaluate in detail the negative consequences of the pandemic on vulnerable older patients. Many factors might contribute to determining changes in the cognitive and physical health of older people during the pandemic, including racial-ethnic differences, socio-demographic characteristics, economic status, and the burden of chronic diseases [10]. Women are at a higher risk for mental disorders such as depression and anxiety [11]. The feeling of loneliness, social restrictions or domestic violence, and level of concern related to COVID-19 have also been indicated as factors contributing to the deterioration of the mental well-being of older adults [12]. Although men suffer higher mortality and morbidity from COVID-19, it is less clear if sex-related differences exist concerning the indirect effects of the pandemic. Therefore, this study aimed to investigate the impact of COVID-19 on mood, social participation, and healthcare use, and whether sex affects physical and mental health conditions in elderly people living in Turkey during the pandemic, using an adaption of the WORLD-WIDE-FINGERS-SARS-COV-2 survey.

Methods

Participants and survey

The cross-sectional study was conducted in Turkey’s three geriatric medicine clinics (Dokuz Eylul University, Adana City Research and Training Hospital, and Sivas Numune Hospital) between March and December 2021. Study participants were volunteers recruited among patients from the three clinics, either during the visit to the clinic or via e-mail. Inclusion criteria included 60 years or older, absence of dementia, having Turkish as a native language, and ability to understand the survey questions. Patients with acute symptoms such as sepsis, delirium, gastrointestinal bleeding, and acute coronary syndrome were excluded from the study.

The questionnaire was adopted from the WORLD-WIDE-FINGERS-SARS-COV-2 INITIATIVE to analyze the direct and indirect effects of the pandemic on mental and physical health. It focuses on changes in lifestyle factors (such as diet and physical activity), the management of chronic non-communicable diseases (e.g., diabetes, hypertension), as well as psychosocial factors that may be associated with cognitive status such as depressive symptoms, sleep disturbances, social isolation are expected to be affected during the pandemic.

The questionnaire was first translated into Turkish by three researchers and then converted into a single text by another researcher. It was then translated back into English by two English-speaking translators and compared with the original survey. The final text was piloted on ten patients to verify the applicability of the survey. The survey was conducted on a digital platform, using “Google Forms”, and some questions were marked as mandatory fields (i.e., sociodemographic characteristics and Likert scales). The user could not complete the survey if any of the obligatory questions were not answered. The questionnaire could be fulfilled by the patient alone or with the help of a relative or healthcare professional.

The core part of the questionnaire contained information about the current date, the country of residence, and the recruitment method (e-mail, face-to-face, etc.). The other parts included the participant’s socio-demographic characteristics and place of residence, symptoms that could be observed during the COVID-19 disease (cough, fever, chest pain, etc.), use of healthcare services during the pandemic period, level of social and physical isolation practiced, lifestyle changes (e.g., physical activity, diet, smoking) and behavior, subjective memory problems, self-rated general health quality, self-reported systemic diseases, working conditions (retired or not) and participation in social life were questioned.

Social and physical distancing were identified according to changes in social activities, use of public transportation, frequency of leaving own housing, and meeting people indoors. Changes, compared to the pre-pandemic period, in lifestyle, behavior and emotional health, including experience of loneliness, time spent with family, consumption of vegetables and fruit, consumption of unhealthy snacks, sleep problems, alcohol use, smoking, physical activity and social activity (e.g., contact with friends and relatives) were rated by the respondents as “decreased, increased, unchanged, or does not concern me” on a Likert-type scale. The survey also included questions about individual concerns about transmission of the virus, discrimination due to the disease, effects of COVID-19 on the economy, and local health policies [13]. Additionally, the Turkish version of the Hospital Anxiety and Depression Scale (HADS) [14] was used, with the permission of Mapi Research Trust©, and according to the Turkish validity study [15]. For the two components of the scale, HADS depression (HADS-D) and anxiety (HADS-A), subdomain cutoff values (≥ 7 and ≥ 10, respectively) were used to identify respondents with abnormal levels of anxiety and depression symptoms.

Statistical analysis

Descriptive data were presented as mean and standard deviation for continuous variables, and numbers and percentages for nominal variables. Comparisons were made between sex groups using the Chi-square test. A p-value < 0.05 was considered statistically significant. SPSS 25.0 (IBM, SPSS Inc.) was used for all the statistical analyses.

Results

A total of 343 individuals were included in the study. The mean age of the participants (± standard deviation, SD) was 68.29±7.47 years, 77.3% were married, 56.3% were living in a big city, and 49.3% had had at least one COVID-19 test. The characteristics of the participants by sex are shown in Table 1. The women were less educated, less often married and more often living alone compared to men (Table 1). The most commonly reported chronic diseases were hypertension (54.2%), hyperlipidemia (28.3%), and diabetes mellitus (27.7%). Women were more likely to report the presence of hypertension and a mental health condition. Women were also more likely to report fatigue among COVID-19-related symptoms experienced since the start of the pandemic. HADS-A and HADS-D average scores were also significantly higher for women than men. Up to 90 % of the study population complied with social isolation rules. The relationship between sociodemographic characteristics and depression was analyzed. Women, increasing age, and anxiety were related to depression, whereas higher education and being married had a lower risk for depression. The results of the logistic regression were shown as a supplementary file.

Table 1.

Characteristics of the study participants by sex

	Women (n:199)	Men (n:144)	p value
Demographics
Age	68.18±7.78	68.45±7.03	0.07
Ethnicity (Caucasian, %)	90.8	85.6	0.23
Education (≥11 years, %)	36.7	68.2	<0.01
Marital status (married, %)	66.3	92.4	<0.01
Living alone (%)	10.6	2.8	0.03
Residential area (living in large urban area, %)	58.3	53.5	0.95
Housing (living in an apartment building, %)	72.9	76.4	0.46
Survey completion
Respondent by himself/herself	71.9	79.2	0.21
On behalf of the respondent or together with relative	18.6	11.8
Self-reported chronic disorders (%)
Hypertension	61.8	43.8	<0.01
Coronary Artery Disease	18.6	29.2	0.07
COPD	7.5	10.4	0.62
Stroke	1.5	4.9	0.17
Diabetes Mellitus	26.6	29.2	0.84
Hyperlipidemia	30.7	25	0.48
Cancer (other than a minor skin cancer)	4	5.6	0.76
Mental health condition (e.g., depression, anxiety, etc.)	15.6	4.9	<0.01
Cognitive impairment	3	0.7	0.29
COVID-19 related symptoms (%)
Loss of weight	10.6	5.6	0.1
Fatigue	63.3	32.6	<0.01
Falls	5.5	1.4	0.13
Fever	16.1	25	0.11
Cough	24.1	29.2	0.53
Shortness of breath	13.6	12.5	0.39
Nausea/Vomiting	6.5	5.8	0.76
Abdominal pain/diarrhea	10.6	11.8	0.74
Mental status change	4.5	5.6	0.88
Anxiety and Depression
HADS-A	7.49±4.18	5.42±3.25	<0.01
HADS-D	6.18±4.36	4.84±3.87	<0.01
Abnormal scores for depression (%)	43.4	32.9	0.04
Abnormal scores for anxiety (%)	23.1	11.8	<0.01
Distancing Measures (%)
Total or partial social/physical isolation	91	88.2	0.54

Abbreviations COPD Chronic obstructive pulmonary disease. HADS-A: Hospital Anxiety and Depression Scale, Anxiety symptoms sub-score. HADS-D: Hospital Anxiety and Depression Scale, Depression symptoms sub-score. P value refers to t-test for continuous variables and Chi-square test for categorical variables

The effect of the pandemic on the use of healthcare and social services is summarized in Table 2. Regarding different services, only 22.4% of non-acute healthcare appointments for chronic conditions were face-to-face visits. Approximately 95% of the patients stated that they did not need social and home care services. While 4.5% of the women with appointments used mental health services, the rate of the men using them was 1.5% (p = 0.04).

Table 2.

Health care services utilization since the start of the pandemic, by sex

	Women					Men
	Not needed (%)	Patient canceled (%)	Health-care personnel canceled (%)	Normal appointments (%)	Telemedicine (%)	Not needed (%)	Patient canceled (%)	Health-care personnel canceled (%)	Normal appointments (%)	Telemedicine (%)	p
Health care visits related to non-acute chronic conditions	49.7	20.6	5.5	23.6	0.5	55.6	16.7	4.2	20.8	2.8	0.30
Dental care	82.9	5.5	2.0	9.0	0.5	88.2	2.1	2.1	6.3	1.4	0.36
Mental Health services	89.4	4.5	1.5	4.5	0.0	94.4	1.4	0.7	1.4	2.1	0.04
Social worker’s instructions	98.0	1.0	0.5	0.5	0.0	98.6	0.0	0.7	0.0	0.7	0.46
Home care services	93.0	2.0	1.0	4.0	0.0	95.8	1.4	1.4	0.7	0.7	0.26

Worries related to COVID-19 are illustrated in Fig. 1. Women had more concerns about getting coronavirus infection, transmitting the virus to others, and being discriminated against because of the infection (p < 0.05).

Fig. 1.

Worries about COVID-19, by sex

Changes in lifestyle, behavior, self-rated memory, and general health are summarized in Table 3. Reduction in time spent with family, contact with family and friends, physical activity, and hopefulness for the future were reported by both females and males in similar proportions. Experience of loneliness, the number of meals, use of unhealthy snacks, and the use of digital services increased in both groups, with the feeling of loneliness being more frequently reported by women. Additionally, 30.9% of the participants reported that their memory was worse compared to the beginning of the pandemic, and the self-rated general health status worsened in 27.1% of the respondents. Internal disagreements within the family increased in 30% of the participants during the pandemic period, and 3.2% reported increased fear or experience of domestic violence.

Table 3.

Impact of pandemic-related restrictions on social participation, by sex

	Women				Men
	Decreased (%)	No effect (%)	Increased (%)	Does not concern me (%)	Decreased (%)	No effect (%)	Increased (%)	Does not concern me (%)	p
General health status perception	27.7	69.3	3.0	0.0	26.4	72.2	1.4	0.0	0.45
Subjective memory problems	0.0	62.3	35.7	2.0	0.0	70.8	24.3	4.9	0.08
Time spent with family	53.7	18.6	27.2	0.5	42.3	18.1	38.9	0.7	0.13
Contact with friends and relatives	87.4	5.0	7.0	0.6	84.0	6.9	8.4	0.7	0.55
Experience of loneliness	16.0	19.1	64.9	0.0	14.5	34.0	49.3	2.2	< 0.01
Experience of closeness with other people	93.0	4.5	2.5	0.0	79.0	11.1	3.5	1.4	0.07
Internal disagreements and contradictions within the family	8.0	54.3	30.6	7.1	4.2	60.4	29.2	6.2	0.31
Fear or experience of domestic violence or violence by close relative	2.5	75.4	3.5	18.6	3.5	77.1	2.8	16.7	0.52
Hopefulness for the future	77.4	20.6	1.0	1.0	66.0	27.8	5.6	0.6	0.05
Daily physical activity	71.3	21.6	4.5	2.6	66.6	22.2	9.1	2.1	0.40
Smoking	4.0	58.3	6.5	31.2	4.9	64.6	7.6	22.9	0.44
Alcohol use	5.5	61.3	1.5	31.7	7.0	63.9	3.5	25.6	0.18
Sleep problems	8.0	58.3	27.1	6.6	7.0	67.4	19.5	6.1	0.58
Number of meals and snacks per day	9.0	47.7	42.2	1.1	9.1	41.7	47.9	1.3	0.80
Appetite	12.6	47.7	38.2	1.5	8.3	43.8	46.5	1.4	0.67
Vegetable consumption	14.6	57.8	27.1	0.5	11.1	58.3	29.8	0.8	0.80
Fruit or berries consumption	12.6	51.3	35.1	1.0	10.4	47.9	40.9	0.8	0.75
Unhealthy snacking	8.0	55.8	35.2	1.0	5.6	52.8	38.2	3.4	0.43
Remote work	5.5	52.8	12.0	29.7	5.6	54.9	13.2	26.4	0.49
Use of internet	5.5	36.7	39.7	18.1	7.7	31.3	47.9	13.2	0.49
Using digital services for everyday routines	6.0	38.7	32.7	22.6	7.0	36.8	39.6	16.6	0.71
Using digital services in social and health care services	7.0	45.7	29.1	18.2	9.1	41.0	36.1	13.8	0.60
Using digital services to keep contact with family and friends	11.0	20.1	60.8	6.1	11.8	18.8	65.3	4.2	0.77

Discussion

This cross-sectional study on older adults showed that the COVID-19 pandemic in Turkey was associated with changes in lifestyle, behavior, and emotional health. About the latter, women experienced increased loneliness, anxiety and depression more often than men, and the use of digital services to keep contact with family and friends increased in both sexes. The women were also more concerned about getting and transmitting the infection, and the risk of discrimination and stigma due to the infection.

During the pandemic, older adults have been the most affected by the disease in terms of morbidity and mortality [3]. The number of patients with COVID-19 has far exceeded the current capacities of healthcare systems around the world, resulting in harmful discrimination against infected older adults [16]. On the other hand, the measures taken against COVID-19, such as lockdowns, restriction of routine health services, maintenance of only emergency health services, and visit bans due to social isolation, adversely affected elderly individuals [17]. Up to 90% of those who responded to restrictions with high compliance had problems accessing healthcare in the present study. While the restrictions disrupted routine health checks for many individuals, it was shown that a significant part of the participants stayed away from health institutions for fear of being infected. It turned out that in response to the restrictions, face-to-face medical appointments around the world have been drastically reduced. Telemedicine offers the option to access health care for patients under restriction, and studies show promising results for even use in geriatric patients as well [18]. A recent study in Australia indicated that 51.4% of the 2990 respondents received medical attention during the second pandemic-related lockdown, with a lower percentage (39.7%) in Victoria. Telehealth consultation in that study was 29.3%, thus higher than the current sample (2.8%) [19]. This may be due to the high number of less educated women in our study population, the reluctance to seek help due to loneliness and a reduced sense of hopefulness for the future, and the fact that nearly half of the participants were from a small province. Regular health appointments for non-acute chronic conditions were reported to be 27.2% in a Finnish study in older adults at risk of dementia [4]. In parallel with the aforementioned study [19], accessibility to health services can be affected by many social determinants, such as age, poverty, and the infrastructure of health services, and due to social security programs, inequalities in access to health care may be seen even in different regions of the same country. The present study also showed that 22.4% of the participants could get medical help by meeting face to face, and approximately 5–10% of the respondents could use dental care, mental health, or home care services. It is worth noting that dental health care is of great importance for the quality of life. Still, it is one of the most neglected healthcare problems [20, 21], and it is thus crucial to monitor and address the dental care needs of older adults during and after the pandemic.

In such a difficult period for older adults, it was reported that memory problems increased by 35.7%, while it remained unchanged for 62.3% of the participants. The mix of both neutral and negative effects of COVID-19 on memory may be due to varying levels of social involvement, enjoyment of time with relatives, and pre-existing mental well-being. In this context, increasing the use of digital services to keep in touch with family and friends can be an important strategy in coping with social isolation and loneliness [22], and this was reported as increased by 62.7% of the study respondents. In studies assessing the impact of COVID-19 stay-home orders on behavioral and psychosocial changes, decreased physical activity and increased symptoms of depression and anxiety have been frequently reported [23]. Considering physical activity, a study conducted in Japan between the ages of 85 and 89 years reported a decrease in physical activity in 28.1% of participants [24], whereas, in the Longitudinal Aging Study Amsterdam, approximately half of the respondents (48.3 to 54.3%) reported reduced physicality [25]. In our study, 69.4% of participants stated that daily physical activity decreased. Physical activity may be affected adversely by cultural differences, exercise habits, age, comorbidities, fatigue, being unaware of home exercise programs, and emotional state.

Additionally, fears of limited care for coronavirus infection during the pandemic due to shortages of medical equipment and staff, prohibited indoor gatherings, restriction of physical activity, and disruption of regular home health care services pose a significant risk of emotional distress [26]. The women were more susceptible to the experience of loneliness, symptoms of anxiety and depression, and COVID-19-related emotional distress. In women, the rate of high levels of depressive symptoms was 43.4%, while it was 23.1% for anxiety. This could be related to the fact that they were, compared to men, more frequently unmarried, living alone, and vulnerable to loneliness [27]. Consistent with our results, a recent study from Spain involving adults aged 60 and over also showed a higher prevalence of depression in women than in men (28.5% vs. 14.2%) [28]. Being a woman and being retired were found to be related to a pandemic-specific worsening in mental health in the UK population before and during the pandemic-related restriction measures [29]. Living alone or experiencing loneliness may lead to the inability to compensate for the detrimental emotional effects of lockdown measures [30].

In our study, eating habits were also affected during the pandemic. It should be noted that the pandemic-related restrictions have brought difficulties for older adults to meet their basic needs, such as a healthy diet. A Dutch study of older adults reported that 32.4% of patients snacked more during the pandemic, 12% ate less, and 6.6% lost weight [31]. In another study, snacking and appetite were unchanged in about 80% of the participants compared to pre-pandemic. In contrast, a decrease in the appetite of 10.7% and an increase in snacking of 36.4% were reported in the Finnish study [4]. Various predisposing factors can contribute to an increase in the risk of malnutrition, including difficulty in accessing markets, loneliness and reduced social support, increased anxiety and depression, skipping hot meals, and local cultural differences.

The present study has some strengths, including the relatively large sample size and the multicenter approach. Also, we used the WORLD-WIDE-FINGER-SARS-CoV-2 survey, which is harmonized across several countries, and the HADS scale, a validated tool to screen for symptoms of anxiety and depression. To the best of our knowledge, this is one of the first studies to investigate the impact of the pandemic on the social participation and mental and physical health of cognitively intact older adults in Turkey. On the other hand, the study has limitations that should be considered. To begin with, the cross-sectional nature of the study makes it impossible to explore the cause-effect relationship. Due to the methodology of the study, the patients with major cognitive impairment were excluded; therefore, the results cannot be generalized to the population. In addition, the timing of the study may have affected the results as the patients were included in the study during the partial restrictions or when they were removed in the third wave. Furthermore, self-reported information is prone to recall bias, which might affect the results.

Conclusions

The pandemic has had a significant psychosocial effect on Turkish older adults, especially women. As a strategy of the health care policy, easy access and follow-up to the health system should be provided, and the necessary support should be procured to minimize the detrimental effects of the pandemic on older adults. Therefore, strategies should be established to provide social and medical assistance to older adults, and action should be taken for the potential future epidemic periods regarding the different needs and characteristics of women and men.

Author contributions

AB, ATI, DK, and AEA constructed the study concept and design; FSD, AGY, FM, and KAS helped acquisition of data; FM, ASLR, and MK contributed to manuscript revision; EAB made the statistical analysis; EAB, DK drafted the manuscript and ATI established critical revision of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

The study was approved by the Dokuz Eylul University of Non-Interventional Clinical Researches Ethics Board as a multicenter study and conformed to the Declaration of Helsinki. Permission was also obtained from the Turkish Ministry of Health for research on COVID-19. All participants provided written informed consent.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.