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Abstract

Older adults were disproportionately affected by COVID-19. The purpose of this study was to explore experiences of sudden-onset social isolation and factors that influenced it among older adults. A qualitative thematic study with a survey component was conducted comparing 18 older adults in two groups: 12 reporting physical health challenges and 6 reporting no physical health challenges. Three qualitative themes describe experiences of (a) avoiding risk to personal health as the reason to postpone healthcare, (b) grieving church and church friends as a lost social connection, and (c) compound stress due to converging factors related to personal health, public health, racial justice movement and critical national events. Those with physical health challenges were less able to postpone seeking healthcare, suffered from compound stress, and were more likely to feel isolated when unable to participate in church activities. Religious, faith, or spiritual supports may be important buffers against social isolation during public health emergencies, especially for older adults with physical health challenges and when there is concurrent social unrest.

Keywords

pandemic social connection stress postponed or forgone healthcare faith communities

What do we already know about this topic?

Older adults experienced reduction in formal and informal supports during the COVID-19 pandemic, which affected their health and social experiences and outcomes.

How does your research contribute to the field?

Compound stress—the confluence of multiple stressors including public health observance, racial justice movement, and critical national elections—was a finding only in the group of older adults reporting physical health challenges.

What are your research’s implications toward theory, practice, or policy?

Shared value communities such as faith communities (church and church friends) may serve as a robust protective factor, should be available and increased as sites of intervention for health and wellness related activities and to alleviate the social isolation of older adults.

Introduction

An unprecedented public health crisis, COVID-19 resulted in more than 6.5 million hospitalizations and more than 1 million deaths in the United States (US) since the beginning in January 2020 until December 30, 2023.^1,2 Advanced age was a risk factor for higher mortality, especially if coupled with underlying health conditions such as hypertension, chronic kidney disease, lung disease, and frailty.^3,4 Although individuals older than 65 years of age comprise 17% of the total U.S. population, over 80% of COVID-19-related mortality in 2020 and 2021 occurred in this group.³

At the same time that older adults negotiated health-related risks and associated decisions, they faced social isolation due to disrupted formal and informal supports, including reduced help from family caregivers who were themselves experiencing isolation, higher stress, multiple demands, and compromised resources.^5,6 The pandemic compelled older adults to transitions they may not otherwise have considered, such as moving in with adult children for caregiving reasons; or having adult children move in due to new flexibility in remote work arrangements, job loss, financial hardship, or lack of support; or moving out of congregate residential settings because these settings proved underprepared for the pandemic, influencing perceptions of vulnerability.^7,8 These changes affected the extent to which older adults were able to remain connected within their social contexts and obtain needed supports including healthcare.

Studies showed that COVID-19 interfered with health-related decision-making and interrupted or reduced health service use among older adults. For example, 62% of older adults had at least 1 unmet need, with health-related needs (such as medication refills, medical supplies, or food) more prevalent among people with health conditions such as diabetes and chronic obstructive pulmonary disease.⁹ Over 30% of older adults experienced delayed medical care, with 17.6% perceiving a negative impact on their health as a result.¹⁰ Psychological factors and loneliness were found to be predictors of delaying healthcare among older adults. A higher percentage of older adults who sometimes or often felt left out, isolated from others, or lacked a companion reported delaying or avoiding care, especially among those with emotional or psychiatric problems, due to being afraid to go, deciding to wait, or not being able to afford it.¹¹ Depressive symptoms predicted delaying overall medical care aside from being female and having a college degree or higher.¹² Depressive and anxiety symptoms were associated with higher odds of challenges accessing healthcare and not going to a hospital or seeing a doctor when needed.¹³

Social isolation affected approximately 30% of community-dwelling (non-institutionalized) older adults during the pandemic as compared to 24% prior to the pandemic.^14,15 In a comparison of 2 waves of Health and Retirement Study panel data before and during the pandemic, older adults experienced increasing physical and social isolation due to social distancing policies, particularly those who were more concerned (on a scale of 1-10) about the COVID-19 pandemic.¹⁶ A higher level of social isolation was associated with worsening depression and anxiety, and difficulty finding assistance with daily activities.¹⁷ Social isolation and loneliness were associated with depressive symptoms, while anxiety symptoms were associated with pandemic-related worry in a network analysis of interrelationships among social connectedness, loneliness, depressive symptoms, anxiety symptoms, and pandemic-related worry.¹⁸ Another similar study showed greater coupling of social isolation with affective symptoms.¹⁹

In the lifecourse perspective that accounts for the impact of the pandemic, worry about the risk of infection and death, and fear of spending time with others are concomitant with experiencing loss.⁷ Human agency and historical context, component concepts of the lifecourse perspective^7,20
-22 are well suited to examining individual lives in relation to broad and multifaceted global public health and other historic events.

Human agency refers to conscious decisions to exert control over circumstances, engage with life goals, and exercise planfulness.^7,20 Elder²¹ described losing and regaining control as the “control cycle” (p. 50). Health, wealth, and social relationships enable individuals to exert control as circumstances and contexts present new challenges and opportunities.⁷ Social inequality and health inequities undercut the ability to exercise human agency.^7,22

A combination of socio-demographic, economic and health factors such as gender, education, and functional limitations were found to be significantly associated with healthcare use among older adults during the pandemic. Persons of color (categories included Hispanic, Asian, Black/African American, and Pacific Islander) experienced a higher risk of infection, hospitalization and need for intensive care.²³ Approximately one-third of older adults in the Health and Retirement Study 2020 COVID-19 subsample delayed seeking healthcare, with female older adults or older adults with a bachelor’s degree, poor self-rated health and activity of daily living limitations more likely to delay medical care.²⁴ Unmet health-related needs were more prevalent among older people living in high-poverty areas and among the Asian population.⁹ The intersection of gender and racial identity adversely affected outcomes among Black, Indigenous, and other people of color in a study of inpatient hospitalizations for COVID-19.²⁵ Underlying adverse outcomes across communities of color are structurally rooted social determinants of health including low income, disparities in access to healthcare and housing, and policing and carceral system effects.²⁶

Settersten Jr et al⁷ underscored the importance of examining short- and long-term consequences of reduced or no sharing in key social and cultural lifecourse transitions such as birthdays, graduations, engagements, deaths, new jobs, retirements, etc., due to reduced ability or inability to participate in these transitions disrupted by the timing of historical events. The convergence of multiple changes, many beyond individual control, can change life trajectories, interfere with attachment to communities, shift interdependence with others, affect relationships and outlook on life, and older people’s experience of purpose, belonging, and worth.^7,22 Given these intertwined changes, Settersten Jr et al⁷ recommended that the pandemic-associated short- and long-term physical health and social experiences “should be tracked” to reflect their consequences in various groups or subgroups (p. 3).

The present study’s comparison of those with and without physical health challenges, and in a time of sudden-onset isolation, aims to do so. To our knowledge, this comparative focus has not been part of qualitative studies on this topic to date. The following two research questions were explored: (1) If physical health challenges are present, what is the experience of social isolation among older adults in comparison to those without physical health challenges during the pandemic? (2) What factors influence this type of social isolation?

Methods

This study converged qualitative interviews about health and social connections with quantitative data from two survey questions related to physical health. Both qualitative (semi-structured in-depth interviews) and quantitative (survey) data were collected concurrently, with qualitative questions preceding the survey responses.²⁷ Whereas qualitative interviews garnered subjective perspectives, survey questions elicited descriptive information.

Sample

A purposive study sample was recruited from September 2020 through July 2021, during which time there were active public health guidance and home-sheltering mandates across many states in the US.

Recruitment

The study was advertised by distributing study flyers to social service providers, in the national family caregiver alliance research registry targeting stakeholders and service providers, and 2 congregate housing and care communities, 1 in the US Midwest, and 1 on the West Coast. In addition, a public health diversity expert assisted to increase participation by older adults in racial/ethnic minority groups. All participants underwent telephone screening for eligibility prior to enrollment in the study. Inclusion criteria were as follows: 65 years of age or older, ability to speak over the phone or Zoom Video Communications, and ability to understand and speak English.

Per IRB approval, participants gave verbal informed consent to the first author, voice-recorded at the beginning of interviewing. The consent form was electronically emailed to the participants prior to the interview date, and reviewed before the interview began, with an opportunity for participants to ask the researcher any questions. Participants received $25 gift cards for participation. University of California Davis Health Institutional Review Board approved the study prior to initiation (approval number 1646206-1). Table 1 provides a description of the study sample.

Table 1.

Description of the Study Sample.

Physical Health Challenge(s) Yes/No	Age	Gender Male/Female	Race/ethnicity	Marital status	Education	Annual Income (in thousands)	Living arrangement
Yes	94	F	White	Widowed	College graduate	$25 to $49	Congregate housing
Yes	75	F	White	Divorced	College graduate, Some graduate school	Less than $25, Savings	Congregate housing
Yes	83	M	White	Married	College graduate	$25 to $49	Congregate housing
Yes	93	M	White, Other	Widowed	College graduate	$25 to $49	Community-dwelling
Yes	84	M	White	Married	Some college	$50 to $99	With caregiver’s family
Yes	83	F	White	Divorced	Graduate degree	$50 to $99	Congregate housing
Yes	85	F	Black or African American	Divorced	College graduate	Less than $25	Community-dwelling
Yes	72	F	Black or African American	Married	College graduate	$25 to $49	Community-dwelling
Yes	78	F	White	Married	Graduate degree	$25 to $49	Community-dwelling
Yes	75	F	Black or African American	Married	High school diploma/GED	$50 to $99	Congregate housing
Yes	78	M	Black or African American	Married	Some college	$25 to $49	Congregate housing
Yes	76	F	White	Married	High school diploma/GED, professional certificates	$50 to $99, Savings	Community-dwelling
No	76	F	White	Widowed	Graduate degree	$25 to $49	Congregate housing
No	71	F	Black or African American	Divorced	Graduate degree	$50 to $99	Community-dwelling
No	83	F	White	Divorced	Graduate degree	$25 to $49	Community-dwelling
No	74	M	White	Married	Graduate degree	$50 to $99	Community-dwelling
No	78	F	White	Married	Graduate degree	$100 or more	Community-dwelling
No	69	M	White	Married	Some college	$50 to $99	Community-dwelling

F = female; M = male.

The sample consisted of 18 older adults. Mean age was 79 years old with 39% aged 80 and older. Sixty-seven percent were White, and as many reported being female. Forty-four percent lived either in a congregate housing and care setting or with family, with the rest being community-dwelling. All older adults considered themselves retired except two, who were employed part-time and not working outside the home for pay, respectively.

Data Collection

The first author collected both qualitative and survey data over Zoom Video Communications and telephone. First, qualitative questions elicited health-related information about getting health care in and outside the home, and social connection-related information about being able to maintain connections with family, friends, and within the community. Qualitative interviews lasting 42 min on average (range 21-74 min) were transcribed by a professional transcriptionist and de-identified.

Subsequently, 2 survey questions elicited health-related information. The first question asked whether participants faced physical health challenges during the pandemic (yes/no), with examples including “arthritis, diabetes, heart conditions.” Thus, our question pertained to the health of the body. The second survey question elicited information on participants’ overall perceived health status, with 5 answer options ranging from poor to excellent.

Data Analysis

Qualitative data analysis proceeded in phases.²⁸ In phase 1, all authors familiarized themselves with the data by reading transcripts. In phase 2, data were coded inductively by all 4 authors developing initial codes. In phase 3, codes were refined in 8 iterations of coding over a period of 5 months, keeping a record of memos in addition by 3 authors (T.K., Y.H., and J.B.), with potential themes discussed. In discussions, phase 4 codes were differentiated by typology, for example, those pertaining to isolation from family as one type of isolation; isolation from community as another type of isolation.

Given the analytic interest in comparing those with and without physical health challenges, older adults were split into 2 groups: those reporting physical health challenges (N = 12) and those reporting no physical health challenges (N = 6) on the yes/no survey question. The coded qualitative dataset was split accordingly, to examine experiences within and between the 2 groups of older adults in terms of health and healthcare seeking, loss of social connections, and stressors. The final themes in phase 5 are a result of this coding process, derived from the data.²⁸ This final phase accounts for the overall analysis and the entire analytic dataset, equivalent to saturation in Braun and Clarke’s²⁸ systematic steps of the analysis. All co-authors were trained as academic faculty representing disciplines of social work, gerontology, nursing, public health, and medicine. For quotes presented below, Krippendorff’s alpha²⁹ was computed for inter-coder reliability based on the independent rating of 3 authors (T.K., E.R., and J.B.).

NVivo Pro³⁰ was used to manage and code qualitative data whereas survey data were entered in Excel and summarized with descriptive statistics, including calculating Krippendorff’s alpha using STATA.³¹

Reflexivity

Prior to undertaking the study, the primary researcher had a prolonged experience of observing older adults’ social relationships and social isolation in a congregate setting.^32,33 The primary researcher undertook this present study to explore sudden-onset social isolation specifically during COVID-19 including among community-dwelling older persons, in addition to those living in congregate housing.

Results

Twelve (67%) older adults reporting physical health challenges described arthritis, mobility issues (using a walker), use of prosthetics, frailty, asthma, hypertension, and chronic obstructive pulmonary disease. Comparing physical health challenges with perceptions of overall health status shows that the two may not correlate directly, and can be similar among those with and without physical health challenges, as follows: of the 12 with physical health challenges, 1 described overall perceived health as excellent, 6 (50%) as very good, and 5 (42%) as good. Of the 6 without physical health challenges, 1 described overall perceived health as excellent, 2 as very good, 2 as good, and 1 as fair. Based on prevalence in the qualitative data, postponing healthcare was common, with 50% of those with physical health challenges having postponed care in comparison to two-thirds of those with no physical challenges.

Three qualitative themes were derived from qualitative responses, with Krippendorff’s alpha (kalpha) equaling .89 for inter-coder reliability among 3 coders. The themes of avoiding risk to personal health, grieving church as a lost social connection, and compound stress, are elaborated below with illustrative quotes.

Theme 1. Avoiding Risk to Personal Health

The theme of avoiding risk to personal health contextualizes reasons older adults postponed care. Seventy-eight percent of all older adults and 50% of those reporting physical health challenges postponed care to avoid being infected or dying as a result of infection. Older adults worried about mingling in shared public spaces: “It’s such a virulent disease. I was concerned about catching it, you know, just every time we go somewhere” (P1). Others spoke of being careful: “It’s not overpowering but there is a cautionary approach to things” (P2). One older adult with pre-existing health conditions described the risk getting the virus would pose to her health, resulting in a dire outcome she wanted to avoid:

It’s time for me to schedule cataract surgery, I think, and I’m putting it off because of the pandemic [. . .] I have some pre-existing conditions that I think if I had tested positive, and if I had COVID, I suspect that it would be the end of me. I think I would die alone in a hospital—so I’m certainly not looking forward to that. [. . .] I know that the death process would be very different. I would be alone, or I would be with nurses, but basically, I would die without my family. (P3)

Theme 2. Grieving Church as a Lost Social Connection: “I Mostly Miss the Camaraderie”

This theme illustrates the importance of church activities and faith community to older adults and the impact of its loss on them. Among types of isolation, isolation from church and church friends was most prevalent in both groups, with 7 (58%) of those with physical health challenges reporting this type of isolation in comparison to 2 (33%) of those without physical health challenges. Losing family as a social connection was second in terms of prevalence with 5 (42%) reporting isolation from family in the group with physical health conditions and 1 (17%) in the group with no physical health conditions.

Older adults reported the loss of connection to church in terms of magnitude (largest) and impact (acutely felt): “my biggest thing—I wasn’t able to go to church” (P4). To older adults noting this type of a loss, church was more than a ritualized practice of faith—it meant fellowship and community with others: “that’s definitely gone by the wayside. Because there’s church, and then you have your coffee hour” (P5).

Notably, those living in congregate housing or with family (7 (58%) in the group with physical health challenges and one (17%) in the group without physical health challenges) grieved church as a lost social connection despite higher likelihood of environmental or social supports in comparison to community-dwelling older adults:

I never appreciated church as much as I do now. [. . .] I do miss the people, you know, being at the services. And of course afterwards, the coffee and donuts was after each mass. But I mostly miss the camaraderie, the socializing. That, of course, had to be cut totally and completely out. (P6)

Although 5 (42%) participants with physical health challenges and 2 (33%) with no physical health challenges reported attending church virtually, participants described this as an experience to reconcile, and not the same as attending in person:

On Sunday mornings [. . .] I listen, or watch, the service [virtually] at my granddaughter’s church. After I have watched that service and listened to it, I will zip over to [a church] where I have a grandniece and her family active. And so that’s kind of fun. And then, last Sunday, I even listened to the service at [yet another church]. [. . .] I can sing with them [virtually]! And when we have communion, they warn you before, and you can have your own and do it as they have the service part. [. . .] So, yes, I get plenty of church. But I’m alone, except that I have the computer. And that’s okay. (P7)

Church is a little difficult. The church that I go to does have an outreach where they contact by phone on a weekly basis. They do provide pastoral care in-person for those who are really needing it or wanting it. [. . .] There is a chaplain here also [in congregate housing] that provides care for those. She does broadcast on a—what is it called, CCTV?—for those who want to see the service. (P8)

Theme 3. Compound Stress

Compound stress refers to the additive effect of socio-political events occurring in tandem with the pandemic while at the same time coping with the more direct experiences of the lack of healthcare utilization and social isolation. We refer to this finding as “compound stress” because it was described in terms of exacerbating suffering as older adults described worrying about, witnessing, and being afraid due to reasons that did not affect them personally but reflected the present and perceived future of the nation (US). One older adult referred to the loss of life from the virus on a large scale, and the pandemic’s impact on the economy:

I worry more about the big picture [. . .] how the pandemic, as well as other big issues, are being handled or not being handled. [. . .] I think we had a terrible government that allowed this to happen. And they should be held accountable for the people who have died, for the people—massive numbers of people who have gotten this virus and changed their lives completely; have gone out of business, it’s negatively affected the economy. (P9)

Another older adult referred to the racial justice movement across the nation due to the murder of George Floyd and the ensuing protests not far from their home:

And at the same time, seeing – being of society. Seeing how things are. Being able to witness the George Floyd thing, and as the country – being awoken by this incident. [. . .] And at the beginning, you know, of the pandemic [. . .] we had car jackings. People drive up and look at people’s purses. [. . .] they [neighborhood watch program] were going, “Oh, they’re breaking into homes, coming in the basement. Get your car keys, they’re stealing your cars.” Which did happen. [. . .] I’m super more cautious, but not paranoid, or scared. You know, some people are like, “Oh, get a gun. People are buying these guns.” I’m like, “No, you don’t.” I just feel that invites trouble. So I just stay in a place of peace, not wanting to be frightened by this stuff. And pray. (P10)

Witnessing these social changes had compelled older adults to want to help and contribute, either by volunteering or donating money but both were constrained by the pandemic. In one instance, “we couldn’t do our food shelf” (P1). In another instance:

Physically I couldn’t do what I used to do in the past, was be there. And then I would always give money. [. . .] I wish I had more disposable income, so I could’ve helped out my church more. We have a food ministry, and what happened with the pandemic and need and our community—we went from emergency food shelter to having to open up a pick-up three days a week, because people were looking for food early on at the beginning of the pandemic. (P11)

Discussion

This qualitative thematic study with a survey component examined sudden-onset social isolation among older adults during COVID-19. This study’s comparison of older adults with and without physical health challenges responds to the call to reflect pandemic-associated physical health and social experiences in different groups.⁷ The study contributes findings such as the importance of church and church friends as a shared community, the exercise of decision-making regarding healthcare, and the role of converging historic events in the lives of older adults.

The Importance of Church and Church Friends

Across the groups with and without physical health challenges, the largest loss of social connection in this study was a non-family connection, and referred to church and church friends. Although many studies reported increased social isolation,^14,15,17 to the best of our knowledge, pandemic-related isolation specifically from church and church friends among older adults has not been reported. Similarly, although studies reported worsened mental health in terms of depression and anxiety,^17
-19 to the best of our knowledge, reduction in or absence of church connections has not been part of the examination of deteriorated mental health or social isolation specifically among older people. Notably, the study sample may overrepresent those actively participating in faith communities because it included older adults living in non-profit, mission-driven congregate housing (39%) and African Americans (28%) who have historically valued church as a source of empowerment and mutual help.^34,35

Although the desire for connection with church and church friends suggests loneliness, it also suggests the importance of common values, lending support to longstanding knowledge that for many older persons, church is their primary social circle and offers social capital that can serve as a buffer for health and well-being.^36
-39 Many older adults engage in church activities routinely and exchange information about their health and well-being with church friends, which may in turn incentivize either seeking healthcare or asking for help (eg, a ride to a medical appointment or support) to seek healthcare. This type of help-seeking was reduced substantially during COVID-19 even if participants were able to participate in their faith communities virtually: technology may have helped with social isolation to an extent (involved as a spectator through the computer screen on Zoom), but older adults were still left without the helping circle of their church friends being available to help with tasks such as transportation or companionship, for example. As Li et al¹¹ reported, those who were lonely delayed or avoided care to a higher extent. Possibly, those with physical health challenges in this study relied on sharing and supportive decision-making regarding their well-being with church fellows, and in part delayed seeking healthcare because such support was not readily available due to home-sheltering mandates and inability to participate in face-to-face church activities with church friends. Given the importance of the role of church community, and the value attached to church and church friends as a social connection in this study, future studies may investigate religious and faith communities as sites of intervention for health and wellness related activities and to alleviate the social isolation of older adults.

The Constraining Impact of Health-Related Risk-Benefit Evaluation

Older adults in this study prioritized certain behaviors over others. Whereas prior work showed that one-third of older adults delayed care,²⁴ this study found that more than half of older adults reported delaying care across both groups. The finding of avoiding risk to personal health may reflect taking control by older adults as a choice rather than a necessity among those without physical health challenges who could afford to postpone care. Older adults with physical health challenges were less likely to delay seeking healthcare, suggesting risk-benefit evaluation concomitant with compulsion to seek healthcare due to need. Although studies reported concern about the pandemic^16,18 as a reason not to seek healthcare (ie, due to higher infection risk and mortality), other studies found anxiety and depressive symptoms to be associated with not seeking healthcare.¹³ This suggests varied decision-making as delays due to worry and concern about infection while receiving health services may elicit delay-related additional feelings of anxiety and depression.

More than half of older adults described their perceived overall health as excellent or very good, comparing to a survey study in which also more than half of older adults reported excellent or very good physical health.⁴⁰ This shows similarities in the perception of overall health among those with and without physical health challenges, and, more importantly, shows that other types of challenges (ie, mental health) may reflect on the perceived health status. We note that during data collection, the qualitative portion (administered first) was not intended to inform the survey questions (administered second) yet its preceding the latter may have influenced responses to the survey questions. Possibly, this accounts for similarities in evaluating the perceived health status across the two groups with and without physical health challenges. Additionally, the decision to postpone or forego care may have been independent of perceived health status. Overall, knowledge about push-pull factors in seeking healthcare, especially in times of sudden-onset and shape-shifting public health, personal, social, and historic changes could illuminate health-related decision-making supports needed by older people.

The Compounding Impact of Converging Historic Events

The widely publicized George Floyd murder,⁴¹ its emotional and mental health impact on the US population,⁴² the interplay of the COVID-19 pandemic and the 2020 US presidential elections⁴³ represent shared external threats that cumulatively compelled older persons in our study to experience compound stress. Settersten et al⁷ posited that a shared external threat bolsters collective agency. Possibly, this may have underwritten the shared urgency to participate in church activities with church fellows as an expression of solidarity and prosocial motivation across both groups, older adults who reported physical health challenges and those who did not.

Compound stress due to a confluence of historic events is noteworthy because it was noted only among those with physical health challenges in this study, and has received modest attention in other studies. For example, Prusaczyk et al⁴⁰ found that some older adults were able to exercise resilience even in the face of vulnerabilities during the pandemic. Referring to “chronic stress,” Fields et al⁴⁴ demarcated time, including the George Floyd murder and the U.S. national elections, in their analysis of coping and resilience, showing a greater impact of the elections on negative affect, depression and health worry, but less for older adults than younger adults with regard to negative affect and depression; social isolation remained about the same with respect to the two events. Stanley et al⁴⁵ examined the pandemic as a collective trauma among adults, including older adults, with responses such as grief, disgust, anger, and fear. In all these studies, participants were community-living older adults.^40,44,45 By contrast, the present study found compound stress stemming from a combination of both societal (historic) and personal (physical health challenges) threats among older adults with varied living arrangements including congregate settings in addition to the community setting. Of note is the composition of the sample in the group with physical health challenges (Table 1) in which compound stress was a finding, with a greater prevalence of Black or African American participants (4 vs 1 in the group with no physical health challenges), suggesting trauma associated with long-standing disparities and mistreatment, including poor access to healthcare and abusive policing.²⁶ Due to reduced likelihood in delaying seeking healthcare, older adults with physical health challenges may have been unintentional albeit empathetic witnesses to the ongoing racial justice movement and economic downturns as a result of navigating their communities, in turn experiencing compound stress, not found among those reporting no physical health challenges in this study. In other words, amplified worry and concern about infection and mortality if exposed to the risk while seeking health services was exacerbated by encountering historic events as a conduit of navigating city and town locations. For groups with a history of oppression, this was likely (re)traumatizing. A combination of personal health and broader societal factors may have increased stress and suffering as well as the perceived need for support in terms of church and church participation among older adults with physical health challenges. Although older adults reporting no physical health challenges also reported isolation from church and church friends, their more limited need to navigate healthcare and community settings for health-related reasons may have influenced lesser exposure to social unrest and lesser need to rely on church and church friends as supports.

The lifecourse perspective holds that despite obvious health risks and associated vulnerabilities, older adults have cumulative strengths such as “better emotion regulation, more advanced coping strategies, and a broader range of experiences within which to place the pandemic experience” (p. 4),⁷ suggesting robust agency. While this appears to be reflected in prior studies to an extent,^40,44,45 interrogating multiple external stressors beyond individual control and their interlocking impact with individual physical health factors is worthy of further attention. While social characteristics such as poverty and marital status are widely recognized to affect health and well-being, compound stress experienced as a result of the convergence of the pandemic with the racial justice protests and national elections underscores the importance of detangling cumulative effects of multifaceted events on seeking healthcare and/or experiencing social isolation among older persons.

The study findings are noteworthy given that almost half the older adults lived in either congregate housing or with family, suggesting greater environmental and coping supports yet older adults still noted the missed church connection. The confluence of the pandemic-related delay in seeking healthcare, compound stress due to social factors, and yearning for church and church friends suggests that in times of sudden-onset, varied and complex circumstances such as public health threat, racial unrest, and personal health, older adults may find spiritual supports aside from literal supports helpful, even crucial. Faith may be a robust protective factor, and faith-related supports should be available and increased for older adults across community and residential settings to alleviate suffering.

Limitations

Strengths of this study include intentional sampling of a diverse population, with 28% of the sample representing racial/ethnic minorities, with 1 identifying as Other aside from White in addition, and inclusion of participants from more than one part of the country in the US. Limitations include that this study was a pilot and the sample size is small, representing 18 older adults who were disproportionately well educated (with 72% being either a college graduate or having graduate education); and not poor (with 83% reporting income between $25 000 and $99 999). Co-authors trained as academic faculty developed questions posed to study participants. Perceived health status and physical health challenges were by self-report only, and information about sensory impairments that may affect social isolation, such as hearing and vision loss, were not collected in a targeted manner although older adults were not prevented from identifying these as physical health challenges.

Conclusion

This qualitative study with a survey component showed that sudden-onset isolation, associated with involuntary home-sheltering and altered decision-making about seeking healthcare can exacerbate isolation, especially among those with physical health challenges, and especially in times of converging public health changes, historic racial justice movement and national elections.

The finding on the role of the church—and faith communities by extension—speaks to the importance of social connection in the context of shared values to older people. It suggests that faith, and participation in church activities specifically, may offer unique buffers to older adults in times of unprecedented and overwhelming circumstances. The U.S. Surgeon General’s advisory⁴⁶ notes the restorative influence of religious or faith-based communities with benefits relating to purpose, a sense of belonging, and reduced risk-taking behaviors with adverse health effects as a result of decline in participation. Given the benefits of the role played by the church community, exploring churches and faith communities as sites of intervention for social isolation and health mitigation may prove fruitful.

Supplemental Material

sj-docx-1-inq-10.1177_00469580241273277 – Supplemental material for Comparing Social Isolation in Older Adults With and Without Physical Health Challenges During COVID-19: Church and Church Friends Matter

Supplemental material, sj-docx-1-inq-10.1177_00469580241273277 for Comparing Social Isolation in Older Adults With and Without Physical Health Challenges During COVID-19: Church and Church Friends Matter by Tina R. Kilaberia, Yuanyuan Hu, Edward R. Ratner and Janice F. Bell in INQUIRY: The Journal of Health Care Organization, Provision, and Financing

Supplemental Material

sj-docx-2-inq-10.1177_00469580241273277 – Supplemental material for Comparing Social Isolation in Older Adults With and Without Physical Health Challenges During COVID-19: Church and Church Friends Matter

Supplemental material, sj-docx-2-inq-10.1177_00469580241273277 for Comparing Social Isolation in Older Adults With and Without Physical Health Challenges During COVID-19: Church and Church Friends Matter by Tina R. Kilaberia, Yuanyuan Hu, Edward R. Ratner and Janice F. Bell in INQUIRY: The Journal of Health Care Organization, Provision, and Financing

Footnotes

Acknowledgements

The authors gratefully acknowledge comments on an earlier draft by faculty at New York University Silver School of Social Work: Victoria Stanhope, Susan Gerbino, and Peggy Morton.

Author’s Note

Yuanyuan Hu is also affiliated to University of Minnesota – Twin Cities School of Social Work, St. Paul, MN, USA.

Author Contributions

Study conception and design: Tina Kilaberia, Edward Ratner, Janice Bell. Data collection: Tina Kilaberia. Data analysis: Tina Kilaberia, Yuanyuan Hu, Edward Ratner, Janice Bell. Writing: Tina Kilaberia, Yuanyuan Hu. Critical revisions; Tina Kilaberia, Yuanyuan Hu, Edward Ratner, Janice Bell. Oversight: Janice Bell. Advising: Edward Ratner.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Addressing Challenges of Family Caregiving During the COVID-19 Pandemic Pilot Grant Program funded by the Family Caregiving Institute, University of California Davis Health.

Data Availability

Data availability is limited due to the qualitative nature of the study and associated ethical restrictions.

Ethics Committee

University of California – Davis IRB protocol/human subjects approval number: 1646206-1.

Consent

ORCID iD

Tina R. Kilaberia

Supplemental Material

Supplemental material for this article is available online.

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Supplementary Material

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