Sage Journals: Discover world-class research

Abstract

Purposes: We explored the experience of older adults living with multimorbidity during the COVID-19 pandemic. Methods: Using a phenomenological approach, we conducted semi-structured interviews with 17 participants aged 50 years and older living with multimorbidity. Data collection and analysis were iterative using a thematic approach. We explored participants’ overall pandemic experience as well as querying specifically about pandemic experiences of social isolation, coping and resilience. Results: We describe our findings according to four main themes: (1) Lives disrupted; (2) Diverse social isolation experiences; (3) Coping through seeking solitary and group activities; and (4) Individual ways of enacting resilience and the role of health care to build resilience. Conclusion: We found the experiences of older adults living with multimorbidity during the COVID-19 pandemic were characterized by disruption. When queried social isolation was shared as a prominent concern. We identified the creativity with which participants coped with social isolation and the resilience they marshaled. This study will be used to inform interventions to mitigate social isolation and its effects in a post-pandemic world.

Keywords

multimorbidity social isolation resilience older adults phenomenology

Introduction

Older adults (aged 50 years and older) living with multimorbidity are estimated to be 20% of the Canadian population¹; by 70 years of age half of Ontario, Canada residents are living with multimorbidity.² Multimorbidity has deleterious effects on people’s health^3,4 and quality of life,^4–6 and health system utilization and costs.^7,8 Living with multimorbidity is associated with higher mortality rates.^4,9

While the COVID-19 pandemic affected everyone worldwide, the effects were more pronounced for those living with multimorbidity.^10–13 One of these effects was increased rates of social isolation during the pandemic that have persisted post-pandemic.^14,15 Recent Canadian estimates suggest 19% of Canadians aged 65 years or older feel isolated from others.¹⁶ Those living with multimorbidity may be especially vulnerable to social isolation and loneliness¹⁷ with one study finding this vulnerability appears to remain elevated post-pandemic compared to pre-pandemic levels.¹⁸ Social isolation and loneliness negatively impact peoples’ mental health,¹⁹ risk of mortality,²⁰ cognition,²¹ and can contribute to fatal cardiovascular disease.²² Living alone,²⁰ being female,²³ and lack of community involvement are contributing factors to loneliness and social isolation.^24,25 Given our increasing understanding of social isolation’s “profound threats to health and well-being”,^{26
^,}^p.5, social isolation is a risk that requires attention from health care providers.²⁷

While there are statistics concerning the effects of the pandemic on older adults living with multimorbidity,^10–13 including social isolation,¹⁴ the stories of their experiences during the pandemic are lesser known. Therefore, the primary objective of this qualitative study was to explore the experiences of older adults living with multimorbidity during the COVID-19 pandemic. Here, we did not restrict our participants’ stories, rather we encouraged them to share the entirety of their experiences to ensure we understood the essence of those experiences.²⁸ Our secondary objective, for which we queried specifically, was to explore experiences of social isolation, coping and resilience.

Methods

Design

In this qualitative study, we employed a phenomenological approach to explore the overall experiences of older adults living with multimorbidity during the COVID-19 pandemic as well as querying specifically about social isolation, coping and resilience.

Recruitment and sampling

We recruited potential participants by reaching out to libraries, community organizations, and retirement homes via email, asking them to display a recruitment poster. We also advertised through a regional newsletter in various cities across Ontario. We had no established relationship with potential participants prior to study commencement. Potential participants were given a letter of information explaining the purpose of the study and asked to sign a consent form. Participants had to be aged 50 years or older and living with multimorbidity, defined as having two or more chronic conditions. There were no other inclusion criteria; potential participants did not need to have experienced social isolation during the pandemic to be included. We also used maximum variation sampling to recruit participants who reflected diversity regarding social vulnerability, sex, location (urban/rural) and age.

Data collection

The Principal Investigator (BLR) and Research Coordinator (SIP) conducted the one-on-one interviews, using either a secure Western University Zoom platform or telephone. Interviews, lasting 45–60 minutes, were audio-recorded and transcribed fully verbatim by Transcript Heroes. Transcript Heroes Transcription Services Inc. is a Canadian registered business, founded in 2015 to provide reliable and accurate transcription services through human transcribers [https://transcriptheroes.ca]. Interviews were conducted from June to October 2023. Questions were open-ended and prompts were used as required to facilitate the conversation. The interview began with demographic questions after which we asked participants to think about the pandemic overall and share their experiences during that time. Consistent with our primary objective, we allowed participants to talk about any and all experiences and how these experiences might have changed over the course of the pandemic. We prompted, as needed, that these experiences could include work, personal, health, family, and social experiences. Consistent with our secondary objective, we asked if participants experienced social isolation at any point during the pandemic, and queried specifically how they coped. In a future-facing question, we asked how participants thought we might support people post-pandemic to be resilient. We further asked participants how health care providers could support them in the future. The supplemental file provides the interview guide. No repeat interviews were conducted, and interview transcripts were not returned to participants for comment or correction.

Data analysis

Data collection and analysis were iterative using a thematic approach. Analysis was concurrent with the data collection. Four members of the research team, all female, (BLR, JBB, ALT, SIP) conducted the analysis. They coded each transcript independently line by line. The team met regularly to conduct a group analysis where members reflected on and discussed the essence of the experiences of the participants.²⁸ We made memos of possible intersections among codes and captured our reflections and discussions through iterative consolidating of codes until we arrived at our final interpretation as illustrated by our themes. Data collection ended upon reaching data saturation wherein the themes permitted a thoughtful interpretation of the phenomena under study. The conceptual depth of the data illustrated the central themes with confidence in the researchers’ interpretation.^29,30 NVivo software was used to organize the data.

Trustworthiness and credibility

Trustworthiness was enhanced through audio-recording and transcribing the interviews verbatim and writing field notes after each interview. We conducted individual and team analysis and created memos during the analysis.

Throughout the study, from the initial conception of the study to the preparation of the final manuscript, the research team actively engaged in a reflexive process to mitigate their personal and professional biases.³¹ We were all impacted by the COVID-19 pandemic, which required careful attention to our own unique experiences. BLR is a PhD epidemiologist and had a family member in long-term care during the pandemic. JBB is a PhD in Social Work with expertise in qualitative research. SIP holds Masters Degrees in International Relations and Education and has worked with vulnerable populations. ALT is a PhD epidemiologist and teaches qualitative methods.

Results

Participant context and circumstances

We interviewed 17 participants. Table 1 describes the participants’ socio-demographics. The mean age was 68 years (SD 7 years) and the majority were female (82.3%). Participants were from the province of Ontario, Canada with the majority (64.7%) living in an urban area in Southwestern Ontario. The majority of participants described their self-rated health as Good (58.8%). The remaining described their health as Very good (11.8%), between Fair and Good (5.9%), and Fair (23.5%). No participants rated their health as Poor. The majority lived with at least one other person (52.9%) and had a family physician (94%). There were no participants who refused to participate and none that dropped out of the study.

Table 1.

Participant characteristics.

Characteristics	Responses	n	%
Gender	Female	14	82.4
Gender	Male	3	17.6
Race	White/European descent	9	52.9
Race	Other	8	47.1
Self-reported chronic conditions	Arthritis*	10
	Diabetes*	6
	Hypertension	6	35.3
	Mental health conditions*	7
	Musculoskeletal conditions*	11
	Others*	27
	TOTAL	67
COVID-19 status	Yes	8	47.1
	No	8	47.1
	Missing	1	5.9

Received 1+ COVID-19 vaccines	Yes	14	82.4
Received 1+ COVID-19 vaccines	No	3	17.6

*Percentages not provided as a single participant could identify as having more than one condition within the category.

Overview of themes

We describe the findings from the analysis of the interviews according to four themes. The first theme addresses the primary objective of the study, exploring pandemic experiences which we call Lives disrupted. The remaining three themes arose from our secondary objective to explore social isolation, coping and resilience. The second theme is Diverse social isolation experiences. The third theme is Coping through seeking solitary and group activities. The fourth theme is Individual ways of enacting resilience and the role of health care to build resilience.

We define social isolation as the voluntary or involuntary absence of contact with others.³² We define coping as “an action, a series of actions, or a thought process used in meeting a stressful or unpleasant situation or in modifying one’s reaction to such a situation.”³³ We define resilience as “the process and outcome of successfully adapting to difficult or challenging life experiences, especially through mental, emotional, and behavioral flexibility and adjustment to external and internal demands.”³⁴

Theme 1: Lives disrupted

Participants had different overall experiences of living through the pandemic – ranging from “not a nice way to live” (P1) to “awful” (P10). These experiences were the essence of having lived through the pandemic and varied according to participants’ unique context and circumstances as detailed above.

Participants described a wide range of disruptions and significant alterations in their activities that occurred because of the pandemic; the degree ranged from inconvenient to the dire. Reflecting on those tumultuous times, an individual remarked, “...it was a very trying time; the whole world was put to a stop.” (P3).

Recalling public health measures, some participants shared the disruption in activities such as sports and hobbies. As a participant explained, “Myself, I wasn’t able to go swimming no more. So, I lost the right to be in the water – anywhere basically.” (P5). Another participant stated that, “The unfortunate part was everything that we do – we curl – three times a week I curl. I golf twice a week in the summer – that was canceled.” (P8).

Some activities persisted during the pandemic, but participants indicated they had to conduct these in different ways with a participant stating, “I just had to pick up [the groceries] at the pickup; order them online and pick them up.” (P2). A participant took on a task normally reserved for an expert, “Also haircuts, it was a big thing. I think I cut my own hair four times. You learn to do things that you don’t normally do, right?” (P6). Another participant became vigilant in her cleaning routine because of worrying about contracting COVID-19, stating, “…I clean my home every day, I clean everything, the doors, the vegetables, when children bought for me the groceries, I clean each one, one by one. It was a nightmare for me.” (P14).

For some participants, disruption of meaningful social activities emerged as the foremost struggle. A participant shared, “I couldn’t go to church. I like people…I like to do stuff with people. So, when we couldn’t, I missed that.” (P15). Another participant was the caregiver to her husband and missed the social outings that she had been able to share with him:

“[Before the pandemic] when I was looking after my husband we would go out to meetings and different social things like that. I’d take him for a trip somewhere or something like that. And we couldn't do any of that. We couldn’t do anything, you know, go to a movie or anything like that. So that was really hard.” (P6).

All participants spoke of missing in-person connections with family and friends. A participant noted, “My daughter is out west and my family is out east. So, it really totally restricted any movement to visit.” (P12). Some participants spoke of missing major life events; “My grandson got his master’s degree… during one of the lockdowns. That’s something to celebrate. He should have been able to walk across the stage, and have a little celebration – nothing, right?” (P10).

Participants were sometimes prevented from being with family during major health crises and the death of a loved one. A participant shared the struggle of not being able to see her husband when he was admitted to hospital, “But the second time [he was admitted to hospital] I didn’t see him for three days. Couldn’t get any answers. They wouldn’t tell me anything on the phone, so that was hard.” (P2). Later when he was admitted again and in palliative care, she struggled to obtain access for herself and other family members, “It was a lot of advocating. And not getting answers, not knowing who to talk to. You know, they say you’ve got to talk to so-and-so, and then you can’t find so-and-so.” (P2).

With scant options for social interaction, there were effects on participants’ health. A participant reflected, “...So, I found that was, affected my mood very much, and with nothing really available.” (P9). As time passed, the toll on mental health became increasingly apparent. A participant shared a poignant moment, recounting, “… I remember sitting on my bed crying, because it was the first time in my life that I couldn’t see my mum on her birthday.” (P16). Another participant shared the impact of the pandemic on her mental health which was still being felt in 2023, post-government-imposed social restrictions, “Even today I forgot that our appointment was today so I got a little anxiety… that is the result of the last few years and being socially isolated, I noticed.” (P10).

Theme 2: Diverse social isolation experiences

After inquiring about their overall pandemic experiences, we queried specifically about social isolation. As described in the first theme of Lives disrupted, many participants shared how they missed being able to see family and friends and engage in usual social activities. When queried specifically, we found that social isolation was a profound and defining pandemic experience for many participants, “[What was my greatest challenge?], “my answer is about feeling very lonely.” (P14).

Feelings of social isolation occurred for those in different living and household configurations. A participant who lived alone stated that, before the pandemic, “I’m pretty much a loner in the first place; I don’t do well in crowds.” But she stated that, as a result of the pandemic, “… the whole thing really made me aware of how isolated I really am.” (P17), sharing how she was still experiencing social isolation when interviewed in 2023. Isolation was also an issue for those living in congregant settings such as homeless shelters and assisted living. A participant in assisted living stated:

“Very isolated, because I was just in my room by myself constantly. The interaction was when I opened my apartment door and got my food; that was it. Because we weren’t allowed to play bingo in the dining room, we weren't allowed to go in the dining room.” (P16).

Some participants, despite living with other persons in their household, also spoke of feeling socially isolated, “yeah, all the time.” (P11). In contrast, some participants who shared a household with others found that not being alone helped them mitigate feelings of social isolation, “I was with my wife and we’re not that socially active to begin with, and so it [being socially isolated] didn’t really bother us that much.” (P4).

Theme 3: Coping through seeking solitary and group activities

When asked about how they coped during the pandemic, the essence of participants’ coping was practical, turning to specific activities they sought out in order to cope. These activities can be categorized broadly as those that are solitary and those that are interactive or social.

Solitary activities encompassed a large number of undertakings including yoga; journaling; organizing household/cleaning; playing musical instruments; reading; and watching TV/other media. Often, participants took the available time to pick up activities for which they usually did not have time. A participant said it was helpful to have the time to be, “connected with nature more. Yes, that’s helped me quite a bit too; I got into the dirt – not dirt – it’s now soil to me. So, I enjoyed doing those things that I’ve wanted to do. So that’s how I coped a little bit too.” (P5). Another participant said, “…I turned to reading more than I had been doing, so that was nice. Because I’d kind of got away from it.” (P9). A number of participants talked of turning to spiritual and faith practices including prayer and meditation:

“It’s in my culture to do a morning prayer. So, I would be over at that park, or in my backyard, every morning asking for people to be able to have the strength and the courage to work through what they needed to work through during this time. I don’t know if my prayers were answered but I hope they were.” (P17).

Many participants found alternative ways to engage in interactive or social activities. Some participants connected virtually with faith services, online courses, and support groups. A participant indicated that, “I can listen to church on the radio.” (P9). Another participant found support online:

I also took a course for my mental health during COVID – I paid for it myself. I did that online too, all online… I knew that I had to… I was at the point where I needed somebody to talk to about it all. (P6).

Many participants connected virtually with friends and family. A participant summed up how keeping in touch remotely through text, phone or video platforms was of great help combatting social isolation:

I have a sister that I sort of texted with. She was sort of one of my lifelines. And friends, I have friends that call me all the time sort of thing. So, my friends and my phone – my phone was my – this little thing here [gesturing to her phone] is – that’s my everything, because that connects me with the world. So, if I didn't have that… So that’s my connection. (P6).

For a few participants, their health care providers offered support during the pandemic; a participant who was isolated while caring for her husband noted the value of support from their family physician:

Just being able to call my doctor several times when I was feeling down…I was able to make a few calls to him and just explain what was going on and I could get a phone call and visit with him. And he was very understanding. (P2).

However, many participants did not consider seeking support for their social isolation or mental health concerns from their health care providers suggesting, “I didn’t really discuss the isolation to them, no, but to my family I did, yes. I felt that they [family physician] had other situations to deal with, other than having me tell them something that they already knew.” (P5).

In addition to describing specific coping activities that helped them meet this stressful time; some participants spoke of how they adapted to challenges and exhibited resilience in the face of the pandemic; and how resilience might be cultivated in society moving forward.

Theme 4: Individual ways of enacting resilience and the role of health care to build resilience

When asked about how we can support people to be resilient post-pandemic, participants often first offered their own strategies for being resilient where the essence of resilience was drawing upon internal reserves to enact resilience, with some participants suggesting experiencing hardship previously was the reason they were resilient during the pandemic, “I bounced back from many losses throughout my life, and I think that helps.” (P2). This same participant characterized their resilience similarly to a number of participants, commenting that despite feeling socially isolated, they felt fortunate, “We weren’t wanting anything, needing or wanting anything that we didn’t have. And so it was okay from that point of view.” (P2). Other participants expressed their resilient approach as, “Like, you don’t know what’s going to happen the next day so you have to kind of just take it day-by-day and whatever comes, comes kind of thing.” (P6). Some participants expressed resilience post-pandemic as, “I am more grateful now; before I would take things for granted.” (P16).

When participants talked about how others might be resilient, they spoke of “… just keep everything going as normal as you can; I think that would be the best way to get out of this mess.” (P7). Speaking about why some people still struggle, a participant considered, “It might be their willingness to move forward. But COVID will always be with us, just as the common cold or the flu is always going to be with us.” (P8). Another participant suggested it might be necessary to “push yourself, like don’t get in a rut and stay in COVID, because it’s not as prevalent as it was, but still be cautious.” (P9).

Participants also suggested areas in health care that should be addressed so people can build resilience post-pandemic. A participant noted that, “the biggest thing is mental health… it’s one area of health care that does not get enough attention.” (P6). Another participant spoke about health care should we face another pandemic in the future, “Just to know that the government will support them – that they have good health care; they will be supported if that happens.” (P3).

Discussion

Our study highlights the vulnerability of people living with multimorbidity,³⁵ contributing to the literature on the adverse effects of social isolation in this population.^19–23 These findings have resonance beyond the pandemic because it is important to understand how older adults living with multimorbidity experience on-going social isolation, especially as it can intensify during periods of exacerbation of chronic conditions or limited mobility.³⁶

Our primary objective was to explore the experiences of older adults living with multimorbidity during the COVID-19 pandemic. The first theme from this qualitative inquiry was that participants characterized their pandemic experiences as Lives disrupted. Disruptions occurred in all aspects of life including daily chores, cancellation of plans, and the inability to visit with friends, family or engage in social activities.

The remaining three themes arose from our second objective and data analysis regarding our specific queries on social isolation, coping and resilience.

Theme 2, Diverse social isolation experiences, reminds us to pay attention to the need for human connection to support people experiencing social isolation. Many of the disruptions people described contributed to them feeling socially isolated; the intensity of their experiences varied, with some indicating they did not feel greatly isolated, others describing missing family and friends, while still others experiencing profound isolation leading to feeling unwanted, lonely and despairing. For some, the extent of their isolation related to their context such as living in a congregate setting due to health issues or caring for a family member resulting in being unable to engage in social activities they found meaningful.

As diverse as the participants’ experiences were, so too were their creative ways of coping with social isolation as revealed in Theme 3, Coping through seeking solitary and group activities – such as engaging in hobbies and spiritual practices, reaching out virtually to friends and family, and attending church services and online support groups. Older adults are increasingly online³⁷ making technologically-based activities one solution to social isolation, especially for those living with multimorbidity who face health problems and mobility issues that limit their ability to leave their homes. Our interpretation of participants’ coping strategies was that many activities were purposefully chosen to promote creativity, peace, or connections with nature, or to be productive and meaningful to the participant.

Within Theme 4, Individual ways of enacting resilience and the role of health care to build resilience, participants spoke of the ways they personally enacted resilience which was characterized as a way of approaching life, describing straightforward and simple acts of resilience. This included drawing on inner reserves available because of successfully navigating previous struggles in life and adopting an attitude of gratitude.

In discussing potential solutions to mitigate social isolation, participants spontaneously mentioned the need for health care to be part of the solution to support resilience, especially as it relates to mental health, despite the fact that few of the participants shared their own struggles with their health care providers during the pandemic. This is supported by a recent article describing the need for health care providers to be involved in solving the social isolation crisis.²⁷ This may become more challenging given the increasing numbers of people without a family physician.³⁸

The ways of coping and enacting resilience offered by our participants suggest interventions that can help older adults living with multimorbidity mitigate their risk of social isolation in a post-pandemic world. Collectively, our findings suggest that people’s experiences of social isolation and their ways of coping and being resilient are individual, highlighting the need for interventions to be patient-centred, recognizing the person’s context and circumstance, and their preferences and interests.³⁹ This necessitates a wide range of solutions – technological, in-person and activity-related, and inner resilience, and is consistent with the findings of Kadowaki & Wister who described the importance of exploring a “wider array”^24;p.²¹² of age-friendly interventions to reduce social isolation.²⁴

It is correspondently important that we not make assumptions about who we think is isolated. As an example, social isolation was reported not only among those who live alone, and some participants living in precarious housing described their situation positively. Interestingly, a number of participants indicated they did not reach out to health care providers regarding their feelings of social isolation because they did not want to bother them. While this might be particular to the pandemic when patients were respectful of the care load on their providers, we believe it serves as a cautionary tale to providers that we may not know who is socially isolated – and patients may not share without being asked. This speaks to the need for interventions to identify those experiencing social isolation, and to remove the stigma of asking about isolation, making it as routine as asking about other health risk factors such as smoking and alcohol use. We also need to support providers in valuing the role they can play in mitigating social isolation by opening conversations with their patients about this critical health care issue.²⁷

Strengths and limitations

The strengths of our study include the use of phenomenology which captured the richly diverse and profound stories of participants’ pandemic experience including the common experience of social isolation, as well as their ability to marshal their coping strategies and find ways to sustain their resilience. The rigor in data collection and analysis provide trustworthiness and credibility to the findings. The participants varied across age, gender, race, financial stability, and housing status. The majority of our participants rated their health as good, despite all having at least two chronic conditions. This may mean that sicker people were unable to participate. The majority of our participants had a family physician so experiences of health care might be different for those who do not have access to a family physician, a situation that is increasing in Canada and elsewhere.³⁸ Evidence in the literature^40–42 is mixed concerning whether social isolation differs between urban and rural areas. We were not able to examine the role of rurality in our study as our participants were from more urban regions than rural, with most being from an urban area in Southwestern Ontario. The study was conducted in Ontario and so the transferability of our findings outside this region may be limited.

We captured diverse experiences of the pandemic and queried specifically to understand better social isolation, coping and resilience. We reached data saturation with 17 participants. We chose not to limit our inquiry to a particular part of the pandemic such as experiences during social restrictions; however, many people focused on the height of the pandemic when restrictions were in place from approximately March 2020 to June 2021,⁴³ with some participants indicating they were still feeling the effects of the pandemic in 2023 when we interviewed them.

Because the pandemic was a unique global experience, we cannot assume that our participants’ experiences of social isolation would be the same today post-pandemic. Further, the focus on the pandemic among participants who did not necessarily identify as being socially isolated may lessen the external validity of our findings post-pandemic where social isolation is not caused by government-imposed restrictions, and more likely to be caused by a complex combination of variables such as exacerbated illnesses and social withdrawals which our inquiries were not necessarily well-positioned to examine. Therefore, we acknowledge that it would be more conceptually valid to develop interventions based on post-pandemic experiences of social isolation, rather than during the pandemic when social isolation was exacerbated beyond what it would typically be, and among some patients who did not necessarily identify as being socially isolated. As well, we cannot assume our findings would be the same had social isolation been an inclusion criterion. However, we believe our findings still have value to inform interventions for those with social isolation, interventions that need to be tested in our current post-pandemic environment to support older adults living with multimorbidity to adopt coping strategies. This can include engaging in rewarding activities and staying connected to family and friends through technology, helping them build resilience and potentially mitigate social isolation.

While living with multimorbidity was an inclusion criterion, we did not specifically probe how living with multimorbidity impacted participants’ experience of the pandemic or social isolation, which may have further limited the richness of our data and our ability to delineate these experiences from those of the general population, and extrapolate these finding to the development of interventions for people living with multimorbidity and social isolation post-pandemic. In a similar way, we did not intend to apply our findings to those without multimorbidity. Our study examined the experiences of the pandemic within participants living with multimorbidity. We know that social isolation is prevalent among other groups of people⁴⁴ including older adults more generally.^14–16 However, we cannot state whether the themes we identified would be the same or different in older group of adults without multimorbidity.

It may be reasonable to suggest that the coping strategies and resilience we observed may be broadly applicable to all older adults, with some studies identifying similar solutions to mitigate social isolation.^18,45 However, even within participants living with multimorbidity, we observed a range of experiences and coping strategies, once again emphasizing the need for a tailored approach to offering interventions to mitigate social isolation.²⁴

The health effects of social isolation motivated the research described in this paper; our findings will support future research to support older patients living with multimorbidity and their family physicians to address social isolation. As part of our larger research program on social isolation, we are developing an intervention to facilitate family physicians’ learning about the health effects of social isolation and supporting them in having conversations with their older adults living with multimorbidity. The findings from this qualitative study are informing the educational component of the intervention and, together with findings from our survey study, will support family physicians in identifying and discussing social isolation, and in offering suggestions and resources to mitigate the social isolation experienced by their patients.

Conclusions

The burden of social isolation was laid bare by the COVID-19 pandemic. We explored the experiences of older adults living with multimorbidity, finding their experiences centred around the various ways the pandemic disrupted their lives. When we queried specifically about social isolation, we found it was experienced in diverse ways but was a prominent concern. We also identified the creativity with which participants coped with social isolation and the resilience they marshaled to meet the challenges of the pandemic. Social isolation is prevalent among this population and interventions to mitigate social isolation and its effects are urgently needed.

Footnotes

Acknowledgment

We would like to thank all the participants who shared their experiences and thoughts so generously.

ORCID iDs

Bridget L. Ryan

Judith Belle Brown

Saifora I. Paktiss

Amanda L. Terry

Ethical consideration

Ethical approval for the study was provided by the Western University’s Health Sciences Research Ethics Board (reference number 121265).

Consent to participate

Written consent was obtained through either an online Qualtrics platform or by paper as participants preferred.

Consent for publication

Written consent to use de-identified quotes from participants’ interviews was obtained through the same online Qualtrics platform used for consent to participate (or by paper as participants preferred).

Author contributions

Author contributions: BLR, ALT, and JBB designed this qualitative study. SIP and BLR conducted the interviews. All authors contributed to the data analysis. All authors drafted and critically revised the paper. BLR is the guarantor.

Funding

The authors disclose receipt of the following financial support for the research, authorship, and publication of this article: This study is funded by Canadian Institutes of Health Research (CIHR) under their Operating Grant: Addressing the Wider Health Impacts of COVID-19. The views expressed in this publication are those of the authors and not necessarily those of the CIHR, or the Department of Family Medicine, Schulich School of Medicine & Dentistry, Western University of Ontario, Canada.

Declaration of conflicting interests

The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Data cannot be made available according to our REB approval and the potential of qualitative data to identify participants.*

References

Xiao

Beach

Senthilselvan

. Prevalence and determinants of multimorbidity in the Canadian population. PLoS One. 2024 Jan 30; 19(1): e0297221. Available from: https://doi.org/10.1371%2Fjournal.pone.0297221

Ryan

Bray Jenkyn

Shariff

Allen

Glazier

Zwarenstein

, et al. Beyond the grey tsunami: a cross-sectional population-based study of multimorbidity in Ontario. Can J Public Health. 2018 Jul 18;109(5-6):845–54.

Marengoni

Angleman

Melis

Mangialasche

Karp

Garmen

Meinow

Fratiglioni

. Aging with multimorbidity: a systematic review of the literature. Ageing Res Rev. 2011 Sep;10(4):430-9. doi: 10.1016/j.arr.2011.03.003. Epub 2011 Mar 23. PMID: 21402176.

Skou

Mair

Fortin

Guthrie

Nunes

Miranda

Boyd

Pati

Mtenga

Smith

. Multimorbidity. Nat Rev Dis Primers 2022 Jul 14;8(1):48. doi: 10.1038/s41572-022-00376-4. PMID: 35835758; PMCID: PMC7613517.

Fortin

Lapointe

Hudon

Vanasse

Ntetu

Maltais

. Multimorbidity and quality of life in primary care: a systematic review. Health Qual Life Outcomes. 2004 Sep 20;2:51. doi: 10.1186/1477-7525-2-51. PMID: 15380021; PMCID: PMC526383.

Brijoux

Woopen

Zank

. Multimorbidity in old age and its impact on life results. Z Gerontol Geriatr. 2021 Nov;54(Suppl 2):108-113. doi: 10.1007/s00391-021-01920-9. Epub 2021 Jun 23. PMID: 34160675; PMCID: PMC8551110.

Lehnert

Heider

Leicht

, et al. Review: Health care utilization and costs of elderly persons with multiple chronic conditions. Med Care Res Rev. 2011;68(4):387-420. doi:10.1177/1077558711399580.

Soley-Bori

Ashworth

Bisquera

Dodhia

Lynch

Wang

Fox-Rushby

. Impact of multimorbidity on healthcare costs and utilisation: a systematic review of the UK literature. Br J Gen Pract. 2020 Dec 28;71(702):e39-e46. doi: 10.3399/bjgp20X713897. PMID: 33257463; PMCID: PMC7716874.

Ryan

Allen

Zwarenstein

Stewart

Glazier

Fortin

, et al. Multimorbidity and mortality in Ontario, Canada: A population-based retrospective cohort study. J Comorbid. 2020 Jan 1; 10. doi:10.1177/2235042X20950598.

10.

Makovski

Steichen

Rushyizekera

van den Akker

Coste

. Relationship between multimorbidity, SARS-COV-2 infection and long COVID: a cross-sectional population-based French survey. BMC Med. 2025 Apr 15;23(1).

11.

Chudasama

Zaccardi

Gillies

Razieh

Yates

Kloecker

, et al. Patterns of multimorbidity and risk of severe SARS-CoV-2 infection: an observational study in the U.K. BMC Infect Dis. 2021 Sep 4;21(1).

12.

Agrawal

Azcoaga-Lorenzo

Fagbamigbe

Vasileiou

Henery

Simpson

, et al. Association between multimorbidity and mortality in a cohort of patients admitted to hospital with COVID-19 in Scotland. J R Soc Med. 2021 Oct 21;115(1):22–30.

13.

Bustos-Vázquez

Padilla-González

Reyes-Gómez

Carmona-Ramos

Monroy-Vargas

Benítez-Herrera

, et al. Survival of COVID-19 with multimorbidity patients. Healthcare (Basel, Switzerland) [Internet]. 2021 Summer;9(11):1423. Available from: https://pubmed.ncbi.nlm.nih.gov/34828470/

14.

Ernst

Niederer

Werner

Czaja

, et al. Loneliness before and during the COVID-19 pandemic: A systematic review with meta-analysis. Am Psychol. 2022 Jul; 77(5): 660–77.

15.

Savage

, et al. Loneliness among older adults in the community during COVID-19: a cross-sectional survey in Canada. BMJ Open. 2021 Apr; 11(4): e044517.

16.

MacCourt

. Social isolation of seniors - Volume 1: Understanding the issue and finding solutions [Internet]. 2017 Feb [cited 2024 Aug 1]. Available from: https://www.canada.ca/en/employment-social-development/corporate/partners/seniors-forum/social-isolation-toolkit-vol1.html

17.

Hajek

Kretzler

König

. Multimorbidity, loneliness, and social isolation. A systematic review. Int J Environ Res Public Health. 2020 Nov 23;17(22):8688. doi: 10.3390/ijerph17228688. PMID: 33238506; PMCID: PMC7700324.

18.

Malani

. Trends in Loneliness Among Older Adults from 2018-2023 | National Poll on Healthy Aging [Internet]. https://www.healthyagingpoll.org/. 2023. Available from: https://www.healthyagingpoll.org/reports-more/report/trends-loneliness-among-older-adults-2018-2023

19.

World Health Organization . Advocacy Brief: Social Isolation and Loneliness among older people [Internet]. p. 20. Available from: https://iris.who.int/server/api/core/bitstreams/116323b7-0b9d-4c03-802b-741253da4fdb/content

20.

Neil-Sztramko

Coletta

, et al. Impact of the AGE-ON tablet training program on social isolation, loneliness, and attitudes toward technology in older adults: Single-group pre-post study. JMIR Aging. 2020 Apr 20; 3(1): e18398.

21.

Hawkley

Cacioppo

. Loneliness matters: A theoretical and empirical review of consequences and mechanisms. Ann Behav Med. 2010 Oct; 40(2): 218–27.

22.

Freak-Poli

Ryan

Neumann

, et al. Social isolation, social support and loneliness as predictors of cardiovascular disease incidence and mortality. BMC Geriatr. 2021 Dec; 21(1): 711.

23.

Shankar

McMunn

Demakakos

, et al. Social isolation and loneliness: Prospective associations with functional status in older adults. Health Psychol. 2017 Feb; 36(2): 179–87.

24.

Kadowaki

Wister

. Older adults and social isolation and loneliness during the COVID-19 pandemic: An integrated review of patterns, effects, and interventions. Can J Aging Rev Can Vieil. 2023 Jun; 42(2): 199–216.

25.

National Academies of Sciences, Engineering, and Medicine . Social isolation and loneliness in older adults: Opportunities for the health care system [Internet]. Washington, D.C.: The National Academies Press; 2020 [cited 2023 Jan 31]. Available from: https://www.nap.edu/catalog/25663

26.

U.S. Surgeon General . Our Epidemic of Loneliness and Isolation [Internet]. 2023. Available from: https://www.hhs.gov/sites/default/files/surgeon-general-social-connection-advisory.pdf

27.

Mullen

Tong

Lum

, et al. The role of primary care in the social isolation and loneliness epidemic. Ann Fam Med. 2024 Mar 1; 3102.

28.

Richards

Morse

(2013). Readme first for a user’s guide to qualitative methods. (Vols. 1-0). SAGE Publications, Inc, https://doi.org/10.4135/9781071909898

29.

Vasileiou

Barnett

Thorpe

, et al. Characterising and justifying sample size sufficiency in interview-based studies: systematic analysis of qualitative health research over a 15-year period. BMC Med Res Methodol. 2018 Nov 21; 18(1): 148. Doi:10.1186/s12874-018-0594-7.

30.

Berger

. Now I see it, now I don’t: researcher’s position and reflexivity in qualitative research. Qual Res. 2015; 15(2): 219–34. https://doi.org/10.1177/1468794112468475.

31.

Charmaz

. Constructing grounded theory: A practical guide through qualitative analysis. 2nd ed. London: Sage Publications; 2014.

32.

American Psychological Association . APA Dictionary of Psychology. [cited 2025 Jul 16]. APA Dictionary of Psychology: Social Isolation. Available from: https://dictionary.apa.org/social-isolation.

33.

American Psychological Association . APA Dictionary of Psychology. [cited 2024 Oct 4]. APA Dictionary of Psychology: Coping Strategy. Available from: https://dictionary.apa.org/coping-strategy.

34.

American Psychological Association . APA Dictionary of Psychology. [cited 2024 Oct 4]. APA Dictionary of Psychology: Resilience. Available from: https://dictionary.apa.org/resilience.

35.

Brown

Reichert

Boeckxstaens

, et al. Responding to vulnerable patients with multimorbidity: an interprofessional team approach. BMC Prim Care. 2022 Dec; 23(1): 62.

36.

National Seniors Council . Report on the social isolation of seniors [Internet]. Government of Canada; 2016 Jul [cited 2024 Aug 15]. Available from: https://www.canada.ca/en/national-seniors-council/programs/publications-reports/2014/social-isolation-seniors/page05.html.

37.

Government of Canada SC . Statistics Canada. 2023 [cited 2024 Oct 4]. Canadian seniors more connected than ever. Available from: https://www.statcan.gc.ca/o1/en/plus/4288-canadian-seniors-more-connected-ever.

38.

Gumas Evan

Lewis Corrine Horstman Celli Gunja Munira

. Finger on the pulse: The state of primary care in the U.S. and nine other countries (Commonwealth Fund, Mar. 2024). https://doi.org/10.26099/p3y4-5g38

39.

Stewart

Brown

Weston

Freeman

Ryan

McWilliam

McWhinney

. Patient-centered medicine: Transforming the Clinical Method. 4th ed. CRC Press; 2024.

40.

Menec

Newall

Mackenzie

, et al. Examining individual and geographic factors associated with social isolation and loneliness using Canadian Longitudinal Study on Aging (CLSA) data. Latham-Mintus

, editor. PLoS One. 2019 Feb 1; 14(2): e0211143.

41.

Pickering

Wister

O’Dea

Chaudhury

. Social isolation and loneliness among older adults living in rural areas during the COVID-19 pandemic: a scoping review. BMC Geriatr. 2023 Aug 23; 23(1): 511.

42.

Repke

Ipsen

. Differences in social connectedness and perceived isolation among rural and urban adults with disabilities. Disabil Health J. 2020 Jan; 13(1): 100829.

43.

Rodrigues

Gabby

(March 17, 2020). “Ontario government declares state of emergency amid coronavirus pandemic”. Global News. Corus Entertainment. Archived from the original on May 26, 2020. Retrieved March 17, 2020.

44.

Shapo

. The importance of continuing to tackle social isolation and loneliness in a post-pandemic era -lessons learned and the way forward. J Integrated Health. 2024; Available from: https://urfjournals.org/open-access/the-importance-of-continuing-to-tackle-social-isolation-and-loneliness-in-a-post-pandemic-era-lessons-learned-and-the-way-forward.pdf

45.

Berg-Weger

Morley

. Loneliness and social isolation in older adults during the covid-19 pandemic: Implications for gerontological social work. J Nutr Health Aging [Internet]. 2020 Apr 14;24(5):456–8. Available from: https://link.springer.com/article/10.1007/s12603-020-1366-8.

The experience of older adults living with multimorbidity during the COVID-19 pandemic: A phenomenological study

Abstract

Keywords

Introduction

Methods

Design

Recruitment and sampling

Data collection

Data analysis

Trustworthiness and credibility

Results

Participant context and circumstances

Overview of themes

Theme 1: Lives disrupted

Theme 2: Diverse social isolation experiences

Theme 3: Coping through seeking solitary and group activities

Theme 4: Individual ways of enacting resilience and the role of health care to build resilience

Discussion

Strengths and limitations

Conclusions

Footnotes

Acknowledgment

ORCID iDs

Ethical consideration

Consent to participate

Consent for publication

Author contributions

Funding

Declaration of conflicting interests

Data Availability Statement

References