Psychological Wellbeing and Psychological Distress in the Elderly During the COVID-19 Pandemic

BACKGROUND: The elderly population is deemed to be the most vulnerable to the eff ects of the COVID-19 pandemic. From March 2020 to April 2022, the implementation of psychological distancing is still being applied in Indonesia. In the light of the pandemic, mental health problems among the elderly require further exploration. This study examines the mental health status of the elderly during the COVID-19 pandemic in Indonesia and the factors that aff ect their mental health, such as loneliness and attachment to God. METHODS: A sequential explanatory type of the mixed-method approach was adopted for the purposes of this study. In particular, the researchers fi rst conducted a quantitative survey, analyzed its results, and then explained them in more detail using qualitative research. RESULTS: The results show that loneliness is a predictor of mental health in the elderly, while attachment to God does not correlate with mental health. More specifi cally, we described that minimal activity, inability to meet children and grandchildren, and inability to recite the Qur’an were the main factors triggering sadness among the elderly during the COVID-19 pandemic. Furthermore, we defi ned that elderly people use productive and religious activities, and communication as main coping strategies. CONCLUSION: Loneliness has been a serious problem for the elderly during the COVID-19 pandemic, impacting their mental health. The fi ndings of this research can be used as a basis or reference for maintaining the mental health of the elderly during the pandemic. АННОТАЦИЯ ОБЩИЕ СВЕДЕНИЯ: пожилые люди считаются наиболее уязвимой для влияния пандемии COVID-19 группой населения. С марта 2020 г. по апрель 2022 г. в Индонезии действовала и продолжает действовать политика психологического дистанцирования. Проблемы психического здоровья пожилых лиц в условиях пандемии требуют дальнейшего изучения. В данном исследовании рассмотрено состояние психического здоровья RESEARCH


INTRODUCTION
Despite all measures taken, the incidence of COVID-19 remains high in Indonesia. There are three signifi cant impacts of the  pandemic that were felt globally: the economic impact (massive layoff s and reduced salaries), the environmental impact (industrial closures, tourism, etc.), and the psychological impact (increased fear of death, loneliness, and issues related to future security) [1]. Despite causing a severe economic downturn, the environmental eff ects of the COVID-19 pandemic were rather positive due to reduced levels of pollution across the globe [1,2].
In addition, a study of 157,213 participants living in America concluded that calm, happiness, and optimism decreased during the COVID-19 pandemic [3].
Studying the state of mental health during the COVID-19 pandemic has become highly relevant and important, especially amongst the elderly population.
The elderly population is deemed to be the most vulnerable to the eff ects of the pandemic [24]. It has been shown that more than 80% of the deaths caused by COVID-19 in America were among people over the age of 65 years (CDC COVID-19 Response Team, 2020). Those who are aged 60 had the highest level of confi rmed deaths compared to other age groups. Even in Indonesia, the number of COVID-19 deaths as of 5 November 2021 had reached 143,534, including the elderly population (https://covid19.go.id/peta-sebaran-covid19).

Recruitment
We recruited participants by spreading the recruitment link online. We approached colleagues, friends, and psychology students who have elderly family members and asked them to act as guides when completing the questionnaires. Each participant signed a consent form before completing the questionnaire.

Procedure
We used Google Forms to share the above link with colleagues, friends, and psychology students. An online format was chosen to minimize any risk of spreading the COVID-19 virus. After the data was collected, we analyzed the data using mental health level categorization. The data collected was also used to determine potential participants for the planned interviews. Interviews were conducted by psychology students whom we had befriended beforehand.

Mental Health Inventory (MHI)
MHI-5 was chosen as a data collection tool to measure the mental health status of the elderly. The MHI-5 is a shortened version of the 38-item based on fundamental theory [34], then expanded to fi ve items [35]. This measurement tool reveals two important aspects: psychological well-being (2 items) and psychological distress (3 items). The MHI-5 has a reliability value of 0.67.

Attachment to God
Attachment to God was measured using the Muslim

Loneliness
Loneliness was measured using the University of California, Los Angeles (UCLA) Loneliness Scale 6, also known as ULS-6. The ULS-6 measuring instrument was developed by Hudiyana et al. [37]. The ULS-6 measuring instrument has shown good quality in terms of measuring loneliness in cross-cultural studies and has been tested in three countries, namely Indonesia, Germany, and America. ULS-6 has a reliability of 0.89. by social isolation, impacting their bio-psycho-social vulnerability [27]. In particular, Lumbantoruan et al., 2021 defi ned that social isolation leads to loneliness, which increases the risk of depression, anxiety disorders, and suicide, especially among elderly patients living in nursing homes. Similar results were reported by Stolz et al., who interviewed 557 participants aged 60 years and over, showing that loneliness increased during the lockdown. Another factor that aff ects the mental health of the elderly is an attachment to God. Individuals believe that their closeness to God will provide a sense of security and help them in times of diffi culty [29].
Homan [30] and Kent et al. [31] demonstrated that there is a link between attachment to God and mental health.

Study design
A sequential explanatory form of mixed-method approach was adopted for this study. Using this approach allowed the combination of quantitative and qualitative elements in a sequential manner and the building of subsequent phases of the research on what had previously been determined. In particular, the researchers fi rst conducted quantitative research, analyzed the results, and then explained them in more detail using qualitative research [32].

Sampling
Incidental sampling was chosen as a sampling strategy for this study. Participants in this study found it diffi cult to communicate well, so the selection of participants was based on communication skills. Interviews were conducted with the elderly participants who had extreme high and low mental health status, as based on the survey. the interview transcript, merging codes into categories, and developing themes [37]. Thirdly, quantitative and qualitative results were integrated.

Participants
Overall, 82 elderly individuals with an age range of 60 to 90 years old were recruited for the purposes of the quantitative part of this study. The majority of participants were women (73.2%). Quantitative sample characteristics are shown in Table 2.
Further, nine elderly participants with very low (three participants) and very high (six participants) mental health status categories were invited to the qualitative interviews. This was done to examine the diff erences in the groups' responses and capture diverse perspectives. Qualitative sample characteristics are presented in Table 3.

Guide Interview
In-depth interviews were used as a data collection tool.

The interview guide was developed following Veit and
Ware [34], indicating that mental health is measured based on two opposing dimensions. The positive dimension is represented by psychological well-being and the negative dimension by psychological distress.
The interview guide is shown in Table 1.

Data analysis
Data from two diff erent approaches was analyzed separately following the guidance off ered by Creswell and Creswell [32]. The analysis was completed via three steps. Firstly, quantitative data was analyzed using JAMOVI to categorize it and create correlations between variables and perform regression analyses. Secondly, qualitative data was analyzed via the content analysis.
Content analysis includes several steps such as coding of  Religious activities can be one of the ways to avoid and prevent the elderly from experiencing such sadness, which included prayer, reading the Qur'an, and Dzikr.
The elderly also mentioned other activities such as going to the fi elds or doing productive activities at home.

Regression Analysis
Based on the regression analysis, there is a signifi cant eff ect of loneliness on mental health (R²=0.20; p <0.001).
However, the eff ect is relatively small. The magnitude of the infl uence of loneliness on mental health is 20%, while other factors infl uence the remaining 80% (Table 4).

Qualitative result
We deepen the results of quantitative research with qualitative methods. The results of the interviews can be described according to two major themes, namely psychological distress and psychological well-being.  Furthermore, we defi ned that elderly people use productive activities, religious activities, and communication as their main coping strategies.

Strengths and limitations
This study has two main strengths. Firstly, to our knowledge, it is the fi rst study to explore the mental health status among elderly individuals in Indonesia.
Secondly, the results of this study can be used as the basis for understanding mental health in the elderly to take further appropriate action.

SAD
Limited activities (unable to make friends, cannot meet grandchildren, cannot recite the Koran together) and are suspicious of others regarding COVID-19

Religious activity
Praying, Reading the Qur'an and Dhikr.

Productive Activity
Productive activities are going to the fi elds, planting fl owers, making coff ee and selling crackers.

Comparison with the existing literature
The results of this study generally confi rm that psychological distancing causes problems such as feeling lonely [38], especially amongst adults who cannot use technology [39].
Similar results were found among elderly people in Europe who reported a higher loneliness due to physical distancing during the pandemic [40]. Although other studies confi rm that loneliness in the elderly occurs only in those with multiple physical and mental health diagnoses, it is associated with reduced loneliness in those with larger social networks [41].
No correlation between attachment to God and mental health was confi rmed in this study. In contrast, another study noted that there was an eff ect of attachment to God on mental health [30,31]. According to the qualitative data results, in order to cope with loneliness, elderly individuals use worship-related practices, showing their attachment to God. Therefore, we suspect that attachment to God might well be a moderating variable, while religious coping is a mediator between loneliness and mental health.

Implications for future research
We suggest the following implications for future research.
Firstly, the attachment to God variable may need to be reviewed using diff erent approaches. Such studies might confi rm why Attachment to God has no relationship with mental health status (or indeed otherwise). Secondly, the religiosity variable can be studied further and compared with the attachment to God variable. Finally, considering that Indonesia is known to be a religious country, exploring certain religious concepts could be helpful to a description of how religious concepts infl uence mental health.

CONCLUSION
This study confi rms that the loneliness caused by lockdown is a factor in mental health issues among the elderly population, whereas attachment to God has no apparent eff ect. The results show that reduced activity, inability to meet children and grandchildren, and inability to recite the Qur'an are the main factors triggering sadness among