Framing the COVID-19 Pandemic for Minority Older Adults Through a Family Lens: Results of a Qualitative Thematic Analysis of Survey Responses.

This study assessed COVID-19 experiences among minority older adults in Houston, Texas. An electronic survey was administered to community-dwelling older adults, and the open-ended responses of 458 minority adults were analyzed using thematic analysis. Through an inductive coding approach, 2 unexpected main themes emerged regarding family: fear of COVID-19 spreading among their family and modifications to family and community interactions. These older minority adults framed their personal COVID-19 experiences through the lens of family and their community, demonstrating the importance of integrating family considerations into pandemic planning, response, and recovery efforts for minority older adults.

Introduction

The COVID-19 pandemic has demonstrated the important relationships and expectations among older adults (1,2), who may be experiencing narrowed social networks because of closures of their usual aggregation places of community centers and places of worship (3). Many older adults are dependent upon their family members, whether it be for their caretaking needs or for their connection to the outside world (1). Resiliency is much more difficult for older adults because they often lack access to technology and are unable or uncomfortable with technology (4,5). Despite the decrease in opportunities for typical family and community activities like church events, many communities have found a way to continue to assist older adults through programs like grocery shopping initiatives and even digital means (1,2).

In response to the disproportionate impact of COVID-19 on Black and brown communities (6–8), researchers have stressed the role of culture when working with minority populations (9,10). For example, the PEN-3 Model acknowledges the role of culture in decision making across 3 domains, including relationships and expectations. This study assessed COVID-19 experiences among community-dwelling older adults identifying as a racial and/or ethnic minority. Studies of this nature are valuable for understanding the perspectives and opinions of older adults during public health crises and can positively contribute to future policies meant to mitigate the negative effects of pandemic measures like lockdowns.

Method

Working with community-based organizations and senior living centers, an electronic survey was administered to older adults 55 + , in the Houston metroplex, between November 2020 and January 2021. (A more detailed description of the survey development and dissemination can be found at X.) This study was approved by an independent institutional review board in October 2020 (IRB ID: STUDY00002584).

The overall sample contains 575 respondents, with this analysis focused on a subset of the 458 minority survey respondents. The survey sample was overwhelming female (77.5%), in which nearly one-half (46.1%) were married or living with in a household with 3 or more persons (39.5%) (Table 1). A manual thematic analysis (11,12) focused on analyzing open-ended responses to the following survey questions:

Table 1.

Demographic Characteristics of Minority Survey Respondent Subset.

	n	%
Marital status
Married	211	46.1%
Divorced	66	14.4%
Single	106	23.1%
Widowed	59	12.9%
Separated	14	3.1%
No response	2	0.4%
Age
50-59	57	12.4%
60-69	184	40.2%
70-79	140	31.9%
80 or older	58	12.7%
Missing/no response	19	4.1%
Gender
Male	99	21.6%
Female	355	77.5%
No response	4	0.9%
Household size
1	107	23.3%
2	145	31.7%
3	61	13.3%
4	52	11.4%
5 or more	68	14.8%
No response	25	5.5%
Race/Ethnicity
Black/African American	293	64.0%
Multiracial	6	1.3%
Other	11	2.4%
Hispanic	148	32.3%
Experience with COVID-19
Yes	255	55.7%
No	196	42.8%
No response	7	1.5%

How has the COVID-19 pandemic affected the daily management of your health condition?

As someone with a chronic/serious medical condition, what are your biggest concerns about your health/healthcare since the COVID-19 pandemic?

Please tell us about your experience with COVID-19 or the experience of someone you know with COVID-19.

Using an inductive coding approach, codes were derived directly from the data, allowing preliminary codes to emerge that reflect the participants’ experiences following guidelines for thematic analysis (13). Open-ended survey data were coded thematically (lead author) according to the main themes that appeared in the data, which were collectively agreed upon by the researchers, all of whom identified quotations that appear in the article. The identified quotes are effective in representing the basic concerns of the sampled minority older adults and their challenges in adapting to COVID-19.

Results

Although asked about their individual experiences with COVID-19, these older minority adults used family as a centralizing lens when responding to open-ended survey questions. Two main themes identified by the researchers were (1) fear of COVID-19 transmission among their families; and (2) modifications to family interactions (Table 2).

Table 2.

Results of Thematic Analysis of Open-Ended Questions With Corresponding Codes and Representative Quotes.

Theme 1: Fear of COVID-19 spreading among their family

Corresponding Code: Fear of contracting COVID-19 from family members −“My adult children still socialize in groups.” −“My sons had COVID we had no contact with them only to give them food.” −“My sister got Covid after going to a club. She lives with my elderly mother. My son works for Amazon and he has been feeling bad. I told him he needs to get a test before he comes back over. It isn't easy because he needs transportation, so I just let him use the car. I am afraid to ride with him. I gave his girlfriend cleaning supplies and to keep everything extra clean for my grandkids. She is now sleeping separately from him until he knows his results.” −“My granddaughter. Fortunately, I did not receive the virus even though we came in direct contact before she contracted the virus.” −“My sister had it. We have been concerned as a family not to get infected.” −“My cousin (75) died after being exposed by grandchild that resided with her. Two other family members have recovered (ages 66 & 78). Although I have not experience, I have greatly reduced my time outside of my home and do not have close contact with the 2 younger members of my household.”

Corresponding Code: Fear of transmitting COVID-19 to family members −“My kids had to live elsewhere while I recovered, and my boyfriend took care of me.” −“My family had a small gathering for Christmas even though we all wore mask and distanced for a dominos game everyone became infected. One asymptomatic person infected the entire family including my 86-year-old mother. I am a symptomatic as are other household members. The entire family took COVID tests on Monday; all but 2 of 9 were positive.” −“I am concerned and protective of my grandchildren and keeping my family free of COVID.” −“I was very sick. I had issues with isolating so I had to have other living arrangements and not have grandchildren over.”

Theme 2: Disruptions and adaptations (modifications) to family and community interactions

Corresponding Code: Social isolation from family −“…I can't see grandkids, staying away from family.” −“My daughter and son-in-law had it. I had to isolate from them during the holidays.” −“…not able to socialize and see family.” −“Limited time with family.” −“Presently we are separated for our loved ones like everyone else.” −‘I have little or no contact with many of my family members and/ with my peers.” −“…can't see children or grand children.” −“I just stay away from family get togethers because two people had it.”

Corresponding code: Not being able to attend community events −“I also don't get to enjoy the physical and mental activities such as line dancing, dominoes, and socializing at the centers.” −“Only not being able to go with my life, as far as being able to go to senior activities, exercising with others.” −“I am not able to exercise because all of the facilities that were available to me that I was going to are closed. Exercise helped me maintain a healthy weight and it was also a way for me to interact with other people my age.” −“Really miss Church. I used to do it every Sunday and some weeknights.” −“Not attending in person worship service. I am not taking the risk of gathering with so many people without temperature checks and screening for symptoms of illness” −“…unable to do volunteer community service work. There is just no socialization.”

Corresponding Code: Changing family demands −“My mother and Aunt are more dependent on me for their medical visits.” −“More stress on me, my son is mentally stressed and depressed; he has no insurance and the burden is on me. Also caring and trying to keep my 87-year-old mother safe from covid.” −“My children and grandchildren do everything for me.” −“I am reliant upon my family to get to medical visits when it can't be telehealth visit through [the local hospital].” −“I am dependent on my daughter or grandchildren to transport me to medical appointments.” −“I am a caregiver for my parent. Unfortunately, I can't get them transported”

Corresponding Code: New adaptations −“However new forms of communications (Zoom & telephone, other social media) have almost overcome the physical need to socialize as more people are actually able to gather at one setting from their individual whereabouts and participate THAN EVER KNOWN BEFORE. TECHNOLOGY IS A BLESSING FROM GOD!” −“We have virtual events and socialize outdoors to reduce exposure.” −“Church services and social meetings are now virtual.” −“Since I am involved in a variety of online activities offered by the centers and others, I still manage to do fine.”

(1) Fear of COVID-19 Spreading among Their Family

Respondents reported fears of contracting COVID-19 from their family members who had tested positive or were engaging in high-risk activities. Several respondents gave examples of their family members who were engaging in activities that put them at high risk of contracting the virus. One respondent shared “my adult children still socialize in groups.” Many respondents reported similar experiences of limited or no contact with family members who had been exposed or tested positive for COVID. Other respondents explained how after testing positive, they tried to keep their family from also contracting the virus by adjusting their living arrangements. One participant shared that “my kids had to live elsewhere while I recovered, and my boyfriend took care of me.” These examples point to the challenges faced in curtailing the spread of COVID-19 within multigenerational living situations of these older adults.

(2) Modifications to Social Interactions

COVID-19 forced many participants to modify their social interactions with family and community members. There were many examples of families canceling family get-togethers and holidays. “My daughter and son-in-law had it. I had to isolate from them during the holidays.”

Others revealed more general isolation from family members including “[I] cant see children or grandchildren” and “I have little or no contact with many of my family members.” Respondents reported how the lockdowns disrupted their routine activities such as exercise, church, and other community services. One respondent described how “I also don't get to enjoy the physical and mental activities such as line dancing, dominoes, and socializing at the centers.” These responses highlight the loss of normal socialization that comes with these activities.

Some respondents reported an increase in family care-giving responsibilities for both elderly parents and relatives. One respondent directly connected more care-taking responsibilities to more negative mental health impacts: “More stress on me, my son [is] mentally stressed and depressed—he has no insurance [therefore] the burden's on me. Also caring and trying to keep my 87-year-old mother safe from COVID.” Respondents explained how their older relatives need more help with transportation: “My mother and aunt are more dependent on me for their medical visits.” Other respondents revealed that they were relying on their children to help them during the lockdown to various degrees. “My children and grandchildren do everything for me” according to one participant.

Individuals also highlighted positive adaptions to maintain their relationships with family members and friends. “Church services and social meetings are virtual.” Another participant directly connected these types of visits to their current well-being: “Since I am involved in a variety of online activities offered by the centers and others, I still manage to do fine.”

The use of technology, specifically Zoom, allowed for individuals to maintain their relationships and interactions with family and community members.

Discussion

This study assessed COVID-19 experiences among minority older adults, who unexpectedly framed their responses in the context of their family, which suggests the importance of community activities and organizational ingenuity in finding ways to continue to assist older adults through community programs (1,2). While many shared experiences of limited family interactions to mitigate the risk of contracting COVID-19, they also shared the difficulty of limiting interactions when residing with or depending on family members. Importantly, these older adults demonstrated their resiliency in the forms of new adaptions of virtual interactions to maintain their family relationships, which differs from previous research reporting older adults struggling with technology (4,5). While the use of phone calls and even video calls are not new, the use of such technologies for church and other community events emphasizes the importance of these family and community interactions for these older adults. This finding aligns with previous research demonstrating that communities have used digital means to stay connected during the pandemic (1,2).

Women are often the caregivers of the household, and for this group of older minority adults, their family demands were highlighted even in questions asking about their individual health. Participants mentioned changing family demands of both their children and their parents and older family members, emphasizing the unique challenges faced by families who are living in intergenerational housing situations. This centering of the family unit as a part of their own health and the acknowledgment of the interplay between their family's health and actions highlights the need to expand the pandemic response to include a more gendered and family approach.

These findings emphasize the importance of a culture of minority populations in defining health challenges and outcomes highlighted by the PEN-3 Model. The PEN-3 cultural model centralizes culture when defining health problems and framing their solutions (14). It also emphasizes the role of the collective in defining the health experiences of individuals and underscores its importance in influencing health-related decisions. These findings highlight the importance of the Relationships and Expectations domain, specifically the influence of family and kin in nurturing decisions surrounding effective management of health problems.

These findings are significant as older minority adults framed their experiences and concerns regarding the COVID-19 pandemic through the lens of family and their community. Their personal relationships permeated their responses and demonstrated the importance of integrating a family and community lens into pandemic planning, response, and recovery efforts. The cultural focus on family as a frame for understanding personal experiences with the pandemic can be harnessed in current and future efforts in minority communities to increase vaccine acceptance and uptake.

Limitations

This is a one-time survey that relies on self-reports and recollection of events. Findings may be different if the questions were asked at different points in the pandemic, as the landscape of the pandemic has drastically changed with the widespread availability of vaccines and a better understanding of effective treatments for those with severe illness. Open-ended questions were optional and not completed by all participants, which may bias our qualitative findings. However, the valuable insights from the open-ended questions that were explored here provided additional information that would have otherwise been overlooked in the survey and could be further explored in future work.