case study older person

• Research article
• Open access
• Published: 29 June 2020

Elderly patients with complex health problems in the care trajectory: a qualitative case study

• Marianne Kumlin   ORCID: orcid.org/0000-0002-5639-4120 1 , 2 , 3 ,
• Geir Vegar Berg 2 , 4 ,
• Kari Kvigne 1 &
• Ragnhild Hellesø 3  

BMC Health Services Research volume  20 , Article number:  595 ( 2020 ) Cite this article

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Elderly patients with multiple health problems often experience disease complications and functional failure, resulting in a need for health care across different health care systems during care trajectory. The patients’ perspective of the care trajectory has been insufficiently described, and thus there is a need for new insights and understanding. The study aims to explore how elderly patients with complex health problems engage in and interact with their care trajectory across different health care systems where several health care personnel are involved.

The study had an explorative design with a qualitative multi-case approach. Eleven patients ( n  = 11) aged 65–91 years participated. Patients were recruited from two hospitals in Norway. Observations and repeated interviews were conducted during patients’ hospital stays, discharge and after they returned to their homes. A thematic analysis method was undertaken.

Patients engaged and positioned themselves in the care trajectory according to three identified themes: 1) the patients constantly considered opportunities and alternatives for handling the different challenges and situations they faced; 2) patients searched for appropriate alliance partners to support them and 3) patients sometimes circumvented the health care initiation of planned steps and took different directions in their care trajectory.

Conclusions

The patients’ considerations of their health care needs and adjustments to living arrangements are constant throughout care trajectories. These considerations are often long term, and the patient engagement in and management of their care trajectory is not associated with particular times or situations. Achieving consistency between the health care system and the patient’s pace in the decision-making process may lead to a more appropriate level of health care in line with the patient’s preferences and goals.

Peer Review reports

The World Health Organization [ 1 ] highlighted the need to implement an integrated people-centred health service, particularly for people with chronic or complex health conditions in need of care and support. Elderly persons with multiple health problems often experience disease complications and functional failure, resulting in a need for health care across different levels of care and social services. It has been shown that such care trajectories can be complex when many health and social personnel are involved [ 2 , 3 ].

Several terms have been used to describe patients’ needs that span levels of health care system, including care pathways, clinical pathways, critical pathways, care trajectories, standardised patient pathways and care bundles. The term care pathway can be defined as the management of care and chronological activities of a health care process for a well-defined group of patients during a well-defined period of time [ 4 ]. Standardised care pathways have been suggested as a solution for ensuring patient safety, improving risk-adjusted patient outcomes, increasing patient satisfaction and optimizing the use of resources [ 5 ]. Nevertheless, studies have shown that standardised care pathways are more effective in contexts with predictable care trajectories and low uncertainty and complexity [ 4 , 6 , 7 ]. At present, health care authorities have an increased demand for patient treatment standardisation and patient treatment individualisation. Standardised care pathways promote procedures and standardised activities. However, questions have been asked if these pathways are a risk to patient preferences and if individual needs will receive less attention [ 8 , 9 ].

In this study, we chose the term care trajectory that is commonly used to describe a patient’s journey through the health care system. According to Allen et al. [ 10 ], the term refers to ‘the unfolding of patients health and social care needs, the total organisation of work associated with meeting those needs, plus the impact on those involved with that work and its organisation’ [ 10 ]. They provide a framework for the understanding of the linkages between individual trajectories of care and broader health and social care systems.

Many elderly patients with multiple health problems perceive health services as complex and challenging to comprehend, and therefore need support from health care professionals to ensure continuity of services. The transition from hospital to home can be an uncertain and challenging experience [ 11 , 12 , 13 ]. Information and participation in planning and decision-making during hospital stays and discharge may be inadequate; therefore, elderly patients should be encouraged to participate. Studies have shown that patients’ health needs must be considered and the hospital environment should be organised and prepared to encourage patients’ participation in their discharge planning [ 14 , 15 , 16 , 17 ].

International as well as Norway health authorities have deployed standardised care pathways for specific patient groups. However, in Norway, no care pathways have been fully established and understood for elderly patients with multiple health problems [ 18 ]. Local tailoring combined with standardisation can be important in developing pathways that enable different purposes and contexts [ 19 , 20 , 21 ].

Research has emphasised the need to expand our understanding of complex care trajectories and why integrated health and social service care can be challenging. The importance of investigating how individual activities and decisions take place in an organisational context and how involved persons interact has also been emphasised [ 22 ].

The perspectives of elderly patients with complex health problems of care trajectories have been insufficiently described in previous studies [ 8 , 19 , 23 , 24 ]. New insights are required to achieve an integrated care pathway. Therefore, this study aims to explore how elderly patients with complex health problems engage in and interact with their care trajectories across different health care systems where several health personnel are involved.

The study used an explorative design. We adopted a qualitative multi-case approach to obtain an in-depth understanding of patients’ perspectives of care trajectories and how patients participate during their hospital stay, discharge and return to home process. This case approach was considered appropriate for examining patients’ real care trajectories because it was possible to account for the diversity of context [ 25 ]. The multi-case method enabled the exploration of inequalities and similarities across care trajectories, aiming to identify common patterns [ 26 ]. We recruited 11 patients representing diversity across contexts for our data collection. For each case, observations and multiple interviews were carried out to elucidate the divergent aspects of care trajectories. The cases provided us with rich and comprehensive information relevant to the aim of this study [ 25 ].

Setting and participants

The Norwegian health care system consists of two organisational structures. The local municipalities are responsible for providing primary care services, including general practitioners (GPs), intercommunal emerging primary care centres, home care services, nursing homes and preventive services. The Ministry of Health and Care Services is responsible for specialist care, which involves all hospitals. In 2012, the government implemented the Norwegian Coordination Reform [ 27 ] to strengthen the interaction between different levels of health services and to secure coordinated health care. Development of integrated care pathways, especially for patients with long-lasting complex health needs, has increased the focus on developing pathways. This reform, combined with the Patients Right Act, emphasises the importance of patient participation in improving the continuity and quality of care.

To identify patients who met our inclusion criteria, the study’s starting point was conducted at two different hospitals located in the same health region: one rural and one urban hospital. We intended to follow patients during their hospital stays and trajectories across different health care levels. We considered it inappropriate to recruit patient participants prior to possible hospital admissions. The recruiting process was, therefore, conducted at the hospital departments.

Patients were selected from the surgery and internal medicine departments of the hospitals. The inclusion criteria for the patient participants were as follows: older than 65 years, having 2 or more chronic diseases and living at home before hospital admission. The exclusion criteria were if the patient was not capable of giving consent or in the terminal phase. A contact nurse in the eligible departments informed the patients verbally and in writing about the study. Eighteen patients were requested for participation. Eleven patients consented to participate whereas seven patients declined due to worsening health conditions. The patients varied in age and the distance between their homes and the hospitals. Patients from nine different municipalities were involved. The population ranged from 2000 to 27.000 inhabitants. Characteristics of the patients who agreed to participate and the observation period for each patient are shown in Table  1 . No participants dropped out of the study.

Data collection

We applied an observationally driven approach to this case study [ 28 ]. The starting point for the data collection was to meet the patient in the department where he or she was hospitalized. The first author (MK), a PhD candidate and an experienced geriatric nurse, conducted field notes and conversations with the patients and repeated more structured interviews with the patients during the observation period. The professional background of the researcher was known to the participants. Moderate participant observation was used; the researcher was identifiable, interacted with the participants and engaged in activities, but did not participate in the setting [ 29 ].

The focus of the observations was to identify situations and activities during the care trajectory in connection with the health services and patient’s interactions with the involved persons. Typically, observation points at the hospitals involved sitting with the patient and observing activities and dialogue between the patient and health personnel, observing morning meetings with the staff group, noting pre-visits and doctors’ attendance at the patients’ rooms and following patients during discharge and their transfer home. In the municipalities, the observations commenced at the professional base of the homecare nursing or the multidisciplinary team and following the staff on their visits to the patients’ homes. On some days, when the first author visited patients at their homes or rehabilitation units, the next of kin was also present. The length of the structured interview varied from 5 to 45 min, according to the patient’s health status and day-to-day condition. The main theme of the interview was on the patient’s past, current, and future perspective on the care trajectory (See additional file  1 ). Overall, the first author conducted 24 structured interviews and 86 h of observations. The data were collected from November 2017 to June 2018.

Analysis process

The first author transcribed all the recorded interviews verbatim. Field notes were written down as short sentences during the observation. Immediately after the observations, the field notes were expanded into full sentences. All the data was de-personalised before analysis. A thematic analysis approach using Braun and Clarke’s [ 30 ] was applied . Initially, the first author read the field notes and the interviews thoroughly and chronologically for each case to identify essential characteristics and patterns. Notes were taken to describe the descriptive and analytical attributes of the data. Thereafter, the data were read and coded systematically and the codes were organised into possible sub-themes for the entire cases as illustrated in Table  2 . The back-and-forth process between the codes and possible themes involved reviewing relevant research and theoretical perspectives to help understand the data. This process revealed three main themes.

Ethical considerations

The study has been notified by the Norwegian Centre for Research Data (ID: 54551) and assessed and approved by the hospital data controller of the two hospitals.

Participation in this research was based on informed, voluntary consent. Ethical issues related to consent were considered during the recruitment process. During the observation period, the first author had a special awareness of maintaining voluntary and consent-based participation. Information about the possibilities to withdraw any time from the study was given both verbally and in writing. The first author had no contact with the patients before they were informed of this study by the nurse. The patients’ consent to participate was given both verbally and in writing. To ensure that patient anonymity is protected, some of the demographic data were rewritten. Hospitals and municipalities involved in the studies were anonymised.

The overall findings of this study suggest that patients’ engagement in managing their care during the care trajectory is not a linear process regarding time and space or situations and events that need action. They chose a variety of strategies to participate in their care management, driving the care trajectory forward and handling barriers. The patients were engaged and positioned themselves according to three identified themes: continuous consideration of opportunities and alternatives, consideration for appropriate alliances and circumvention of the health care initiation of planned steps.

The analyses revealed that the care trajectory is characterised as a landscape of complex and interconnected events and situations—sometimes planned, chaotic or ad hoc. In some settings during the care trajectory, patients need to deal with many activities simultaneously. The observations revealed that, in some situations, patients had to manage information on the follow-up treatment, medication changes, decisions regarding further health care and readiness to return home or nursing homes, which was given at the same time.

Another simultaneous event that occurred during hospital stays was when health personnel decided to move a patient to another ward or unit at the hospital because of limited space while they were prepared for discharge. Such a situation could be sudden and unexpected to the patient. On the day of discharge from the hospital, several activities, such as ongoing treatment and various controls, were conducted. In the municipality, the patient could receive health care services from several units with different health personnel involved, including homecare nursing and home care assistance, multidisciplinary team, physiotherapists and GPs. Parallel to primary care health services, patients also received outpatient treatment at the hospital.

To provide an in-depth understanding of the themes, cases that are typically for each theme are chosen.

Continuous consideration of options and alternatives

A strategy some patients used was to continuously consider options and possibilities on how they managed different actions and challenges during their care trajectory. The patients expressed their views on their current health situations. Furthermore, they also questioned how they could manage their situations and use their strength and energy appropriately and weighed different possibilities. They consider what was most important, what could wait and what was not possible.

Sometimes patients felt they were not ready to make decisions concerning changes in their housing situation or plan for further health care. They chose to see ‘what happens’ and prolong the decision. In situations involving several individuals and rapid changes in care environments, patients deliberated about their strength and capacity and assumed a distant or observant position.

Below, we chose to present two typical cases that describe the patients’ considerations of their opportunities and alternatives to housing conditions and further health care. The patients needed long-term decision-making beyond the period of hospitalisation and discharge planning. They held off on deciding until they were ready for it.

Anna was admitted to an internal unit at the local hospital due to chronic breathing difficulty that worsened. Anna lived in her apartment in a community near the hospital. A homecare nurse visited her once a day; and during the rest of the day, Anna managed by on her own. In the early phase of her stay at the hospital, she expressed that she was afraid she could no longer manage by herself at home; her health condition was too poor. However, she was still looking for possible options for going home and thinking about what she might need in terms of health care and facilitation, such as night visits by homecare nurses. This option was important for her, as it made her feel safe about being alone at home.

A few days after hospitalization, Anna was discharged to a rehabilitation unit in her home community. During her stay at the hospital and the rehabilitation unit, there was a conversation between her and the health personnel about either being discharged to her apartment or being moved to a nursing home. Anna was reluctant to be active in these decisions . Several times during these weeks, she expressed that she had to be in better shape and wait for further development before making a decision as illustrated in this quote:

‘When I feel that I can’t manage myself at home, there is no point in trying. Then, I just have to get help from someone by applying for a permanent place in a nursing home or a sheltered house. However, I have to say I am not ready for that yet. If I do not get any better, then I will have no choice, but I have to decide on that later. I will take it one day at a time and see what happens .’

After 3 weeks at the rehabilitation unit, Anna expressed that she needed to take it 1 day at a time but could already take a more active position:

‘I still have problems with my breath, but I am so satisfied and feel I am in better shape. I know my body. Next week, I will go home with help from homecare nurses. Tomorrow, we are going to have a meeting here. Then, we will decide on the number of visits I will need from the homecare nurse. Then, I will know. We are going to have the meeting together with the leader at the unit. ’

Anna’s case shows how several patients constantly considered their capacity and strength and continuously searched for possibilities and options. Anna chose to wait and hold off on deciding whether she should return home or to a nursing home.

May considered changing the house conditions to achieve the appropriate level of care for herself and her husband. She lived with her husband, who received assistance every day from homecare nurses due to illness and functional decline. They lived in a single house with bedrooms on the second floor. May took care of housekeeping, organised health care, and kept in touch with their GP and homecare nurses, among others. I (first author) met May when she was admitted to a hospital because of vertigo and declining general conditions, and followed her during her hospital stay and some months after her return home. After her discharge, she and her husband started receiving additional homecare nursing assistance, and a personal emergency response system was installed in their home. She worried that she and her husband could fall down their stairs. She mentioned several times that she and her husband were discussing applying for sheltered housing. According to May, the health personnel in community care told them many times that they could move to a sheltered house. She expressed:

‘We intend to apply for it, but we have not chosen to do so yet. Now, life goes on as before. It's stable, and I’ve got a personal emergency response system. The neighbour picks up the mail for us. Basically, we do not want to move out of the house as long as we can manage to lock the door!’

The cases show the constant considerations of what options would be the best for them.

Consideration of appropriate alliance partners

One strategy that patients used to handle unclear situations and considerations of health care was to search for health personnel they found trustworthy who could help them organise their health care needs. The patients described the people that supported them in their daily living and the trustworthiness of the health personal. These trusted persons and health personnel were strong alliances for patients during their care trajectories.

The following case describes how a patient actively searched for health care personnel who could help or take responsibility in his situation, which involved persistent health problems.

Eric was a patient with a complicated and persistent illness. After spending several weeks in a hospital for diagnosis and treatment, he was discharged and sent home. He lived with his wife in an apartment. Eric followed-up with two different wards at the hospital and received homecare nursing and physical therapy from the municipal health service. In daily life, he expressed that he and his wife had many unanswered questions about his health problems and symptoms. Eric mentioned several times how challenging it was to find health care personnel at the hospital who could give accurate information and somebody who could be responsible for his ongoing medical treatment. He was told that he needed to contact his GP, but he felt his GP was not particularly involved. Due to his limited interaction with his GP, Eric felt his symptoms were initially not taken seriously, and he lost trust in his GP. At one point, Eric felt he needed advice related to specific symptoms involving his leg and ongoing treatment but felt that he was not likely to receive proper health care. Thus, he approached a homecare nurse he trusted to contact the doctor at the hospital on his behalf about his concern with the leg. He told he did it this way:

‘The call becomes a priority when the nurse calls to ask about the symptoms. I talked to the nurse about this physiotherapist too, he needs a case summary and referral from the doctor. Now it’s okay, I got this by the doctor when I was at the hospital for treatment this week.’

This case illustrates how a patient actively searched for alliance partners to obtain access to proper health care in a setting where he needed to interact with many actors at different levels.

Circumventing the health care initiation of planned steps

We also identified cases where patients circumvented the hospitals’ formal planning systems because the situations were not well-facilitated or appropriate for their ability to participate. In some cases, patients design their care trajectory. The following case is an example of how a patient circumvented the hospital’s planning process.

Henry was admitted to a hospital because of heart failure. Some complications in his health situation unexpectedly prolonged his hospital stay. Because Henry suffered from hearing loss and slowed speech, it was challenging for him to understand and follow the information that was given to him at the hospital. During the pre-visit, the nurse and doctor discussed Henry’s return home. The nurse announced that Henry would need to establish some home care services, if nothing else, to help with his medication. During his doctor’s patient rounds, Henry did not have sufficient time to ask questions or give feedback. Henry tries to tell the doctor he has some questions, but it takes time because of his trouble with the speech. After a few seconds, the doctor says he can contact a nurse when he remembers.

After the visit, Henry told me (first author) that he was unsure about what the doctor meant when he told Henry that he should stay for at least one more day, that is, whether it meant that he might return home the next day or not.

Henry lived with his wife in a single house located in a rural area far from the hospital. His next of kin and health personnel from the community could not visit him during his hospital stay. He described his lasting relationship with the leader of the local homecare nursing facility and his GP. He expressed trust in the local health service like this.

‘I regularly visit my GP to take blood samples. I think my doctor is very capable. The leader in the homecare facility is a decent person. He knows about everything. He has helped us several times.’

During his hospital stay, Henry spoke of having phone contact with the leader of the homecare nursing facility. Together, they organised his need for health care and the assistance that he would require after discharge. He also contacted a neighbour to take care of snow shovelling at his home. The leader of the homecare nursing facility stated that he had known Henry and his wife for a long time. He added that Henry had been clear about coming home instead of being transferred to a nursing home. According to the leader, phone contact served as a way to stay in contact with the patient during the latter’s hospital stay.

This case is an example of how a patient actively chose another approach to handle the further direction of his care trajectory. The hospital’s environment and discharge planning did not functionally allow Henry to interact with health personnel. The next of kin could not be near the hospital for support. Therefore, he sought a new option for handling his situation and circumvented the hospital personnel’s plans and processes for discharge.

How the patients were engaged with and interacted in their care trajectories varied and was influenced by their health conditions and how their situation afterward could be managed. We found that the patients, who are often described as vulnerable, carried out considerable ‘homework’ to navigate their health condition as well as the system they accounted [ 31 ]. The patients constantly considered opportunities and alternatives in interaction, negotiations and relationships between many actors, or ‘players’ [ 22 ] for handling the different challenges and situations that occurred during their care trajectory. To understand why and how they searched for appropriate alliance partners to support them, and in some situations, how they circumvented the planned steps and took different directions in the care trajectory will be discussed against the conceptualisation of care trajectory game (CTG) [ 22 ]. The CTG framework merges Strauss et al.’s [ 32 ] descriptions on illness trajectories and Elias’s [ 33 ] game model and provide a framework to understand and address the dynamics and complexity in the system and thus, move away of thinking trajectories in mono-causal explanations which appear to be the characteristics of current policy [ 3 , 8 ].

The complexity in the patients’ care trajectory became visible throughout the patient’s multiple considerations about options and multiple alternatives they needed to take into account. They were dealing with balancing their strength and capacity and the complexity of the health care system in how they could be involved in decision-making. Their considerations seemed to be a continuous process. We identified that patient participation in their care trajectory was not linked to specific times or situations. Issues regarding the need for necessary health care and life modifications or changes in living arrangements were deliberated for patients throughout their entire hospital stays and continued after discharge. It was often an ongoing negotiation between patients, health personnel and next of kin. Patients wanted to have options, but time for recovery was often essential in preparing them for participation in decision-making. The patients’ also seemed to keep a watchful waiting whereby they try to maintain the status quo to desired preferences for as long as possible. The patients in this study used different strategies in situations with a disagreement between their preferences, health care need and initiation of planned steps. For example, they waited to be ready for decisions, circumvented planned steps and found a new direction in their trajectory. Allen et al. [ 22 ] point on that ‘disagreement’ over plan for further direction in the care trajectory not necessarily needs to be negative for the patient. The negotiations and different input from the involved can bring new opportunities and options, which are more in line with the patients’ preferences. It is not appropriate to try to simplify the complex care trajectories, but rather organize the services so that several opportunities and alternatives can be included [ 22 ]. Today’s health care system is characterised by overall expectations to the health personnel to working quickly and efficiently in bed administration, and hospital period is shortening [ 34 , 35 ]. With reference to CTG, health professionals can form an alliance to achieve an effective transfer of care. As an example to press for a nursing home placement rather than a home discharge, that can be easier to organize. From a health personnel perspective can this solution simplify the complexity in the organization of the patient care trajectories, but on the other side lock and hinder the patient’s ability to see different opportunities and alternatives, which are in preference to the patient’s wishes [ 22 ].

Our findings describe situations with interactions between patients and many health personnel at different health services levels. These situations increased the patients’ perceived considerations regarding which personnel could take responsibility for their treatment and organisation of their care. Existing literature has described patients’ and next of kin’ experiences of fragmentation regarding obtaining control and access to the health care system during discharge and follow-up care, which are in line with our findings [ 36 , 37 , 38 ]. We found that to handle fragmentation and uncertainty about health care, the patients sought alliance partners who could help in their interaction with and access to health care. When complexity increases in the care trajectory, fragmentation increases between the involved actors, leading to a re-grouping of those involved [ 22 ]. Unanswered questions about health problems and symptoms were uncertainty patients in our study experience and a lack of available and appropriate information. Kneck et al. [ 39 ] have pointed out that the patient is expected to be an active partner, but that the patients at home can have insufficient information to manage their illness. They may be unsure of ‘which symptoms might occur and who to contact for different needs’ [ 39 ]. Mattingly et al. [ 31 ] use the term ‘chronic homework, about tasks the patients and family caregivers are expected to carry out when moving health care from hospital to home. Their supporting network was essential to handle this ‘homework’, and to strengthen the patient’s possibility to take responsibility for their care. In our study, the patients described how they used their alliance partner strategically as an important support to achieve access to health care and to drive the plan further in the trajectory.

When the patients experienced that they were not involved in decisions concerning themselves, they used their strategies to circumvent the system. Insufficient facilitation of patient participation in the care environment is another barrier described in our study. Time and space for patients to participate in discussions about their health and the need for health care were not always arranged properly. Despite these situations, the patients considered their possibilities and alternatives and circumvented barriers and make their further plans . According to CTG, the resources available can both shape the complexity and cause those involved to make various moves to circumvent barriers.

Findings in our study describe inadequate facilitation of participation and necessary access to health care, norms and the view of the elderly person may contribute to it. Health professionals’ views of the elderly and younger are highlighted as a possible challenge in access to treatment and follow-up [ 40 , 41 ]. Hamran et al. [ 40 ] found that only based on a norm understanding that ‘they are just old’ access to health care could be less, and the time for treatment and improvement was expected to be resolved in the same way as young people who do not have the same complexity. Norms and values are interviewing with the actions and decisions in the care trajectory and increases complexity [ 22 ].

Implication for practice

For an elderly patient with complex health problems, there is expedient to develop a care trajectory that is developed to meet the need for flexibility. In practice, it can mean accepting that the patient is about participating in managing and making decisions, often a continuous and long-term process. Facilitating for this in organizing the health system service, and time and space for the patients’ considerations to managing necessary modifications in everyday life such as re-housing or move to a nursing home.

Methodological strengths and limitations

Triangulation of data sources, observations and individual interviews were used to investigate the care trajectory from different perspectives and settings, which was appropriate given then intention of the current study to gain a richer and deeper insight of patients’ care trajectories.

The first author who conducted the observations and interviews was an experienced geriatric nurse. The researcher’s assumption, skills and knowledge will influence the focus in observations and shape the interpretation [ 42 ]. Background as a nurse gave the advantage to understand the field. To strengthen the trustworthiness, additional reflection notes were performed describing choices, questions or thoughts that arose during the observations and were for review by the research group.

The first author followed each patient over a long period, which contributed to a broad understanding of each patient’s case. We experienced some challenges in recruiting participants due to patients’ health conditions and vulnerable situations. Despite that the participants’ age, living situation and home setting varied. Since the findings are based on a small sample, they should be considered with caution in the light of generalizability. Nevertheless, we believe these findings provide new insight and understanding of the complexity of elderly patients’ care trajectories.

The patients’ considerations of their health care needs and adjustments to living arrangements are constant throughout the care trajectory. These considerations are often long term, and the patients engagement in and management of their care trajectory is not associated with particular times or situations. It may be important for elderly patients’ time for recovery in order to consider different possibilities and options before managing necessary modifications in everyday life.

Disagreements between preferences, the need for health care and the initiation of planned steps, leads to different strategies from the patients. They wait to be ready for decisions, circumvent planned steps and find a new direction in their trajectory.

Achieving consistency between the health care system and the patient’s pace in the decision-making process during the care trajectory, may lead to a more appropriate level of health care in line with the patient’s preferences.

Abbreviations

General practitioner

Care trajectory game

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Acknowledgments

We would like to give our sincere thanks to the patient who participated in this study. Furthermore, we will thank all the staff in the hospitals and the municipalities who helped recruiting and facilitating the study.

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The data materials generated during the current study are not publicly available due to the sensitive and identifiable nature of the data. Despite names and other identifiers being removed, the in-depth nature of the interviews and field notes themselves may mean that participants can be identified from the full transcripts.

This project is founded by a grant from the Inland Norway University of Applied Sciences and a grant from the Innlandet Hospital trust Norway. The funding body has had no role in the design of the study, the data collection, the analysis and the interpretation of data or the writing of the manuscript.

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MK, KK, GVB, RH contributed to the conception and design the study. MK performed the data collection and the analysis, and developed the manuscript. KK, GVB, RH contributed to the interpretation of analysis. MK and RH critical revised the manuscript. All authors read an approved the final manuscript.

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The project was notified by the Norwegian Centre for Research Data (NSD), ID: 54551. NSD assessed that the processing of personal data was regulated in The Personal Data Regulations [Forskrift om behandling av. personopplysninger]. NSD considered that the project did not raise any ethical issues, which was in need of ethical approval. The project was also assessed and approved by data protection officer at the hospital.

Participation in this research was based on informed and voluntary consent. All patients that filled the inclusion criteria received verbal and written information about the study. A senor nurse in the department assessed and assured the patient’s consent competence. No participants included in this study had a cognitive decline. All participants consented to participate on their own behalf and signed an informed consent. They were free to withdraw from the study at any time.

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Interview guide. Patient interview schedule

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Kumlin, M., Berg, G.V., Kvigne, K. et al. Elderly patients with complex health problems in the care trajectory: a qualitative case study. BMC Health Serv Res 20 , 595 (2020). https://doi.org/10.1186/s12913-020-05437-6

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A Multiple Case Study of Older Adults’ Internal Resiliency and Quality of Life during the COVID-19 Health Emergency

Jonaid m sadang, daisy r palompon, deane joy e agoncillo, namera t datumanong, jamal tango p alawiya.

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Corresponding Author Jonaid M. Sadang, RN, RM, LPT, MAN, MAEd, PhD h.c., DScN College of Health Sciences, Mindanao State University, Marawi City, 9700 Lanao del Sur, Philippines E-mail: [email protected] or [email protected]

Received 2023 Feb 25; Revised 2023 Apr 22; Accepted 2023 May 16; Issue date 2023 Jun.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/ ) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Few studies have been conducted on unique conditions such as coronavirus disease 2019 (COVID-19) as an emerging health emergency, despite the strong link between resilience and quality of life in older persons. This study validated the expanded need-threat internal resiliency theory, which claims that an older person who establishes a strong sense of internal resiliency adapts to the situation by maintaining a better disposition.

The underlying methodology in this study was a qualitative design using multiple case studies with non-probability purposive sampling to choose the target participants aged 60 years and above.

This cross-case analysis showed two major themes that explained and described the similarities and differences between the internal resiliency and quality of life of older adult participants with their respective sub-themes. Furthermore, this study concluded that older adults who have developed a strong sense of internal resilience, as manifested in the participants’ coping strategies during the COVID-19 pandemic, have sustained quality of life and better life satisfaction.

The study proposes a shift in the perspective of aging by emphasizing the importance of resilience as a dynamic process helping in the coping process and adapting to new emerging pandemics, leading to improved quality of life amid adversity.

Keywords: COVID-19, Older adults, Quality of life, Qualitative research, Philippines

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic, initially discovered in 2019 in Wuhan, China, caused a global public health emergency, impacting hundreds of countries and severely affecting the general population health, 1 , 2 ) particularly older people, worldwide. 3 , 4 ) The likelihood of critical disease resulting from infection with the virus is particularly concerning for those >60 years of age. Hence, experts and older adult advocates have emphasized the importance of protecting, caring for, and supporting this vulnerable population. 5 ) Different places throughout the country have been placed under a lockdown or community quarantine in response to the mounting threat of the pandemic, including travel restrictions, the closure of various public and private establishments and offices, and the stringent implementation of home isolation and social distancing preventive measures. 6 , 7 )

Since the COVID-19 outbreak, various researchers have investigated the impact of this pandemic on the psychological health of older people, which substantially influenced their life satisfaction and quality of life as individuals. 4 , 5 ) As preventative measures, social distancing and isolation have negatively impacted the overall well-being and health of the older population. 7 ) Most literature on the COVID-19 pandemic has identified the negative psychological impacts of such measures on older people because of their considerable implications on people’s daily life activities, affecting their holistic functioning and well-being. 1 , 2 , 5 )

During the COVID-19 global health emergency, people aged ≥60 years are at a higher risk of depression, poor health-related quality of life, and low life satisfaction. 1 , 5 ) Restricted social networks and high levels of social isolation act as mediators, amplifying negative moods and reducing life satisfaction. 8 ) Quality of life refers to one’s perception of the influence of illness or medical conditions, such as the COVID-19 crisis, on several domains of functioning, including physical, psychological, social, and spiritual aspects. 1 , 4 , 9 ) Therefore, quality of life is a vital predictor of overall health and resilience. 9 ) However, infectious disease outbreaks, such as emerging health emergencies, have negatively impacted these domains of functioning, particularly in older people, generating emotional distress and developing depressive symptoms, highly reducing the quality of life of this demographic group. 1 , 5 ) Previous studies during the severe acute respiratory syndrome (SARS) outbreak highlighted the extensive decline in survivors’ quality of life, and its negative psychological implications, mainly because of the quarantine measures during the SARS outbreak. 9 )

Resilience has multiple facets that vary by age. For older people, common health problems may disproportionately affect resilience, whereas health crises such as COVID-19 exacerbate existing mental and physical conditions. 2 ) Similarly, some people suffer from the mental effects of such situations, while others, such as the older population, are resilient and move on with their lives, as already documented. 10 ) Internal resiliency refers to an older person’s ability to cope with adversity or a stressful experience (e.g., the COVID-19 crisis) and return to normalcy by surviving difficulties and positively adapting to circumstances. 4 , 11 , 12 ) Adaptability improves life satisfaction and quality of life in older adults during emerging health emergencies. 10 , 11 )

Resilience refers to the capacity to improve after failure, making a mistake, or experiencing a poor outcome. A resilient individual would not allow difficulties or problems to impede their objectives or overall achievements. To successfully navigate challenging situations, Dr. Howard 13 , 14 ) worked with hundreds of high achievers before developing the resilience pyramid, which includes Levels 1 to 5, which refer to energy, connection, thinking, awareness, and flow. Resilience is a multifaceted term and can be considered an attribute shared by all people to varying degrees, as well as a dynamic process with bidirectional relationships to developmental and environmental factors and a response or outcome to stress and adversity. 15 )

The original theory on need-threat internal resiliency asserts that older people's health needs can become health threats during the COVID-19 crisis and that older people must develop internal resiliency to maintain their integrity, well-being, and quality of life. 4 , 12 ) However, the theory developed in response to this pandemic may not apply to other emerging health emergencies, necessitating the development of a more comprehensive theory to explain the coexistence of needs and threats in older adults as driving forces in the development of internal resiliency. The unique characteristics of this newly expanded theory provide more specific and detailed processes and outcomes that older people experience during such situations, which is central to the lives of such age groups allowing them to efficiently and effectively cope and adapt. 11 )

One assumption of connection is that “an older person who established a strong sense of internal resiliency adapts to the situation by maintaining a better disposition.” 11 ) The link between resilience and quality of life in older people is long known, and resilience is strongly and favorably associated with subjective assessments of the quality of life in this age group. 16 ) However, few studies have investigated this link in challenging situations, such as COVID-19. 11 ) Most studies showed that negative situations experienced by individuals during global health emergencies reduced life satisfaction; circumstances, such as positive life experiences, social support, good social relations, and psychological strength increased life satisfaction. 7 , 8 , 16 ) Through a multi-case design, the present study explored the similarities and differences between older adults’ internal resilience and quality of life while facing a health emergency to validate the theory’s propositions. When recommendations are deeply rooted in empirical data, multiple case studies offer a more compelling approach. Thus, varying situations enable a deeper exploration of research issues and the development of theories. Theoretical replication in many case studies tests the theory by contrasting the results with fresh cases. Theoretical replication can be demonstrated by additional waves of cases with opposing propositions if a series of examples show pattern matching between the data and propositions. 17 )

Study Objective

This study aimed to validate the proposition of the expanded need-threat internal resiliency theory on emerging health emergencies, which states that older persons who establish a strong sense of internal resiliency adapt to the situation to maintain a better disposition. Hence, this study explored the similarities and differences between older adults’ internal resiliency and quality of life while facing the COVID-19 health emergency. This study included open-ended questions during interviews to achieve this; these questions enquired the participants about (1) how they perceived the COVID-19 pandemic as a person, (2) the challenges they encountered during the COVID-19 pandemic and how they coped with such situations, (3) how their coping and or adapting strategies differed from those of other older adults during this COVID-19 pandemic, (4) their living conditions during this COVID-19 pandemic, (5) their life satisfaction during this COVID-19 pandemic, (6) their quality of life during this COVID-19 pandemic, and (7) some life lessons they learned from this COVID-19 pandemic.

MATERIALS AND METHODS

We performed a qualitative multiple-case study to provide more detailed descriptions and explanations of the phenomena. The case study method is useful for comprehending a topic in-depth in the context of a real-world event, phenomenon, or concern. In multiple case studies, several cases are carefully selected to allow for comparisons across multiple cases and/or replications. 18 ) Many disciplines, particularly the social sciences, frequently use this well-known research technique. While there are numerous definitions of a case study, they all call for a detailed analysis of an event or phenomenon in its original context. For this reason, a "naturalistic" design is often used instead of an "experimental" design, which attempts to exert control over and manipulate the variable(s) of interest. 18 , 19 )

Participants and Locale

This study involved older persons aged ≥60 years who had been staying in Marawi City since the official declaration of the COVID-19 pandemic in 2019 until now. The inclusion criteria were: (1) at least 60 years of age at the start of the pandemic, (2) having evolved coping strategies in response to this emerging health emergency and displaying characteristics of adaptation to this health crisis through the identification of at least one or more specific types of coping activities used in facing the COVID-19 pandemic, and (3) willingness to participate in the study irrespective of their other socio-demographic profiles. Participants in the target sample were excluded if they had cognitive, memory, or physical disabilities that affected their experiences in this situation.

Sampling Technique

Non-probability purposive snowball sampling was used to select sample participants from six older adults based on data saturation. In qualitative research, purposeful sampling is widely used to identify and select cases with relevant information on the topic under study; this includes determining and selecting individuals or groups with specialist knowledge or experience in a phenomenon of interest. It also entails considering participants’ availability and willingness to participate, including their ability to convey their experiences and thoughts in a direct, expressive, and thoughtful manner. 20 ) Snowball sampling is a technique in which study participants or others with access to potential participants recommend individuals having experience or characteristics comparable to the researcher’s interests (Naderifar et al. 21 )). Up to 3–4 cases for comparison can be efficiently handled in a multiple-case study using purposeful sampling comparison. 18 )

Instrument and Data Collection

We conducted semi-structured interviews. The method included a guide questionnaire that allowed the order to be modified depending on the conversation, allowing the researcher to emphasize certain questions while including new ones. 22 ) For instance, questions about the participant’s physical, social, psychological, and spiritual well-being (e.g., how do praying and reading the holy book help you cope with the COVID-19 pandemic and maintain your good outlook?) as older adults during health emergencies were added to explicitly explore their quality of life from a holistic perspective. The schedule was set based on the convenience and approval of the volunteer participants. The interviews were completed within 30–60 minutes, based on the participant’s area of comfort and convenience. The guided questionnaire contained eight general questions translated into the participant’s layman’s dialect to delve further into their experiences with the phenomenon under consideration; probing questions were added based on their flexible responses to these guide questions. Before being used in the study, three qualitative research experts in the respective field of discipline thoroughly reviewed this set of questions. The most typical qualitative data source in healthcare research is semi-structured, in-depth interviews, generally utilized in qualitative investigations. This approach frequently involves discussions between the researcher and participant and uses a flexible interview methodology, including additional follow-up questions, probes, and remarks. This method enables researchers to collect unstructured data, delve into sensitive and often private subjects, and examine participants’ ideas, feelings, and viewpoints on a particular subject. 23 )

Ethical Considerations

The Research Ethics Board of Cebu Normal University approved this study before participant enrollment (No. REC-01-31-22). Additionally, the researchers requested permission from the Office of Senior Citizens of Marawi City, a unit of the Department of Social Welfare and Development. Basic ethical principles in conducting qualitative studies, such as beneficence, respect for human dignity, and justice, were observed throughout the study. Moreover, informed consent was obtained from the participants to ensure that they had received appropriate information about the study, comprehended the material, and had the right to refuse at any moment during the interview without reason. 24 )

Although they were free to avoid answering any questions that would make them uncomfortable and withdraw from the study at any moment, the participants were not subjected to any physical or psychological threat. They were also assured that a guidance counselor would be available before and after the interview if they experienced psychological or emotional stress. The researcher ensured that the study participants’ ethical rights were upheld and that no moral lapses occurred throughout the investigation. Pseudonyms or codes were used to safeguard the respondents’ privacy. The researcher also spoke with the participants about their preference to participate in the study at home, at another location alone, or with assistance. Furthermore, COVID-19 health safety procedures were strictly adhered to protect the researcher and the participants.

Also, this study complied the ethical guidelines for authorship and publishing in the Annals of Geriatric Medicine and Research . 25 )

Data Analysis

This study conducted a cross-case analysis. This analysis allows researchers to compare similarities and differences in the events, actions, and processes that comprise the units of analysis in this case study. Themes, similarities, and distinctions between cases are used to connect the evidence gained to the proposition using cross-case analysis. 26 ) This research strategy simplifies the comparison of the parallels and discrepancies among the events, behaviors, and procedures that form the cornerstone of the case study analysis. With a cross-case analysis, the investigator’s expertise expands beyond a single case. It sparks the researcher’s creativity, brings up new problems, offers fresh viewpoints, produces alternative explanations, develops models, and conjures ideals and utopias. 27 , 28 ) Additionally, this analysis makes it possible for researchers to identify the variables that could have affected the case’s outcomes; seek an explanation for why one case is unique or similar to others; make sense of puzzling or unusual findings; or better express concepts, hypotheses, or theories that found or developed from the initial case. Cross-case analysis helps researchers to understand the potential links between disparate examples, gather data from the first case, develop and refine ideas, and establish or test theories. By applying cross-case analysis, researchers can compare examples from one or more settings, communities, or groups. 28 ) We applied the Miles–Huberman approach, which entails three continuous flows of operations. These include (1) data reduction, the process of choosing, concentrating, simplifying, abstracting, and altering the outcomes of investigations; (2) data display, in which organization and compression of the information allows the drawing of conclusions and the taking of action utilizing a “tool-box”; and (3) conclusion drawing and verification, where qualitative analysts begin to determine what things mean from the outset of data collection by noticing regularities, patterns, explanations, potential configurations, causal processes, and propositions. 29 )

Rigor and Trustworthiness

Credibility, transferability, dependability, and confirmability, the four criteria created by Lincoln and Guba (1985) in ensuring rigor and trustworthiness, were strictly observed and used in the execution of this qualitative investigation. 30 ) To prove its validity, the researchers reviewed each participant’s transcript to identify patterns among all participants to interpret an event so that those who have had it may relate to it easily. While describing the demographic and geographical parameters of the study to check for transferability, the researchers provided a thorough description of the groups under consideration. Peers were engaged in the analysis process for dependability and a thorough explanation of the research methodology was provided. Finally, confirmability was evaluated using a self-critical mindset that considered how the researcher’s preconceptions affected the findings.

This section discusses the results of this qualitative multiple case study that aimed to validate one of the propositions of expanded need-threat internal resiliency, that an “older person who established a strong sense of internal resiliency adapts to situation in maintaining a better disposition,” using cross-case analysis. This study included six senior citizens following set parameters, and data saturation was observed in the data analysis process during transcription. This was undertaken through unit analysis, which involved connecting the transcribed data to the proposition under consideration and interpreting the findings to support this proposition. Following the unit analysis, we developed subthemes and categorized them further into themes connected to the proposition. The results revealed two major themes and their respective subthemes. Theme 1 discusses the differences and similarities in older individuals' coping strategies and responses to the COVID-19 pandemic, also known as “internal resiliency,” which the study participants used to cope effectively with the COVID-19 health emergency. These internal resiliency strategies include acceptance of COVID-19 as an illness, self-discipline and strict observance of health protocols, the practice of healthy lifestyle activities, trust in healthcare professionals, and a strong spirit and strengthening of spiritual beliefs.

Theme 2 describes the similarities and differences in older adults’ life disposition during the COVID-19 pandemic. The participants described their life disposition, particularly in terms of life satisfaction and quality of life, as stable and even improved despite the challenges and adversities they faced (and still face) as a result of the COVID-19 crisis, despite their vulnerability as a population group. Life disposition included a sustained source of living and basic needs, the absence of illness, family as a source of satisfaction, and a strengthened spiritual connection. We identified two notable life dispositions related to the expected consequences of COVID-19 crisis management, including restricted social life and psychological disturbances.

Participant 1 (P1) was a 64-year-old married woman residing with her extended family. Her primary means of support were family and government assistance, such as pensions for older citizens. Compared with before the pandemic, during the pandemic, she spent most of her time at home and frequently visited her relatives during the pandemic. She believed the COVID-19 pandemic to be similar to emerging illnesses in her early childhood, including fever, chills, and cough. Hence, following the authorities' instructions to stay home was the primary step in preventing this illness.

Participant 2 (P2) was a 62-year-old married man who lived with his wife and children. He was currently employed by the government in a provincial agency. He claimed that the COVID-19 pandemic had affected the entire world and that the best way to end this crisis was to adhere to health protocols, including getting vaccinated, wearing masks and face shields, and avoiding close contact with others. He also had symptoms of COVID-19 during the outbreak but had never undergone testing.

Participant 3 (P3) was a 70-year-old married man who resided with his family in their ancestral home. He was a retired elementary school teacher and administrator who received a monthly government pension. He held a doctorate in education and had dedicated his entire life to teaching until reaching retirement age. He confined himself to their home throughout the pandemic and kept busy in their backyard with gardening as a way of coping. He claimed to have carefully observed practicing a balanced diet, exercising, and taking maintenance medications on time to avoid contracting this disease.

Participant 4 (P4) was a 61-year-old married woman who had been working as staff in a university for more than 30 years. Before the COVID-19 crisis, she preferred to visit her siblings and other family members; however, the pandemic prevented her from doing so. She nevertheless consistently showed up for work. She had been exposed to a person with COVID-19 but never tested positive for the illness. She acknowledged that the pandemic brought many difficulties and obstacles to her personal life, but she managed to overcome them.

Participant 5 (P1) was a 64-year-old married man who lived with his wife and children. Before retiring at 60 years of age, he was an overseas Filipino worker (OFW) in the Middle East. After retiring overseas, his business became his primary source of income. He claimed that his business suffered significantly due to the societal restrictions and lockdowns brought on by the pandemic, yet he was still able to operate normally, even during the peak of the crisis. He enjoyed interacting with friends and family, especially before the pandemic, but still managed to maintain the same attitude during the pandemic.

Participant 6 (P6) was a 67-year-old woman who was a retired elementary-level teacher. As she was already widowed, her primary source of income, especially in light of the COVID-19 pandemic, was her government-issued monthly pension. She claimed that the lockdowns and social limitations imposed on the community at the height of the crisis made this pandemic one of the most difficult periods of her life. She had liked to roam around malls after receiving her monthly pension but could not do so after the pandemic began; however, she enjoyed staying at home with her family, especially her grandchildren.

Table 1 shows the cross-case matrix of the participants’ profiles in terms of age, sex, marital status, religion, highest educational attainment, source of living, level of resiliency, coping strategies, and life disposition. This study involved three male and three female Muslim older adults aged between 61 and 70 years, most of whom were married. Majority had earned graduate degrees or at least college degrees. Four relied on jobs, employment, and pensions to make ends meet. Their levels of resiliency were based on Howard’s resilience pyramid, which has five levels: level 1 (energy), level 2 (awareness), level 3 (mindset), level 4 (connection), and level 5 (flow).

Cross-case matrix of the participants’ profiles and levels of internal resiliency during the COVID-19 pandemic

In level 1 (energy), a person must improve their physical vigor. Controlling energy requires examining routines and ways of life to determine what is or is not working. This pyramid level supports the other levels and serves as the basis for resilience. The pyramid's base level, or level 2, is awareness and aids in stabilizing the foundation. The important markers of this level are growing self-awareness and understanding of the causes of stress and how to deal with them. At this level, concentration on what is vital is achieved by controlling stress triggers. Level 3 (mindset) calls for intentionally using thoughts to focus on answers and avoid ruminating on difficulties once control over energy and awareness of the manifestation of our stress is achieved. Level 2 strategies were beneficial. In this step, individuals should also make goals and have a vision for each day or their lives.

In level 4 (connection), a person can help others to become more powerful. Individuals at this level should already be able to manage their emotions and energy levels, as well as set boundaries and be aware of their limitations. Individuals should also encourage others to be their best versions while simultaneously emphasizing the value of their limits to prevent demotivation and burnout.

Finally, in level 5 (flow), individuals safeguard their value as human beings and treat themselves as high-performing. By incorporating these steps, obstacles can be overcome, and progress can continue. Through this process, individuals discover more about themselves, develop new abilities, and overcome the overwhelming feelings that formerly held them back. 13 , 14 )

Thematic Results

Two major themes were derived with their respective subthemes to explain and describe the differences and similarities in coping strategies and life dispositions of the older adult participants amid the COVID-19 crisis. These coping strategies and measures, known as “internal resiliency,” were assumed to be the underlying factors that helped these individuals to effectively adapt to such health emergencies, leading to the maintenance of stability and better life disposition in late life, consistent with the proposition of the expanded need-threat internal resiliency theory, which states that “older person who established a strong sense of internal resiliency adapts to situation in maintaining a better disposition.” These themes and subthemes are summarized in Table 2 and discussed further in the following sections.

Derived themes and sub-themes

Theme 1: Coping strategies and measures used by older adults to adapt well to the COVID-19 pandemic

This theme describes the differences and similarities in coping strategies used by older adults to adapt to the COVID-19 pandemic. These “internal resiliency” strategies were created by such people to adapt well to dangers, trauma, or significant sources of stress, collectively known as emerging health emergencies, to achieve and maintain a sense of purpose and vigor, and to emerge stronger amid such trying circumstances, resulting in sustenance or improved outlook in later life. The internal resiliency strategies used by the participants included acceptance of COVID-19 as an illness, self-discipline and strict observance of health protocols, the practice of healthy lifestyle activities, trust in healthcare professionals, and a strong spirit and strengthening of spiritual beliefs.

Sub-theme 1 (Acceptance of COVID-19 as an illness): The first sub-theme refers to the acceptance of the existence of COVID-19 as an illness, which is among the emotion-focused coping strategies practiced by older adults in facing emerging health emergencies. This subtheme was supported by the following participant statements:

“Sakun na kagya adun a wata akun a miklas sa medicine na ditawn die makapangi-ngisa na paniwala ako a adun talaga a covid-19 sie sa ingud tano aya. Pkaylay tano sa social media ago mga news a tanto a madakul a kya apektowan ago so pud na mindod sa limo o ALLAH swt misabap sa gyangkae a paniyakit. ” [Since I have a son who has studied medicine and was able to ask questions, I believe in the existence of COVID-19 in my community in my situation. We see on social media and the news that many have been affected, and others have even died of this illness]. – P2

“So mga restrictions na tanto a margun lalo so kapakindodolona ko pud a taw, ogaid na paka adap-ako ka kagya inaccept akun angkae a masoswa-swa ago dapat na pka follow tano so mga bitikan ago policy. ” [The restrictions are very difficult, especially in terms of socializing with other people, but I cope with this by accepting the situation and the need to follow rules and regulations.] – P5

Sub-theme 2 (Self-discipline and strict observance of health protocols): The second subtheme considers the participants' self-discipline and strict adherence to health protocols during the COVID-19 crisis to successfully avoid contracting the illness and adjust to the situation. This problem-focused coping mechanism can be employed when facing difficulties. This subtheme was supported by the following participant statements:

“So sitwasyon tano imanto na siebo anan matitimo ko taw. Dapat na may disiplina tayo at alam ntin ang mga protocols na binibigay ng otoridad ago dapat na ino-observe natin yon. Sabinga nila na aya mapiya a taw na so katawan iyan so kapanang-gila. Na kagya sabap sa aya ta ipkaluk ta na obata mapositive ago ma quarantine odi na mawit sa ospital na aya pingola-olako na so makapantag ko paano maiwasan at ma spread a gyangkae a paniyakit ago igira adun a magugudam akun na diyako die quarantine sa kwarto a sakun bo. ” [Our situation today depends on people. We must have discipline, and we should know the protocols given by the authorities and observe them. They stated that a good person knows how to avoid such issues. Because we are afraid that we might be positive, quarantined, or hospitalized, what I did was to prevent and spread this illness, so I usually quarantine myself in the room alone when I feel something is new.] – P2

“Aya syowa akun na pagosar ako sa preventive measures datar o kasulot sa mask, kausar sa alcohol, ago face shield, ago social distancing igira sisie sa public a mga areas. ” [What I did was I used preventive measures like wearing masks, limiting alcohol use, using face shields, and social distancing in public areas.] – P3

Sub-theme 3 (Practice of healthy lifestyle activities): The third subtheme focused on the participants' adoption of healthy lifestyle practices to strengthen their immunity to COVID-19, allowing them to respond effectively to the community's ongoing emergent health emergency. These lifestyle practices included eating a balanced diet, exercising, ensuring strict compliance with medication maintenance, taking vitamin supplements, and engaging in various diversionary activities for mental health. These measures are dimensions of both problem- and emotion-focused coping strategies. This subtheme was supported by the following participant statements:

“Gyangkae a covid-19 na myakapanang-gila so taw. So di pag-exercise na myakapag exercise. Apya so dingka kun na myakan ka lagido gulay ago prutas ka pantagbo sa an pakabagur so lawas ka para kaiwasan ka gyoto a covid-19 a paniyakit. ” [People must be careful about COVID-19. Those who don’t exercise are able to exercise. Even if you don’t eat vegetables and fruits, you are now eating them to strengthen your body and avoid getting infected with this illness.] – P2

“Dyakopn die mag exercise ago regular so kapaginom akun sa maintenance akun a bolong para sa highblood ago vitamins. Diyakopn die garden sa walay para pkatumbang apya maito. ” [I exercise and regularly take my maintenance medication for high blood pressure, and I take vitamins. I also do some gardening at home so that I remain entertained somehow.] – P3

Sub-theme 4 (Trust in healthcare professionals): The fourth subtheme refers to the trust given by the participants to healthcare professionals facing the COVID-19 pandemic. These people have served as sources of information and guidance, especially for observing health protocols against such illnesses and managing symptoms related to COVID-19. This practice is part of problem-focused coping, particularly using informational support to adapt and emerge well in such emerging health emergencies. This subtheme was supported by the following participant statements:

“Sie raknun na kagya adun a mga wata akun a miklas sa medicine na pagisaan akun siran ago sie ako kiran puk-wa sa advice. ” [For my part, since I have a son studying medicine, I usually ask him for advice.] – P2

“Sakun na paratiyayaan akun so mga pkanug akun ko mga doctor ago nurses a health measure sa gya covid-19. Di ako basta basta psong ko madakul a taw ago bako pliyo a daa sabap a ipliyo akun. ” [As for me, I believe what I hear from doctors and nurses about health measures for covid-19. I don’t just go out to meet many people and come out for no good reason.] – P3

Sub-theme 5 (Strong spirit and strengthening of spiritual beliefs): The fifth subtheme refers to the strong spiritual relationships developed by the participants as an overarching coping strategy in facing and adapting to the COVID-19 crisis. These activities involved the practice of the five daily prayers as Muslims, reading the holy book (Qur’an), putting their trust in the creator, doing a lot of dhikr, or constantly remembering the name of God (ALLAH swt). This type of coping is emotion-focused coping, which is unique and widely used among the older population during times of adversity. This subtheme was supported by the following participant statements:

“Naka-adjust ako dahil nilakasan ko ang loob ko at basta malaka e paratiyaya ko ALLAH (swt) na pkakayangka apya antonaa klase a problema. Pakadakulun ka so simbangka ago so tasbik ka, ago kapangadi sa qur’an, na In shaa ALLAH na ipkalimo o ALLAH swt so manosiya a lagidoto. So kasambayang na aya mala pakawgop rakun nago aya lalayon akun a pipikirin na so ALLAH swt. ” [I was able to adjust because I took courage, and as long as you have great faith in ALLAH (SWT), you can withstand any problem. We must increase our prayers and always read the Qur’an (a holy book for Muslims); surely, he will always help and bless us. Our prayers can help us a lot, and I always remember God’s (ALLAH swt) name.] – P1

“Sa prayer ko dinadaan ang lahat. Ang ALLAH swt lang ang nakaka control sa mga bagay bagay. ” [In my prayer, everything goes through. Only ALLAH swt can control things.] – P4

Theme 2: Life dispositions of older adults in the COVID-19 pandemic

This theme describes the similarities and differences in the life dispositions of older adults during the COVID-19 pandemic. The participants sustained or even achieved better life satisfaction and quality of life despite the challenges and adversities they faced as persons in this health crisis, in addition to their vulnerabilities as a population group. This life disposition, as described by the participants, includes a sustained source of living and basic needs, the absence of illness, family as the source of satisfaction, and a strengthened spiritual connection. However, we identified two notable life dispositions related to the expected consequences of the management of the COVID-19 crisis, including restricted social life and psychological disturbance.

Sub-theme 1 (Sustained source of living and basic needs): The first subtheme describes how older adults in this study have sustained their sources of living and basic needs while facing the COVID-19 crisis despite the challenges that this pandemic has posed to the financial and economic stability of the community. Most participants stated that their primary source of living had consistently sustained their basic needs amid the pandemic, paving the way for them to live good and even improved lives as older adults. This subtheme was supported by the following participant statements:

“Mabuti, ganun parin ang aking pamumuhay. In shaa ALLAH na walang pagbabago kasi nakaka-kain parin ako ng maayos at walang problema sa pera dahil hindi naman ako maluhong tao. ” [Good, my living conditions are the same. In Shaa ALLAH, there are no changes because I can still eat well and have no money issues since I am not a luxury person.] – P1

“Okay nman ang pamumuhay ko kahit covid-19 pandemic kasi government employee tayo at may sweldo parin kahit papano. Mas nakatipid pa tayo kasi hindi tayo makalabas at pasyal sa mga malls. ” [My life is good even during the COVID-19 pandemic because I am a government employee and still earn a salary. We can save even more because we can neither go outside nor visit malls.] – P4

Sub-theme 2 (Absence of illness): The second subtheme describes how, despite their vulnerability as a population group, older persons in this study managed to avoid getting sick during the COVID-19 pandemic. However, they accepted the fact that certain physiological changes exist due to their age, which is a normal part of aging and is not directly related to the illness caused by COVID-19 virus. The absence of illness during health emergencies has helped older adults sustain their life satisfaction and quality of life amid adversities. This subtheme was supported by the following participant statements:

“So kambobolawasan akun na mapyadn ogaid na basta pakatowa so edad na dirundn kada so mga sakit sa lawas ka part anan o ageing. ” [My physical health is so far good; however, when we get old, it is normal to feel some changes that include body aches as part of aging.] – P1

“Normal so kaledad a kapka-oyag-oyag akun. Mapiyadn odi na health a magugudam akun kasi na dako katakdi angkaya a COVID-19.” [My quality of life is normal. I feel physically healthy because I am not affected by Covid-19. ] – P5

“Wala namang masyadong problema sa physical na aspeto sa awa ng ALLAH swt. Wala naman akung mga nararamdaman na sakit simula magka pandemya hanggang ngayon. ” [There is not much problem with my physical health at the mercy of ALLAH swt. I have not felt any pain since the pandemic began.] – P6

Sub-theme 3 (Family as a source of satisfaction): The third subtheme describes how older adults sustained their quality of life despite the COVID-19 crisis with the help of their families, who served as sources of satisfaction. This source of satisfaction made their lives easier and more resilient in dealing with such a health emergency in the community, despite the challenges and struggles of the movement restrictions and lockdowns, especially for vulnerable groups such as the older population. This subtheme was supported by the following participant statements:

“Alhamdulillah ka mapipiyatadn ago satisfied ako ka pka ilay akun so pamilyakun ago mapiya so environment akun.” [Alhamdullilah, I am still good and satisfied as long as I can see my family and have a good environment. ] – P3

“Pkaconsider akun a mapiyadn odi na average so kapka-oyag-oyag akun imanto kagya diyako makapliyo-liyo a daa bakun pipikira ogaid na madakul so oras para ko family bonding. ” [I consider my living conditions as good or average as of now because I cannot go outside without worrying, although there is always time for family bonding.] – P5

Sub-theme 4 (Strengthened spiritual connection): The fourth subtheme describes how the older adults in this study have sustained their living conditions despite the adversities brought about by the COVID-19 pandemic through a strengthened spiritual connection with ALLAH (swt), which led to a sustained and even enhanced quality of life in old age. Their prayers and faith in God helped, guided, and aided them in facing this health emergency. This subtheme was supported by the following participant statements:

“Mas myakabagur so paratiyaya akun ko ALLAH swt na sie ako mambo pukwa sa bagur para magagakn angkaya a t’pung a inibgay nyan ruktano. ” [My faith in ALLAH swt grew stronger than before, and that is where I draw courage to pass this test that he gave us.] – P1

“So sambayang akun ago paratiyaya ko ALLAH swt na aya mala a myakawgop rakun para magagakun langon aya ago mawyag-oyag lagid o kapka-oyag-oyag akun kayko dapun a COVID. ” [My prayers and faith in ALLAH swt helped me overcome everything and live the same way as before when there was no pandemic.] – P4

Sub-theme 5 (Restricted social life and finding alternative ways to connect): The fifth subtheme describes how the older adults in this study experienced changes in their normal routines of socialization due to the COVID-19 pandemic, particularly when lockdowns and movement restrictions were put in place in the community to mitigate the rapid spread of illness among the general population, including older adults. However, such restrictions have resulted in a lack of community socialization but have not totally hindered their communicating means with friends and relatives. The participants used alternatives such as social media and other digital platforms to consistently connect with other people. This subtheme was supported by the following participant statements:

“Sie ko kapakindudulona ko pud a taw na myakayto kagya babawalan kmi ran mliyo-liyo ago kokontrol’n eran so kandadalakaw kagya so edad ame mambo malbod katakdan a gya paniyakit. Ogaid na so kapakimbityarae ko mga tunganay ago layok akun na sige sige parin ago knaba pman myaputol ka adun a facebook akun ago pakatawag ako kiran parin sag yaya a cellphone akun. ” [Socialization is minimal only because it is forbidden to go outside because movements are restricted and limited because of our age vulnerabilities. However, my communication with my relatives and friends is still consistent and was not totally cut off because I have Facebook and can still call them via mobile phone.] – P4

“Diyakodn makipundodolona odi na makipumbityarae s apud a taw ago di ako dn pagattend sa mga kalilimod lagido ka-kawing ka dikun kapakay lalo sie rkami a mga myaka edad. ” [I no longer socialize with other people and can no longer attend gatherings like weddings because it is prohibited, especially for older adults.] – P6

Sub-theme 6 (Psychological disturbance): The sixth subtheme describes how the COVID-19 crisis caused psychological disturbances in older adults. Most admitted that its uncertainty as an illness resulted in some fear and worrying while facing the adversities of such a health emergency. Although it has created some disturbances in their mental health as a person, the crisis has not completely negatively affected their life dispositions because of their strong faith and belief in God (ALLAH swt) as the controller of all things in this world and hereafter. According to them, the pandemic was destined to happen and will eventually disappear in God’s perfect time. This subtheme was supported by the following participant statements:

“Sie ko kapamimikiran na mapipiyakodn ogaid na datar oba sa didalum na maaluk akobo ka obako badn masakit sag yaya covid-19. Pero so ALLAH swt na malae limo ka asar ka panarig kawn ago pakabagarun ka so paratiyaya kawn na In shaa ALLAH na dikadn maribat ka pagogopan ka niyan ago ikalimo kaniyan. ” [I am still good in terms of psychological health; however, underneath this, I have little fear of getting infected with this illness. However, ALLAH swt is merciful as long as we trust him and continually strengthen our faith in him, then he will help us, especially in times like this.] – P3

“Mapipiyadn so kapamimikiran akun ogaid na igira kwan na pkapikir akun a ibarat oba-ako katakdi odi na so isako pamilyakun sangkae a covid na di siran pakabaw ago dadun a kataam eran, inoto diyakun plipatan obako di makasusulot sa mask ago pamangni ako sa tabang ko ALLAH swt. ” [I still have a good mind, but sometimes this thought haunts my mind what if I or one of my family members get infected with it and are unable to smell or taste anything, so I always wear a mask and ask for help from ALLAH swt.] – P4

This study was primarily conducted to validate one of the propositions of expanded need-threat internal resiliency theory, which states that in times of emerging health emergency (e.g., the COVID-19 crisis), “an older person who established a strong sense of internal resiliency adapts to the situation in maintaining a better disposition.” This multiple-case study identified two major themes addressing this proposition, describing the similarities and differences between coping strategies known as “internal resiliency” developed by older adults to adapt and cope well with such stressful and challenging situations, resulting in sustained or improved life dispositions.

These themes included Theme 1 “Coping strategies and measures of older adults used in adapting well to the COVID-19 pandemic.” This theme included five subthemes (acceptance of COVID-19 as an illness, self-discipline and strict observance of health protocols, the practice of healthy lifestyle activities, trust in healthcare professionals, and strong spirit and strengthening of spiritual beliefs); and Theme 2 “Life disposition of older adults in the COVID-19 pandemic.” This theme included six subthemes (sustained source of living and basic needs, absence of illness, family as the source of satisfaction, strengthened spiritual connection, restricted social life, and psychological disturbance).

Older people are frequently considered a high-risk population owing to high incidence and fatality rates in most emergent health emergencies, such as the COVID-19 crisis. This is one of the most recent trends. 31 ) People must make significant adjustments to their daily routines to cope with challenging life events such as the COVID-19 pandemic. 32 ) Other containment measures implemented in residential care communities and residences are exceptionally harmful to older individuals, such as limiting outdoor activities and visiting schedules. 31 , 32 ) These measures go beyond general social distancing policies. However, some factors, including a person's coping strategies and resilience, may influence whether potentially stressful situations arising because of the pandemic lead to better or poorer health and well-being. 31 )

Resilience and coping skills are cognitive and behavioral capabilities that might assist older persons in adjusting to changes in their way of life caused by adversities, such as health crises. 11 , 33 ) Studies on older adults in Asia, particularly in The Philippines and South Korea, have reported positive correlations between resilience, coping mechanisms, life satisfaction, and quality of life. Therefore, coping mechanisms and resilience play critical roles in protecting and promoting a better way of life, particularly among older adults. 33 )

Quality of life is one dimension impacted by contextual circumstances experienced during this life period, such as emerging health emergencies like the COVID-19 pandemic. 4 ) These contextual elements can negatively affect the central components of life. Individuals’ coping mechanisms for dealing with environmental stressors mediate the connection between the two. 31 , 34 )

The results of this study highlighted that older adult participants made use of both problem-focused (e.g., self-discipline and strict observance of health protocols, the practice of healthy lifestyle activities, and trust in healthcare professionals) and emotion-focused (e.g., acceptance of COVID-19 as an illness, the practice of healthy lifestyle activities, and strong spirit and strengthening of spiritual beliefs) coping strategies and measures in facing the COVID-19 health crisis to adapt to such situations, as reflected in Theme 1.

Hence, this strong sense of coping, known as “internal resiliency,” established by the participants, allowed them to effectively sustain and even improve their life disposition throughout this health emergency, as reflected in the different sub-themes describing their life disposition as older adults. These sub-themes included a sustained source of living and basic needs, absence of illness, family as the source of satisfaction, and strengthened spiritual connection, as reflected in Theme 2.

These results are consistent with those reported by the study in the United States, in which 74% of the 5,180 older adult respondents described using a variety of coping mechanisms to deal with the COVID-19 pandemic, including problem and emotion-focused coping, which frequently involved exercising and staying outdoors, changing routines, following public health measures, maintaining social connections, and changing attitudes. Such coping primarily led to improved lifestyle choices, quality of life, and self-perception of aging well. 35 ) Furthermore, acceptance (risk ratio=2.710; 95% confidence interval, 3.926–1.493) as a coping strategy negatively predicted the COVID-19-related stress score in a study of older adults coping strategies and their significant connection with COVID-19 pandemic-related stress. This further implies that acceptance as a coping approach positively correlates with the capacity to handle stressful conditions such as the COVID-19 health crisis. 36 )

Although fear, anxiety, and loneliness were continuing stressors in a different study of older couples living alone in India during the COVID-19 pandemic, many of these individuals adapted and emerged resilient to the changing situation because of the various coping strategies used to deal with the health crisis, including accepting one's destiny, developing one's own health literacy, engaging in spiritual practices, and returning to creative leisure activities. 37 )

In a review on on the efficiency of coping mechanisms in older persons, Choudhury and Shivani 38 ) reported that coping mechanisms are imperative for enhancing well-being, particularly mental health, during a pandemic. Problem- and emotion-focused coping are some of the most frequently used techniques, 4 , 31 , 38 ) consistent with the observations among the participants in the present qualitative multiple-case study. Hence, the results of this study successfully prove that utilizing coping techniques to deal with a health crisis promotes and enhances the health and life disposition of older adults, as claimed by the expanded need-threat internal resiliency theory.

The theory of expanded need-threat internal resilience in emerging health emergencies defines the internal resilience of older adults as their capacity to perceive and recognize the threat of an emerging health emergency, allowing them to develop specific coping skills, such as physical, psychological, social, and spiritual strategies, to successfully and efficiently recover from adversities; thrive with persistent purpose; evolve in turbulent, challenging, and uncertain situations, resulting in sustained or improved quality of life while facing a global health crisis. The results of the present study provide strong evidence supporting the claim of the proposition of the expanded need-threat internal resiliency theory that during an emerging health emergency, “an older person who established a strong sense of internal resiliency adapts to the situation in maintaining a better disposition.” This further provides a foundational structure for existing knowledge about the relationship between internal resilience as a vital factor for older adults to sustain and even improve life disposition during a health crisis. Therefore, caregivers of older adults, healthcare workers, community leaders, and those who support the older population should always consider promoting holistic coping strategies, as it empowers and supports such individuals in times of emerging health emergencies.

Limitations

To date, few studies have reported on this phenomenon, especially in this locality. Hence, this study offers baseline literature in this age range, especially considering their vulnerability to emerging health emergencies such as the COVID-19 pandemic. Moreover, this study substantially strengthens the literature body supporting the broader idea of need-threat internal resiliency in older persons. However, this study included only five adults aged ≥60 years in a single area. Thus, older adults in various regions may be able to describe their quality of life and develop internal resilience. Additionally, the participants' educational backgrounds did not accurately reflect each grade or level, even though the value of a multiple case study is increased by including the experiences of participants with low levels of education. Therefore, future studies should use different research approaches and incorporate the demographics of older adults to establish how internal resilience and quality of life coexist when confronted with developing medical issues.

Recommendation

This study offers a change in the perspective of aging by highlighting the significance of resilience as a dynamic process aiding in the coping process and adapting to newly emerging pandemics, leading to successful aging, longevity, and quality of life. It also emphasizes the importance of creating policies and preventive and intervention programs that support older people’s resilience and the accompanying factors that may attenuate the negative effects of adversity on their physical and psychological health. When considering older adults from the perspective of their identified internal resilience, it is evident that dealing with spirituality is fundamental; therefore, this factor must be acknowledged to provide adequate support to older people. Thus, programs and support groups related to spirituality must be strengthened and highlighted in their communities as an essential approach to providing a holistic and people-centered response to older people amid these adversities.

The community is recommended to work on developing religious activities during these trying times with the aid of technology, such as online seminars and small-group discussions with religious leaders, as spirituality is a vital coping strategy for older people that helps them to cultivate strong internal resilience, which can be achieved through collaboration between local leaders, the general public, and line government agencies (e.g., the Department of Health and the Department of Social Welfare & Department). In addition, it is becoming increasingly clear that health professionals and care providers must be equipped with the knowledge and ability to recognize and assist patients' spiritual needs to provide holistic care for this population group.

CONFLICT OF INTEREST

The researchers claim no conflicts of interest.

AUTHOR CONTRIBUTIONS

Conceptualization, JMS; Data Curation, JMS; Investigation, JMS, DRP, DJEA, NTD, JTPA; Methodology, JMS, DRP; Project administration, JMS, DJEA, NTD, JTPA; Supervision, JMS, DRP; Writing-original draft, JMS; Writing-review & editing, JMS, DRP, DJEA, NTD, JTPA.

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