Aging in Place Through the COVID-19 Pandemic: Perspectives from Aging Service Providers

WC workshops host critical dialog among individuals with similar problems or interests in order to share knowledge and foster collaborative learning (Brown & Isaacs, 2005). This method originated in community development and is increasingly used in research as it creates a means to collect data that provide insight into complex issues through the lens of lived experiences and disciplined inquiry (Löhr et al., 2020). Seven principles guide the WC format and include (1) setting the context; (2) creating a hospitable space; (3) exploring critical questions; (4) encouraging contribution from all participants; (5) connecting perspectives; (6) listening for patterns and insights; and (7) harvesting and sharing discoveries (Brown & Isaacs, 2005). WCs are traditionally held in-person around café like tables, though virtual WC formats have been credited with giving participants more time for reflection than in face-to-face settings, potentially positioning participants to make a deeper contribution to topics (Gyllenpalm, 2002). We conducted virtual WCs over Zoom due to pandemic restrictions on in-person gatherings. Institutional approvals were obtained prior to the start of the study (IRB 00141945).

We recruited a group of 34 aging-service providers from the Salt Lake Valley in Utah to discuss challenges and opportunities to support older adults during the COVID-19 pandemic. Participants represented the federally designated Area Agency of Aging (AAA) for Salt Lake County and the State of Utah’s Division of Aging and Adult Services (DAAS) as well as major healthcare and non-profit organizations that serve older adults. The authors utilized a university-maintained database to identify aging-service providers who held leadership and administrative roles in their organizations during the emergency response period of 2020, and who expressed interest in receiving information about research studies. Participants were recruited through invitations circulated via email with information on the study, and participation was voluntary. An IRB-approved Informed Consent Cover Letter was sent to participants by email once they registered for the study. The informed consent document was verbally reviewed between researchers and participants prior to the start of WC sessions. Participants were free to discontinue participation in the study at any time.

Salt Lake County was chosen as the site of the study because of the researchers’ local connections. To contextualize demographic characteristics of this region, it is important to recognize net migration as a transformative factor as the state’s population is expected to grow by over 2.2 million people (a 66% increase) by the year 2060 (Kem C. Gardner Policy Institute, 2022). Salt Lake County is the largest county in the state; about 10% of Salt Lake County residents are over 65 years old; among those age 65+, the median age is 72.9; 44.9% are male and 55.1% are female; the vast majority of adults age 65+ (92.3%) self-identify as white; over half (58.8%) are married; over one-third (34.7%) self-report as having a disability; close to a quarter (21.0%) are active in the labor force; 11.0% are foreign born; and 7.2% live in poverty (Salt Lake County Aging Services, 2018).

A series of three virtual WCs were conducted by trained faculty researchers collaborating to create a structure for the workshops. Each WC was 90 min in length, and WCs were scheduled 2 weeks apart. The majority of participants attended all three WCs. At the start of each WC, faculty researchers provided an overview of the workshop format and goals, and presented three discussion questions. Faculty researchers then facilitated small group discussions in breakout rooms with 5–7 participants. Notes were recorded by research assistants who were paired with faculty in each room, utilizing an online whiteboard that allowed participants and researchers to visually record and “play back” content in real time. Approximately 20 min were dedicated to explore each question. After small groups had an opportunity to explore responses to all three questions, breakout rooms closed and the whole group reconvened for a time of sharing, reflection, and feedback at the end of each workshop. This allowed the entire group of participants and researchers to reflect on the range of ideas and perspectives harvested. The online whiteboard was available for participants and researchers to review throughout the WC workshop series. A full list of discussion questions posed to participants in the WC series is listed in Table 1.

Conversations were recorded, transcribed, and checked for accuracy. Any personal identifiers were removed to maintain anonymity. Researchers worked in sequential phases to thematically analyze data and identify central concepts (Braun & Clarke, 2006). Familiarization with data was ensured through reading transcripts and listening to audio recordings. The team of faculty researchers and assistants identified an initial set of codes based on the whiteboards, and a pair of research assistants independently coded transcripts using NVivo12 software (QSR International, 2018). Codes were cross-read by faculty researchers and assistants, and a codebook was developed by the research team. Codes were grouped into preliminary themes and reviewed by the team. Defining and reviewing themes supported the iterative nature of discerning meaning, synthesizing codes into overarching themes, and identifying patterns between themes.

Data analysis yields a set of themes in response to the primary research questions. The capacity to support AIP through technology, support for social isolation and mental health, and emergency preparedness/in-home safety were prioritized by participants as leading areas of concern. Table 2 provides a summary of strengths, concerns, and critical needs to address AIP during the pandemic. Themes were summarized by researchers at the end of the first WC, and participants were asked to identify topics of leading concern. Participants used Google Jamboards to individually identify topics they considered the most critical to discuss in the subsequent WC sessions. Technology, social isolation, and emergency preparation were the topics that participants selected to discuss. Table 3 identifies insights into these leading areas of concern with sample quotes from participants that provide rich descriptions of perspectives. Several opportunities were identified by participants to meet future needs and include strategies to amplify existing services, address inequities, promote social inclusions, and strengthen resources for caregivers. Recommendations of future strategies are summarized in Table 4.

Themes from the WC workshops resonate with the literature on roles that aging-service providers play in the context of pandemic response (Hoffman et al., 2020; Karlin et al., 2021). Increased state and federal funding have affected access to services and support for many older adults, yet there is a need to look beyond immediate response measures to assess changes that have the potential to sustain impact, and to address unmet needs that have been exacerbated by the pandemic response (Young et al., 2020). Local-governmental and non-governmental organizations have been at the forefront of creating and implementing changes to services (Angel & Mudrazjia, 2020; Pendergrast, 2021). Findings from this study contribute to knowledge on how AAAs have mobilized to mitigate the impacts of the public health crisis and potential ways to sustain long-term positive impact for older adults (Sands et al., 2022; Wilson et al., 2020).

Technology has created new opportunities for older adults to access community resources during the pandemic (Brooks et al., 2022); however, the pandemic has also exposed dire consequences of the digital divide, or the diminished ability to access technology due to societal and social factors (Ramsetty & Adams, 2020). Gaps in internet access and digital literacy create unique impacts to AIP which shapes the health, financial, and social well-being of older adults (Martins Van Jaarsveld, 2020), all of which directly impact one’s ability to age in place. Internet access has become regarded an essential public service, yet remains unattainable for many households (Lai & Widmar, 2021). Long-term measures are needed to address digital equity, and further research is needed to understand how demographic factors, including age, gender, race, and ethnicity, shape technology use (Campos-Castillo & Laestadius, 2020).

Adverse effects of the pandemic have included increases in loneliness and social isolation among older adults, which present as critical challenges in meeting future needs (Banskota et al., 2020; D'cruz & Banerjee, 2020; Finlay et al., 2021; Weil, 2021). Barriers to services and interventions that target psychological distress in older adults include access to technology and digital literacy (Gorenko et al., 2020). While social connection is a known protective factor for older adults, when social interactions are suspended, isolation becomes an even more significant public health issue (Banskota et al., 2020; Sayin Kasar & Karaman, 2021). Older adults with dementia increasingly developed depressed moods and increased suicidal ideation due to loss of familial contact, social isolation, and confinement during the pandemic (Singh, 2017). The ripple effect of social isolation and delayed treatment for mental and physical health among older adults presents an immediate challenge facing aging-service providers. It reflects a larger need to change societal understandings and policies toward mental health and gain more societal acceptance that equitable access to telehealth technologies and transportation to healthcare providers is necessary for equitable aging.

Discussion of emergency preparedness and in-home safety highlights the critical role aging service providers often play helping older adults make modifications to their everyday living environments, which in turn helps support home as a place of personal and social meaning (Tanner et al., 2008). The impact of home modifications on reducing care needs of community-dwelling older adults is significant (Carnemolla & Bridge, 2019) and essential to reducing safety risks for older adults and prolonging aging in place. Among anticipated home repair and modification work, a recent survey found 71% said their home requires accessibility assists inside and outside, 61% said they need to build an emergency response system in the home, and 48% said they need to implement a smart-home device, such as a voice-activated home assistant (Davis, 2021). Barriers that limit the capacity to make home modifications include rising costs of building materials and limited availability of labor (McGarry & Falvey, 2021). The need to have emergency response plans in place, particularly for older adults with increasingly complex health and mobility needs, is integral to community caregiving, health promotion, and disease prevention (Mazumder et al., 2020). Challenges to serving rural, indigent, non-English speaking and ethnic minority older adults were highlighted as a critical vulnerability and emergent need to address through experiences of AAA response efforts in the United States (Fang, 2022).

The issue of support for caregiving was significant within the focus on technology, mental health, and emergency preparedness in this study, pointing to a need for greater attention and support for caregivers within pandemic response efforts (Cohen et al., 2021). Informal networks of caregivers are a critical component to support AIP among older adults who have been globally impacted because of the pandemic (Tur-Sinai et al., 2021). One-in-five Americans provides unpaid care to an adult with health or functional needs; almost 1-in-4 Americans cares for more than one person; and nearly 1-in-5 American caregivers is aged 65+ (AARP and National Alliance for Caregiving, 2020). As the COVID-19 pandemic has progressed, caregivers have reported feeling prepared to provide services for older adults compared to the beginning of the pandemic (Karlin et al., 2021). Caregivers experience high-stress levels due to government regulations, staff shortages, virtual service delivery, transitions to telemedicine, increased workload, and high demand for professional services (Karlin et al., 2021). Additionally, family caregivers often have less training compared to a professional caregiver and may have more limitations to visiting older adults for fear of spreading the virus (Karlin et al., 2021; Lebrasseur et al., 2021).

There were several limitations to this study. First, the WC workshops were conducted in 2021 when the second major wave of the pandemic was subsiding, and the experiences shared by aging-service providers reflect a distinct moment in time. Second, though our findings are strengthened in that participants represented a broad range of aging services (including transportation, health, and social services), participants generally held leadership roles within their organizations, which influence their perspectives and experiences. Third, recruitment was reliant on a university-maintained database which may represent only a portion of aging-service providers in the Salt Lake metropolitan region. Nevertheless, our sample size was an adequate number for the WC method.

This study identified concerns and needs to support AIP that aging-service providers uniquely experienced during the pandemic. The marginalization of older adults during the pandemic has been termed “an invisible human rights crisis” due to the physiological and psychosocial impacts of the pandemic on older adults (D'cruz & Banerjee, 2020). Changes in aging services that were made in response to the pandemic have potential for sustained impact addressing this crisis, yet there is a need to understand gaps and challenges in order to inform future efforts. Engaging aging-service providers with research evidence is necessary to guide future planning and policymaking efforts. Innovative partnerships and response measures that were largely catalyzed by emergency federal funding including the CARES Act, the American Recovery Act, and the freeing of Older Americans Act (OAA) funds require longer-term funding and holistic community response initiatives. As the number of Americans ages 65 and older will be more than double in the next four decades, areas of need to support AIP will only become more pressing.

We respectfully acknowledge that the University of Utah is located on the traditional and ancestral homeland of the Shoshone, Paiute, Goshute, and Ute Tribes. For contributions to this project, we would like to acknowledge research assistants Natalie Caylor, Kimberly Beck, Alannah Clay, and Timothy Gould. We would also like to thank our partner organizations for their support of this project and the invaluable insight of study participants.