Screening measurement of the level of mental health of clients living in social service facilities during the COVID-19 pandemic

Introduction

For the last two years, we have witnessed an event that repeats itself once every few decades. The SARS-CoV-2 coronavirus, which causes the serious infectious and respiratory disease COVID-19, brought the world to a standstill under the massive wave of the pandemic. The pandemic has crippled the health systems of countries around the world as well as the business environment and held up a mirror to our current way of life. We were caught off guard, unprepared, and last but not least, unwilling to change our behavior for the greater good, resulting in the uncontrollable spread of the virus and subsequent death. An important factor confirmed by statistics from countries around the world is that the disease has fatal consequences, especially for people over 65 years old. According to statistics, almost 80% of people who died of COVID-19 were at least 65 years old (Wortham, et al., 2020).

In addition to the economic consequences and the huge number of human lives, the pandemic is also responsible for damage to the mental health of people, especially those most at risk, which in this situation are undoubtedly the elderly. The seriousness of their situation is amplified by the fact that even without the presence of a pandemic, seniors are a group that is marginalized by society and not given enough attention.

Theoretical basics

In one of its articles, the World Health Organization described mental health as a state of well-being in which an individual can realize his own potential, manage the normal stressful situations that life brings, work productively and contribute to the community in which he lives. Keyes (2005) says that mental health is defined as the presence of emotional well-being combined with a high level of psychological, logical and social functioning. Mental health is a subjective and complex term affecting the emotional, psychological and social levels, and together with physical health, with which they interact and there is a strong reciprocal relationship between them, also described by the authors of Nabi et al., (2008), they are inseparable parts that together form the concept of overall health.

Loneliness occurs in all age categories, but is more common in older people (Aylaz et al., 2012). Currently, there is no consensus on what loneliness is. Loneliness was perhaps most simply defined by Hewstone and Cairns (2001), who spoke of it as a deficit in experiencing quality and multiple social relationships. It is also important to add that one of the characteristic features of loneliness is its subjectivity (Peplau, & Perlman, 1982) and thus a certain uniqueness in feeling it. Recent research has indicated that loneliness may occur more frequently and reach higher levels (Pinquart, & Sörensen, 2003) in older people living in social service facilities (SSS) than in those living at home (Grenade, & Boldy, 2008).

Cacioppo et al., (2010) and Yunus et al., (2013) say that loneliness has been identified in both cross-sectional and longitudinal studies as a significant risk factor for the development of depressive symptoms, thus showing that there is a link between loneliness and depression. Depression is one of the most common psychological problems of older people (Helvik et al., 2016). Jongenelis et al., (2004) say that the risk of developing depression in seniors who live in ZSS is 3 to 4 times greater than in those seniors who live at home. In addition, depressive symptoms are associated with declines in health and cognitive function (Segel-Karpas et al., 2017) and also increase the risk of suicide in the elderly (Wang et al., 2015).

Research Problem

During the second wave of the pandemic, it became standard for ZSS clients to be barred not only from contact with the outside world, but also often from contact within the facility itself. In the most critical moments, clients had to remain completely isolated and alone in their rooms. Croezen et al. (2015) Brooks et al. (2020) argue that a reduction in social interaction has a negative impact on the mental and physical health of older people. In Slovakia during the pandemic, no study has yet been carried out that would deal with the mental health of seniors living in ZSS, therefore we decided to map the level of their loneliness, depression and overall general health. We will then compare these levels in terms of age and also focus on the frequency of contact with their loved ones during the second wave of the pandemic. In the context of the above, we ask ourselves the question: How does the level of loneliness, depression and overall general health change in terms of age and frequency of contact with loved ones during the pandemic?

Research objectives and research questions

Theoretical foundations indicate that depression is not an unusual phenomenon in the group of seniors, and for people who live separated from their family in ZSS, this risk increases because they have lost one of the most important social security for them – the family environment (Vitorino et al., 2013, Bujdová, Bujda, & Razzouková, 2013). Avoiding contact with family has the potential to increase the risk of unwanted psychological problems. The pandemic brought with it not only the avoidance of contact, but also reduced physical activity. Physical activity in later life reduces the risk of disease, helps manage current conditions, and develops and maintains physical and mental function (Cunningham, & O' Sullivan 2020). The aim of our research is to find out what the current level of depression, loneliness and overall general health of clients living in ZSS is. Since there are currently no data on the basis of which we could formulate hypotheses, we set the following 4 research questions: (1) What is the level of loneliness, depression and overall general health of ZSS clients? (2) What is the relationship between parameters of depression, loneliness and overall general health in our research population? (3) What is the relationship between the frequency of contact of clients with their family and their level of depression, loneliness and overall general health? (4) What is the relationship between the age of clients and their level of depression, loneliness and overall general health?

Methods

The disease COVID-19 has only been a part of our lives for a relatively short time, and how serious the negative effects of the pandemic will be on the human psyche has not yet been sufficiently explored. Therefore, we classify our research in the exploratory category, in which we will start with descriptive methods and continue with inferential statistical analysis. For data collection, we used a quantitative method, three self-report questionnaires.

Research File

The research team consisted of clients from various ZSS in Slovakia. At the beginning of the testing, all persons were informed about the intention, purpose and goal of the testing, where the processing of their personal data is governed by Regulation of the European Parliament and the Council of the EU No. 2016/679 on the protection of natural persons in the processing of personal data and on the free movement of such data. Tested persons knew that they could leave the testing at any time without drawing any consequences for their person. We also add that the management of the institution was informed about the purpose of the research and they also studied the questionnaire that we created and gave their consent to test their clients.

The selection of clients was ensured by professional staff, namely psychologists, senior workers of the health and social department, who also accompanied them during the testing process. The UMB Ethics Committee granted approval for the implementation of research no. of: 321/2022. We distributed the questionnaires to clients whose psychomotor pace and level of cognitive functions, according to the subjective opinion of the staff, was at a level that allows them to fill in the questionnaire according to their own beliefs. Nevertheless, if the staff judged that the client was a suitable candidate for completing the questionnaire, but had certain obstacles that prevented him from completing it on his own, he was provided with assistance from the staff. We included the filling in of questionnaires in the process of their activation. The study is part of research for rigorous work, the aim of which is to compare the mental state of clients before and after vaccination for the disease COVID-19. The number of respondents is 159 aged over 60 from 11 different ZSS. The research group consisted of 57 men and 102 women. The mean age of men was 72.47 (SD=7.05) and the mean age of women was 79.28 (SD=7.24). We divided the frequency of client contact into six categories, which we present in tab. 1

Table 1 Frequency of contact

Data Collection Tools

Clients filled out a questionnaire prepared by us, which consisted of 3 subtests, namely General Health Questionnaire (GHQ-12), Beck's Depression Inventory (BDI-6) and UCLA Loneliness scale (ULS-8) and several additional questions regarding the degree of contact with family, their psychological state, whether they have overcome the disease of COVID-19 and how they feel about this viral disease.

The General Health Assessment Questionnaire, GHQ-12, consists of 12 items, each of which assesses the severity of psychological status over the past several weeks, using a scale of 0 to 3. Potential scores range from 0 to 36, with higher scores indicating worse status (Goldberg and Williams, 1998). Previous studies show that the GHQ-12 has acceptable psychometric properties (McCabe et al., 1996; Schmitz et al., 1999).

The BDI-6 was derived from the original 21-item version in a clinical validation study in which experienced psychiatrists tried to capture major depressive disorder (MDD) using a shorter version of the BDI test (Bech et al. 2009). The BDI-6 consists of 6 items, each rated on a scale of 0 to 3, and scores can range from 0 to 18, with 0 indicating no depression and 18 severe depression (Blom 2012). The ULS-8 (Hays, DiMatteo, 1987) was derived from the original version of the ULS-20 and is used as a practical alternative to measure the frequency and intensity of loneliness, using a scale from 1 to 4. A total loneliness score ranging from 8 to 32 is evaluated, with higher scores indicating a higher level of loneliness. The questionnaires are not standardized for the Slovak population, but the data showed a sufficient degree of internal consistency (Cronbach's alpha in individual tests: ULS-8: alpha = 0.72; BDI-6: alpha = 0.67; GHQ-12: alpha = 0.90.)

Results

We processed the data in the statistical program SPSS25. After dividing our research set into categories either by age or frequency of contact, we had too small groups to compare. Therefore, we analyzed the data using correlations. We assessed the relationships between variables with Spearman's correlation coefficient.

Table 2 provides a descriptive description of the variables. We can observe that the average of loneliness in our research set is higher than half of the total possible score (>16) according to Shevlin et al. (2013) determines a certain pathology of the condition. Scales for BDI-6: 0-5 minimal or no depression, 6-7 moderate (mild) depression, 7+ severe depression. The average level of depression reaches 4.45, which means that, on average, our participants are on the scale of minimal or no depression, see table 2.

Table 2 Descriptive description of ULS-8 results

Correlations between variables were assessed with the Spearman correlation coefficient. We show the relationships between the variables in Table 3. At the significance level of p ≤ 0.05, we note strong positive relationships between the variables of the total score of depression, loneliness and overall general health. Our research set showed a weak positive relationship between depression and age and also between overall general health and age. Another important indicator when reporting correlation was the contact frequency indicator. Due to the pandemic situation, the contact was mostly by phone. A weak to moderately strong negative relationship was achieved between the indicator of the frequency of contact with the variables loneliness, depression and overall general health. We thus conclude that the higher the participants score in these indicators, the less contact they have with their loved ones. The indicator of the frequency of contact with age achieved a weak positive correlation, so we can conclude that the older a person is, the more contact he has with his loved ones.

Table 3 Sperman Product Correlation Results

Discussion

Through the SenSkype program (online conversations between clients of ZSS Viničky and psychology students in the role of counselors), which began to be implemented at the Department of Psychology of the Matej Bel University in Banská Bystrica during the first wave of the pandemic, we had the opportunity to learn more about the people who live in ZSS. Subsequently, after completing his university studies, one of the authors became a psychologist in a social services facility and continued to learn about the lives and stories of these people. The information provided by the clients of the facilities was the main motive of the given research study. People have different reasons why they find themselves in ZSS, some do not want to be a burden on their families, some can no longer take care of themselves and have no family that can help them. Through interviews with clients, we learned that there are also those who are happy to be in the facilities, as they have made new friends there. During the day, they sing to each other, knit, play cards, perform many social activities that they would not be able to do alone at home. Life in ZSS can restore people's zest for life. Of course, there are also clients who find it very difficult, they suffer from various diseases, they have limited movement, they miss their family, which creates the basis for the emergence of various psychological difficulties.

However, the coronavirus surprised all clients and employees of these facilities. All social activities were cancelled, contact with family members was limited, and subsequently, with the escalating force of the pandemic, contact with clients was also prohibited directly in the facility. At the height of the second wave of the pandemic, we carried out our research, the aim of which was to find out what the level of loneliness, depression and overall general health of the clients of these facilities in Slovakia is and how it is related to their age and the frequency of contact with their loved ones. The results indicate that our group of participants feel lonely on average. Studies that focus on people in senior age describe the fact that loneliness occurs to a considerable extent in senior age and its occurrence is not only rare (Výrost, Baumgartner in: Výrost, Slaměník 2001). Our results are in line with previous research that talked about the level of loneliness of seniors in ZSS before the pandemic situation.

Androvičová, Rácz and Krchnák (2015, in: Šlosiar, Palenčár, Duško 2015) describe the concept of generational loneliness, which represents a situation where an individual no longer has peers in his life, no people in his life from his past with whom he would share memories, opinions, views, ideas, and therefore even a person who has a loving family around him does not find the right understanding and feels lonely (Lovašová, & Garberová, 2018).

In the overall general health parameter, we also recorded increased average values, which according to Shevlin et al. (2013) signal a certain, as they call it, ``case'', that is, a case that needs to be paid attention to. It is typical for seniors that they spend most of their time during the day in sedentary behaviors, i.e. in a position that is defined as activity in a sitting or lying position, where the metabolic rate is at resting level (Hart et al., 2011).

The pandemic also caused the fact that clients who were physically active remained closed in their rooms, some were even confined to bed by the disease. According to many studies, physical activity has an irreplaceable benefit for the health of people, especially the elderly. It has been shown to protect against the development of cardiovascular diseases (Li & Siegrist, 2012), hypertension (Liu et al., 2017) and cancer (Moore et al., 2016). Additionally, physical activity reduces the risk of depression among community-dwelling older adults (Roh et al., 2015). Longauerová and Magurová (2008, p. 115) state that, "The internal balance apparatus, which is located in the inner ear of a person, is set in such a way that it must be exercised every day." A person who, for various reasons, begins to limit his physical activity does not sufficiently stimulate this apparatus. Thus, sedentary behavior does not only result in a loss of muscle mass, but also a weakened balance apparatus, and this causes a person to move slowly and with difficulty, is uncertain in his movements, often falls and thus avoids movement even more, becomes withdrawn, socializes less, etc. This can cause poor mental health and lead to depression, which increased in our cohort with increasing age and declining strength. In their meta-analysis, Colcombe and Kramer (2003) state that physical activity in people aged 55 to 80 years resulted in improved cognitive functions. Research shows that reduced physical activity can also affect mental health and even cause depression.

The results of the correlations indicate that there is a strong positive relationship between the variables we chose to investigate loneliness, depression, and overall general health, which is in line with studies that used a similar test battery such as Elovainio et al. (2020).

As for the frequency of contact, it showed a moderately strong negative relationship with each variable. We note that our participants felt lonelier, more depressed and their overall general health was at a worse level with decreasing contact with family. When contact with relatives and friends is prevented for any reason, whether it is due to bad family relations, pandemic measures, or generational loneliness, it has a negative impact on the psychological experience, behavior, but also the overall general health of ZSS clients.

Contact with family and age had a positive correlation, which means that older people have more contact with family. We attribute this to the fact that the elderly clients are in the facility because their family cannot adequately care for them and they have been forced to put their family members in the care of professionals, but they do not forget about them. It can also be that their family members realize that they no longer have as much time to spend together and want to use every opportunity to be with them. Younger clients rather stated that they have no contact with their family at all, it is possible that they have not even started their own family and their siblings, parents, etc. they are already dead, or they are not interested in them.

Many older people define ZSS as the last stop in their lives, feeling isolated from their families and experiencing loneliness (Dereli et al., 2010). Although 40% of elderly people experience a feeling of loneliness even at home, the percentage is significantly higher for elderly people living in nursing homes, 56% (Drageset et al., 2015). We hypothesize that feelings of loneliness may have worsened due to the pandemic, studies show that loneliness can have significant adverse effects on an individual's mental health and this can lead to earlier death (Rico-Uribe et al., 2018). The aim of the rigorous work is to map the level of loneliness, depression and overall general health of clients living in ZSS during the COVID-19 pandemic before and after vaccination. We are currently in the first phase, the purpose of which was to map the levels of variables, and we perceive the result of these measurements as a guide for social workers, psychologists and medical personnel working in these facilities, as well as for the families of clients. The time we live in is very fast, the pandemic has caused chaos in people and brought more fear to society, but even so, we should not forget those we think are taken care of. The social support of the family can often help a person cope with all the situations that life brings. Social support strengthens the psychological dynamics of the individual, providing them with emotional, material and cognitive help, which they receive primarily from their family, friends, neighbors and various institutions in order to cope with their emotional problems (Aksullu et al., 2004). Elderly people who do not receive social support are gradually isolated from society, which increases the risk of their death (Altınparmak, 2009). If the client no longer has anyone to support him, it remains up to the workers of social facilities. Research indicates that social support from nurses and health assistants in these cases has a positive effect on the quality of life of older people (Drageset et al., 2011).

Limits

Our research group is on average 76.83 years old, which may cause concern as to whether these respondents are suitable candidates for the research, which is administered in the form of questionnaires. Our goal was to obtain data from people in senior age, where we assumed that their cognitive functions are still at a good level, so that they are able to reflect what they really experience. It is important for us to focus on this group of the population, whose isolation during the pandemic was one of the longest and most severe. Due to the pandemic and measures in ZSS, it was physically impossible to administer questionnaires to each client personally, so the authors relied on cooperation with ZSS employees, who were thoroughly instructed on how to administer questionnaires, so that the data would be a real picture of the clients' experience.

Conclusion

Our goal was to compare the levels of mental health of seniors living in ZSS during the coronavirus pandemic before and after vaccination. The aim of this article was to bring to the public how ZSS clients manage the COVID-19 pandemic. Our results show that clients feel lonelier, more depressed, lack contact with family, and their overall general health shows a worse level. This research can help ZSS workers, family members or the public to better understand the experience of seniors who live in these facilities, it can lead to a change in the view of seniors and the approach to them, which could contribute to a more dignified survival of the final phase of their lives. At the same time, it can also inspire people to devote more of their time to the oldest and not to stop perceiving them as full-fledged members of society, because loneliness and lack of interest may be killing them more than the pandemic. There are approximately 900,000 people aged 60 and over living in Slovakia, who make up 17% of the population, and that is why we consider it important to pay attention to this marginalized group and bring it to wider public awareness. In the future, we recommend more complex research, which would include the use of other research methods, e.g. narrative techniques, semi-structured interviews with clients, various projective techniques that would enable the client to express himself more deeply and direct us to a deeper knowledge of their experience and behavior, which would help to increase the quality of life of seniors.

Authors: Mgr. Ivan Brezniak, The author is a graduate of psychology at the Department of Psychology UMB in Banská Bystrica, currently a psychologist at Likava-CSS

Mgr. Zuzana Gredecká, The author is a graduate of psychology at the Department of Psychology of the Matej Bel University in Banská Bystrica, currently a doctoral student at the Department of Pedagogy and Andragogy

*** doc. PaedDr. Lada Kaliská, PhD.,** University teacher, Vice-dean for science, research and art of the Faculty of Economics and Business Administration in Banská Bystrica.*

The contribution was made with the support of financing by the project KEGA 039UMB-4/2021.

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