Anxiety, Depression, Loneliness, Spirituality, and Social Support in Older People During the COVID-19 Pandemic

The COVID-19 pandemic has resulted in the threat of death. Some older people feel they are not ready to face the end of their lives, so psychosocial problems arise, such as loneliness, anxiety, and depression. This research study aims to explore some psychosocial aspects, namely spirituality, social support, depression, anxiety, and loneliness in the elderly during the pandemic. The research design was cross-sectional. The total sample was 142 people selected using the purposive sampling method. Data collection used various scales to look at spirituality, depression, anxiety, and loneliness. The results showed that median spirituality and social support scores were high. The median depression and loneliness scores were mild. The average anxiety score for the elderly was normal. Based on the Pearson and Spearman correlation tests, relationships were shown between spirituality and anxiety scores, social support and anxiety scores, anxiety and depression scores, and loneliness and depression scores. The elderly need spirituality and social support when facing the end of life, and during the COVID-19 pandemic, to prevent the emergence of psychosocial problems. Social support and high spirituality must be maintained, even though the pandemic has subsided, in case such a health crisis occurs again.


Introduction
Aging is a natural, progressive, and irreversible process.The most important consequences of the aging process are a decrease in life expectation (increased likelihood of death), interference in vital bodily functions, reduced range of adaptation, and a reduced state of general health (Andrieieva et al., 2019).These changes will impact all aspects of life, including psychosocial conditions.Psychosocial problems in the elderly include anxiety about death, loneliness due to the death of a partner, and depression due to chronic illness (Stuart, 2013).Older people are otherwise prone to experiencing psychosocial problems or mental disturbance when isolating themselves or removing themselves from society's activities for various reasons, including the COVID-19 pandemic (Yildirim et al., 2021).The COVID-19 pandemic has forced older people to limit themselves leaving the house so they do have an impact on mental health in old age (Guner et al., 2021;Khademi et al., 2020;Yildirim et al., 2021).The restrictions caused problems such as increased boredom, loneliness, anxiety, worry, and psychological health disturbances.These conditions require good social support (Stuart, 2013).Older people can prevent depression and psychosocial problems through their spirituality (Mahwati, 2017).
In almost five decades , the percentage of older people in Indonesia has more than doubled, namely to 9.6% of the population (25 million), with about 1% more female elderly than male elderly (10.1% versus 9.10%) (Statistics Indonesia, 2019).Of all older people in Indonesia, the young older people (60-69 years) far dominate, with a magnitude of 63.82%, followed by the middle elderly (70-79 years) at 27.68%, and older people (80+ years) at 8.5% (Statistics Indonesia, 2019).This year, five provinces have a population structure where aging people account for more than 10%, namely DI Yogyakarta (14.5%),Central Java (13.36%),East Java (12.96%),Bali (11.3%), and West Sulawesi (11.15%) (Statistics Indonesia, 2019).Badan Pusat Statistik (BPS) noted that, in 2019, the dependency ratio of older people to the productive population was 15.01.Every 100 people of productive age in Indonesia must support 15 older people (Statistics Indonesia, 2019).
Many older people experienced anxiety, loneliness, and depression during the COVID-19 pandemic.In a study in China, it was found that 37.1% of older people experienced depression and anxiety during the pandemic (Meng et al., 2020).A study in Poland showed that older people experienced moderate and high levels of loneliness, at 58.83% (Dziedzic et al., 2021).Research in Turkey with 354 elderly found an increase of 51.1% in worry about COVID-19 (Guner et al., 2021).A study in Turkey on 556 elderly found that 51.5% of the effect of anxiety on depression was explained by older people, who reported psychological results such as hyperemotionality, longing for family, feelings of loneliness, tension, and being overwhelmed (Yildirim et al., 2021).
According to Erickson, the stages of psychosocial development in older people are self-integrity versus despair (Laurence & Romanoff, 2023).Older people who can achieve self-integrity will have satisfaction through positive concepts and attitudes toward life (Townsend, 2016).The decline in body condition and the reduction in physical abilities experienced by older people can cause them to feel that this is a disaster, because death can take their lives at any time.Older people may feel that they are not ready to face death, so they feel anxious and afraid of waiting for the end to come.Older people are one of the groups at high risk of experiencing severe illness if infected with COVID-19.Older people with comorbid diseases have an even higher risk of severe illness and death if exposed to COVID-19 (Perrotta et al., 2020).The COVID-19 pandemic increases anxiety in older people (Khademi et al., 2021;Meng et al., 2020;Yildirim et al., 2021).Spirituality influences a person's readiness to face death (Khanna & Greyson, 2014), and they can accept the reality of their life with less regret and despair.Spirituality in older people facing the end of life can provide positive emotional support.
Older people need social support to obtain optimal psychosocial health (Bruggencate et al., 2019).The older people group (> 60%) is still the group that contributes the most to deaths due to COVID-19 (50%), even though it only accounts for 11.3% of all positive cases.The case fatality ratio for the older people group is also the highest (12%) compared to other age groups, at four times the national rate.Accord-ing to an analysis of deaths based on age and comorbidity history, older people have a 19.5 times higher risk than other age groups (Ministry of Health Republic of Indonesia, 2021).Social support refers to comfort, attention, and appreciation, qualities that are relied upon in times of difficulty (Bruggencate et al., 2019).The COVID-19 pandemic is a particularly difficult situation for older people, so they need social support from their family and environment.Older people can obtain social support by interacting with others, such as by making social contacts.Social support may come from various parties, but the most meaningful, concerning psychosocial problems in older people, is social support from those who are emotionally close, such as family members (Lee & Goldstein, 2016).Good social support for older people will increase their satisfaction with life (Şahin et al., 2019).Based on the description above, the researcher is interested in exploring the relationships between spirituality and anxiety, social support and anxiety, anxiety and depression, and loneliness and depression during the COVID-19 pandemic.

Methods
The design of this study was cross-sectional, with 142 samples.The study population amounted to 567 older people.The sample size is 25% of the population -141,75rounded up to 142 elderly people.The sampling method used was convenience sampling.The inclusion criteria were good hearing, verbal understanding of information, willingness to become a respondent, and a minimum age of 60.Respondents with cognitive disorders (e.g., dementia, Alzheimer's disease) and severe mental illnesses could not participate in the study.The research location is a Sumberporong Village in Malang Regency, East Java, Indonesia.Spirituality was measured using the Indonesian Daily Spiritual Experience Scale (IDSES) to retrieve spirituality data (Qomaruddin & Indawati, 2019).This is an adaptation of the Daily Spiritual Experience Scale (DSES) (Under-wood, 2011).Social support data were collected using the Multidimensional Scale of Perceived Social Support (MSPSS) (Zimet et al., 1988).The researchers tested the validity and reliability of the MSPSS with a value range of r = 0.478 -0.820 (r > 0.361) and Cronbach's alpha value of 0.891.Depression data were collected using the 15 item Geriatric Depression Scale (short form) (GDS-15), which was tested for validity and reliability with a value range of r = 0.381-0.900(r > 0.361) and Cronbach's alpha value of 0.765.A 25-item Geriatric Anxiety Scale (GAS-25) was used to collect anxiety data.GAS-25 was tested for validity and reliability with a value range of r = 0.386-0.824(r > 0.361) and Cronbach's alpha value of 0.794.The revised University of California, Los Angeles Loneliness Scale (UCLA LS-R) was used to collect data on loneliness.The UCLA LS-R was tested for validity and reliability with a value range of r = 0.388 -0.832 (r > 0.361) and Cronbach's alpha value of 0.748.The time needed to complete the questionnaire is approximately 45-60 minutes.
The univariate analysis used in this study calculates the average anxiety variable.In addition, the median value of spirituality, social support, depression, and loneliness variables is calculated.The Pearson and Spearman correlations provide the statistical analysis to test the relationship between several variables.This research has received ethical approval from the Ethics Committee of the Health Polytechnic of the Ministry of Health of Malang (No: 089/ KEPK-POLKESMA/2021).

Results
The characteristics of the respondents are shown in Table 1.The average age of the respondents was 64 years, with the lowest age being 60 years and the highest being 87 years.Seventy-eight participants (54.9%) had an elementary school education, and 125 participants (88%) did not work.Most participants, namely 98 people (69%) did not have income.The majority (71.1%) of the participants (101 people) were women.
The results of the analysis of the distribution of data on spirituality, social support, depression, and loneliness, using the Kolmogorov-Smirnov parameter, showed that the data distribution was not expected (p < 0.05), while the distribution of anxiety data was normal (p > 0.05).The transformation of variables with an abnormal data distribution uses log10 with the results of abnormal data distribution.
Table 2 shows the results of the research data collection.The median spirituality score was 72, which is high, where the lowest score was 17, and the highest score is 81.Meanwhile, the median social support score was 58, which is high, with the lowest score being 30, and the high- This study's variables were tested for correlation and met linearity (p < 0.05).This study found a relationship between spirituality and anxiety scores in older people (p < 0.05) with a weak relationship strength.The higher the spirituality score, the lower the anxiety score.There is a relationship between social support scores and anxiety scores in older people (p < 0.05), with a weak relationship strength, where the higher the social support score, the lower the anxiety score.There is a relationship between anxiety scores and depression scores in older people (p < 0.01), with a weak relationship strength, where the higher the anxiety score, the higher the depression score.There is a relationship between loneliness and depression scores in older people (p < 0.01).Table 3 shows the correlation test.

Discussion
The research results show that the spirituality of the elderly participants is relatively high.High spirituality is supported by the fact that all the participants have a religion, which can help improve spirituality.High spirituality can reduce anxiety in the elderly, as proven by the average elderly person's anxiety being in a normal condition.This study found a relationship between spirituality scores and anxiety scores in older people; the higher the spirituality score, the lower the anxiety score.The correlation results have a weak relationship because, although older adults have a high spirituality score, the COVID-19 pandemic still makes them anxious.Older people in the Sumberporong village had several routine and incidental activities to increase their spirituality, and they all have religious beliefs.Belief in a specific religion can determine the importance of spiritual needs and can always remind them of the existence of God.Religion and spirituality can help improve mental health (Lucchetti et al., 2018;Weber & Pargament, 2014).Older people in the research village carry out joint worship activities at the mosque while implementing health protocols.Older people who have difficulty coming to the mosque perform worship activities at home, including praying five times daily and performing dhikr.
Most older people are still living with their children, spouses, or relatives, so they can exchange information and life experiences with their families.The family plays a strategic role in meeting spiritual needs because they have strong emotional ties and interact daily.In addition, the village government where the older people live, in collaboration with other agencies, holds activities to improve their spirituality.One of the activities is counseling to encourage older people to live healthily.The village also has a school for parents, which provides education to help older people be healthy in all waysbiologically, psychologically, socially, and spiritually.Activities carried out in the village help older people to improve their spirituality.Good spirituality helps reduce anxiety and several studies have proven that good spirituality can help overcome fear.A study in China of patients with gynecological cancer, who had low death anxiety, found that they had higher spiritual levels (Agorastos et al., 2014).
Another study states a relationship between spiritual health and death anxiety in hemodialysis patients (Taghipour et al., 2017).Reflections on the pressure on health workers during the COVID-19 pandemic showed that health workers with higher spiritual levels showed lower anxiety (Prazeres et al., 2020).This suggests that mental health professionals should include spiritual or religious treatments to address mental health problems (Reutter, 2012).
The results of the current study showed that social support for the elderly was high, and their average anxiety level was normal.This study found a relationship between social support and anxiety scores in older people.The higher the social support score, the lower anxiety score.Aged people get social support mostly from their families.More than 90% of the participants live with their spouse or family, who help the older people in meeting their daily needs.In addition to families and partners, there are activities to increase social support, such as the aforementioned counseling held by the local village government in collaboration with other agencies.There are also special sports activities for older people, namely the Ling Tien Kung therapeutic gymnastics group, to improve physical health and prevent complaints caused by degenerative diseases.Through socialization activities such as gymnastics, older people make friends who support each other with some of their problems.They can exchange ideas and provide solutions to issues at hand.Family and environmental concerns help older people overcome mental health problems, such as anxiety.Emotional support and social involvement help older people gain happiness (Shah et al., 2021).
High satisfaction can help reduce anxiety (Crego et al., 2021).One study shows that higher levels of social support are associated with lower anxiety (Schug et al., 2021).Psychosocial resources, such as social support, have contributed to helping with mental health issues during the COVID-19 pandemic (Schug et al., 2021).Another study shows that, during the COVID-19 pandemic, social support has been negatively correlated with anxiety, whereas good social support will help reduce anxiety (Ao et al., 2020).Older adults with higher levels of social support use fewer mental health services for anxiety (Bretherton, 2017).
The research results of the current study show that the average older person's anxiety is normal, and depression is mild.Anxiety is closely related to depression.This study found a relationship between anxiety scores and depression scores, where the higher the anxiety score, the higher the depression score.COVID-19 is an infectious disease that can be transmitted through direct contact, through saliva and droplets, and in poorly ventilated settings.COVID-19 continues to mutate, and the morbidity rate fluctuates.People infected with the virus will experience mild, moderate, or severe respiratory problems or can recover without requiring special treatment.Older people with comorbid diseases such as diabetes, cardiovascular disease, cancer, and chronic respiratory disease are likelier to develop more severe infections.COVID-19 causes older people to experience increased anxiety (García-Fernández et al., 2020).Restrictions on social activities during the pandemic have also increased their anxiety (Ferreira et al., 2021).Older people who experienced depression in the village where the research was carried out lived alone without family and suffered from chronic physical illnesses.
Older people who experience chronic physical pain are at risk of having mental problems.Those who live alone or have chronic diseases are prone to anxiety, which can cause a decrease in their quality of life (Ferreira et al., 2021).Quality of life is used to evaluate a per-son's well-being.It is seen in wealth and work and can also be seen in mental health.Reducing anxiety levels is important.Often older people do not realize they are experiencing anxiety and do not know how to control it.Anxiety that is left untreated can trigger depression (Yildirim et al., 2021).
The results of the current study show that loneliness and depression were mild.The study found a link between loneliness and depression.Social activities are still allowed to be carried out during the COVID-19 pandemic, and health protocols must be consistently applied, even after the number of infected people has dropped.
When the number of infected people increases, isolating older people becomes an option to reduce transmission and protect more seniors, who are a high-risk group.Self-isolation is unsuitable for older people who rely heavily on social contact outside the home, such as home care services, elderly communities, and places of worship.Those without close family or friends, who depend on volunteer services or social care support, may experience loneliness and isolation (Kasar & Karaman, 2021).Some older people have poor mental and physical health and often do not have access to health services, leading to other potential problems.Older people who experience separation from the outside world are often excluded and find health services inaccessible.Those who can move outside the home must continue to apply health protocols such as wearing masks, keeping a distance, and washing their hands.According to some of the participants in our study, these health protocols make activities less enjoyable and are not carried out optimally.This study also found that older people who experience depression are those who live alone and can no longer carry out certain activities because of their physical illnesses.Many of these aged people stay at home, or even in bed.These conditions can trigger an increase in loneliness in older people, which is a risk factor for depression (Dziedzic et al., 2021;Kutlu & Demir, 2016).
The global health emergency regarding the COVID-19 pandemic has improved and lockdowns have been lifted, but that does not mean that COVID-19 has disappeared (Ministry of Health Republic of Indonesia, 2023).Older people, who are a vulnerable group for COVID-19 with a higher risk of death compared to other groups, must continue to implement the steps they took during the pandemic, such as the habit of washing hands, continuing to wear masks when sick with symptoms like COVID-19, and continuing to eat nutritious food.They should keep doing good deeds to increase their spirituality.Good habits during the COVID-19 pandemic must still be carried out as an anticipatory step in case another health crisis or disaster occurs.

Conclusion
There is a correlation between several research variables.Good spirituality will help reduce anxiety.Social support from the family helps to prevent anxiety in older people.Older people who experience anxiety will be at risk for depression.Loneliness is linked to depression.Older people need spirituality and social help from those around them during the COVID-19 pandemic to prevent the emergence of psychosocial problems such as anxiety, depression, and loneliness.The good habits from the COVID-19 pandemic must still be carried out as an anticipatory step in case another health crisis or disaster occurs.

Table 1 .
Characteristics of Respondents

Table 2 .
Scores for Spirituality, Social Support, Depression, Loneliness, and Anxiety

Table 3 .
Score Correlation Between Research Variables