Introduction

Since its outbreak the novel coronavirus-19 (COVID-19) has remained one of the major challenges of our time. This global catastrophe appears to have had two-dimensional health consequences for older adults: high risk of being infected and psychological distress. Besides its immediate and dire consequences on health and wellbeing, COVID-19 caused massive disruptions and uncertainties prompting policy measures and responses on a scale not seen before. Confronted with unprecedented crisis, governments around the world adopted and enforced numerous measures in seeking to contain and slow-down the spread of disease and its consequences. These measures ranged from safety protocols like hygiene and social distancing, to various forms of restrictions on social gatherings, and to enforcement of lockdowns. Other measures included travel restrictions, border closures and enforcement of quarantines and isolations. Although the measures were generally viewed positively in that they helped protect people from the COVID-19, they produced many undesirable effects at individual and societal levels [1]. Aside from causing possible negative emotions like depression, anxiety, stress and feeling of insecurity and helplessness [2,3], such measures left many people socially isolated and with reduced access to health and care services [4].

Though people of all ages were at risk of contracting COVID-19, older adults were particularly vulnerable and suffered severe consequences including high mortality rates [3,5]. This helps explain why several studies took interest in and focused on assessing the impact of COVID-19 on the elderly [6–8]. Recently published studies reported that older adults, especially those with chronic disease such as hypertension, cardiovascular disease, or diabetes, faced a particularly high risk of mortality due to COVID-19 [4,9]. Empirical studies found that while the risk perception of getting infected by COVID-19 tended to decrease as age increases, perceived severity was higher among the older people [10]. Other evaluations showed the devastating effects of the COVID-19 on the mental health of older adults [11–13]. In short, recent studies revealed how COVID-19 compounded health contexts for older people, many of whom already suffered from physical and mental health issues.

Older adults make up a significant proportion of Australia’s population. Many of them were born overseas and speak languages other than English. Members of this group, commonly known as the culturally and linguistically diverse (CALD) population, are among some of the most disadvantaged in society. It must be noted that the word CALD lacks a universally accepted definition. In Australia, the term is generally used to refer to individuals who have cultural background different from the majority of Anglo-Celtic Australian culture. While some scholars tend to use other characteristics in defining CALD population [14], the term used in this paper refers to people who were born in non-English speaking countries and who do not speak English as the main language at home. They suffer from a range of adversity associated with socioeconomic conditions, poor health and educational qualifications, lower employment levels and higher poverty [15], which were exacerbated during the COVID-19 pandemic with possible effects on their health and general welfare. Statistics show that older adults aged ≥60 years accounted for 90% of Australia’s COVID-19 deaths. Furthermore, older CALD adults have a greater chance of being infected than non-CALD, irrespective whether they were first- or second-generation immigrants. The COVID-19 deaths for older CALD adults are 3 times higher than non-CALD (6.8 deaths per 100,000 compared to 2.3 deaths) [16]. The grey literature frequently reports a high prevalence of pre-existing chronic conditions and mental disorders (e.g., isolation, fear, anxiety, and stress) among the older CALD adults in Australia.

Research attention has rarely focused on understanding the situation of the CALD communities during the pandemic, and more specifically older people who may be some of the most vulnerable amongst them. In one of the very few studies, Mude et al. assessed the impacts of COVID-19 on CALD populations living in the greater Western Sydney region in Australia [17]. They found that the pandemic further complicated the situation of CALD populations; it caused major disruptions to employment, housing, relationships with partners, among others. Hamiduzzaman et al. explored risk perceptions and coping strategies amongst CALD adults in South Australia during the pandemic [11,12]. They found that COVID-19 caused considerable psychological and emotional burdens among CALD adults, due to their lack of health education and isolation owing to old age. While these findings are valuable, further disaggregation of data (e.g., by gender or age groups) is critical for informing specific interventions. Existing data showed that low-income women are 4 times more likely to die from COVID-19 than high-income men, and nearly 5 times more likely than high-income women [11,12]. It is, therefore, assumed that the low-income older women with CALD backgrounds may have suffered intersecting marginalization and compounding disadvantage during COVID-19, since they lack equitable access to information and services, have poorer health literacy, and are often underprepared for such disasters [18–20]. Hardly any attempt has been made to investigate and understand the effects that COVID-19 had on these women and their coping strategies. Their cognitive, emotional, and behavioral changes during COVID-19 continue to remain under-investigated. Consequently, little is known about the psychological impacts of the pandemic on older CALD women and their responses and preparations, which is important for future disaster or crisis planning.

This article explores the perspectives of older CALD women’s risk perceptions and coping behaviors with the pandemic, adopting ‘older’ as over 60 years of age as defined by the United Nations [21]. This is a significant topic in the context of the Australian government’s multicultural access and equity policy which seeks to ensure access and equity for all CALD people. Focused in the state of South Australia, COVID-19 impacted the economy and socio-cultural life in general, its healthcare and social services. South Australia saw three highly restrictive lockdowns, restrictions on international and domestic cross-border travels, and changes to business and governmental operations. This had the potential to impact older CALD women, many of them had family networks dispersed across Australia and internationally. This project builds on the collaboration between the South Australia’s Multicultural Non-Government Organizations, Rural and Remote Health in South Australia, and Flinders University.

Materials and methods

This mixed methods study involving survey and interviews received approval of the Flinders University Human Research Ethics Committee (Project ID: 2215) and complied with protocols compliant with the Declaration of Helsinki 2000.

Results

Table 1 presents descriptive statistics of the demographics of the participants. A total of 109 older women completed the surveys and, in relation to ethnicity, 67% (n = 73) of them were European CALD, 27.5% (n = 30) were Asian, and rest of them were African (n = 4) and South American (n = 2) by background. In terms of age group, 32.1% (n = 35) were in the 75–79 years bracket and the second largest group was in 80–84 years (22.9%; n = 25). According to Modified Monash Model, most of the participants (63.3%; n = 69) in this study were from metropolitan areas (MM1), but a significant number of participants were found living in small rural towns (MM5–35.8%; n = 39). About 50.4% (n = 55) of the women had education level of high school or above, and 16.5% were with no formal education.

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Table 1. Descriptive statistics of demographics and the indicators of risk perceptions and precautions (n = 109).

https://doi.org/10.1371/journal.pone.0301366.t001

Table 2 illustrates the participants’ risk perceptions, coping behaviors, and emergency preparation. The mean sum-score of the three items about infection risk was 7.9 (SD: 2.8), indicating a below neutral chance of being infected among the women. However, the mean sum-score of dread risk, unknown risk, and fear (M: 43.5; SD: 4.9) reported a somewhat agreement among the participants that they had feelings of anxiety, concerns, and fear because of COVID-19. The first item of ‘dread, unknown risks and fear of being affected’ had the highest mean score of 4.4 (SD: 0.9), which indicated that the women strongly identified the COVID-19 as a global disaster. These participants also strongly agreed (M: 4.3; SD: 0.8) with the statement that COVID-19 is something completely new to them. Many of them were not sure that they will not be affected by COVID-19 (M: 2.5; SD: 1.1).

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Table 2. The participants’ risk perceptions and coping behaviors (n = 109).

https://doi.org/10.1371/journal.pone.0301366.t002

Mean sum-score of coping was 79.8 (SD: 9.3), indicating agreement with the four items of coping behaviors [I listen to the experts and follow their advice (M: 4.0; SD: 0.9); I try not to do anything in rash (M: 4.0; SD: 0.6); I talk to family and friends to learn more about the situation (M: 4.2; SD: 0.6); and I wash and disinfect my hands more often than usual (M: 4.4; SD: 0.7). Interestingly, mean scores for accessing online health information (M: 2.8; SD 1.4) and tendency to minimize anxiety by eating, drinking, smoking, or taking medication (M: 2.1; SD: 1.2) were below neutral. Mean sum-score of emergency preparation was 23.9 (SD: 6.8) indicating a neutral position with the 8 indicators of emergency preparation. The participants somewhat agreed that they don’t want to go shopping everyday (m: 3.6; SD: 0.9), but their response was below neutral when they were asked about collecting contact details for emergency services (M: 2.9; SD 1.0).

Table 3 confirms that the women’s coping score significantly differed between age groups (60–74 years vs 75 years and over), but no variation was observed based on the participants’ residence, ethnicity, education, and occupation. The emergency preparation was differed based on the participants’ residence (metropolitan vs rural towns) and occupation status (not in labor force vs in labor force); while no significant variation was found based on the participants’ ethnicity, age, and education.

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Table 3. Participants’ characteristics and distribution of coping and emergency preparation scores across different categories (N = 109).

https://doi.org/10.1371/journal.pone.0301366.t003

While the quantitative analysis provided us with understanding of risk perceptions of COVID-19 and coping with back-to-back disasters, our thematic analysis offered insight into what the women may have perceived to be most at risk (e.g., people, health, or family) during a disaster and what they perceived were responsible for and/or required to ameliorate these risks (e.g., emotional coping, behavioral changes, information, or services). The analysis allowed us to observe patterns in the meaning of women’s experiences, and to locate specific examples to elucidate further their perspectives of coping with disasters. Three priori themes that guided deductive coding and clustering codes into themes, thereby enabling the richness of participant experiences within each of following three themes.

Discussion and implications

Given the lack of studies focused on how various vulnerable groups managed during the COVID-19 pandemic, we aimed to investigate the experience of one of Australia’s most disadvantaged groups—the older women in CALD communities with a specific focus on risk perceptions, coping behaviors among them and the strategies they employed during the pandemic. This is the first of its kind—to the best of our knowledge—where the experience of this specific group of people was investigated and documented. It showed current levels of risk perception among the older women in South Australia’s CALD community and how they have reacted and managed during stressful situations during the COVID-19 pandemic.

In general, the findings show high levels of risk perception and behavioral coping among the older women in South Australia’s CALD communities who participated in the study. The risk of being infected by COVID-19 showed as particularly high amongst those with pre-existing health issues. The findings were broadly consistent with other studies elsewhere that showed females to perceive COVID-19 related risks more than males and, consequently, were more active in following preventive and coping strategies than their male counterparts [27,28]. Interestingly, our study finds some variations between age groups: lower levels of coping and emergency preparation was reported by those in the oldest age group (75 years and above), compared to those in 60–74 years of age a group. This finding in our South Australian study aligns with similar studies elsewhere where age was found to be negatively associated with risk perceptions, and pre-cautions/preparations [29–31]. One possible explanation for such difference is that those individuals in the oldest of age groups may have experienced similar crises during their lifetime developing better resilience in living with adversities and challenges. Existing research suggests that older adults are more resilient than the younger adults, they have higher emotional regulation and skills to cope with the adversities [32].

The findings of our study reveal that the older women in the CALD community have coped with the pandemic reasonably well, by minimizing risk exposures and adopting precautions in terms of health and hygiene. As elsewhere, reducing risk of exposure to COVID-19 was a common coping strategy employed by them during COVID-19, where they followed health protocols and advice like staying at home, wearing face masks, avoiding crowded places and social activities, shaking hands/hugging/kissing, and frequently washing, cleaning, and sanitizing with disinfectants [33,34]. Not surprisingly, some older women reported shopping online and using telehealth/telemedicine and video conference services as a way of maintaining physical distancing and avoiding personal contact during lockdowns and restricted movements. While this gave them some degree of protection from being infected by COVID, and flexibility and convenience when accessing vital services, and avoiding hassles of transport, and other inconveniences, such changes were reported in a limited number of cases. Although it is difficult to judge how effective such arrangements were, the women’s interview transcripts revealed that services were of important concern to them during the pandemic. Nevertheless, this reflects an evolving trend in service delivery which is likely to see expansions in future adding to efficiency and convenience on both sides involved.

The study also showed that older CALD women attempted emotional coping, as reflected in high scores in some strategies (e.g., imagining positive things to improve mood, thinking about times when it was better, and doing completely new things to cope with the circumstances). In short, we found that older women used both problem-focused as well as emotionally-focused strategies in coping with the pandemic situation [35]. They also followed expert advice like washing hands and avoiding contacts with risk groups, as common elsewhere. A point of departure in the South Australian context was that, unlike in other jurisdictions, the participants were not buying and stockpiling more food and other essential supplies than the usual. This could be attributed to the relatively less severe nature of the pandemic in South Australia at the time of the study and consequently limited nature of the lockdowns imposed which meant that there was less fear of total disruption of the supply chain.

A notable finding of the present study is that aside from health-related issues and concerns COVID-19 has caused considerable stress and anxiety among older CALD women who already suffer from a range of disadvantages. Even though South Australia is among the least affected Australian states and territories in terms the severity and the number of COVID-19 related hospitalization and deaths, the pandemic created an atmosphere of fear and anxiety among the older women, especially those in the CALD communities. It had significant impact on the life and wellbeing of this cohort of population. The isolation under COVID-related lockdowns and restrictions, while helped contain the outbreak, for the older people such measures have increased their isolation and marginalization. For many, isolation itself under COVID-19 related lockdowns were distressing. This was compounded further by reduced contacts and opportunities to visit and socialize with other community and family members. In consideration of the discursivity of family and nurturing responsibilities in women’s lives [36], the importance women placed on family relations and support of others was likewise reflected in text mining results and thematic findings.

The economic fall out of the COVID-19 and associated anxiety was evident. One respondent revealed her anxiety by sharing that her family restaurant business experienced reduced demand and profit since the start of COVID-19. This caused worry about the well-being of her family, as an example of women’s carriage of additional burden in the form of emotional labor during the pandemic [37]. In other cases, respondents reported increased experience of racism and discrimination based on culture and ethnicity, which contributed to additional social isolation and anxiety. Such findings were consistent with the current literature that shows that challenges associated with COVID-19 have led to increased mental and psychological distress and that COVID-19 has acted as a catalyst to expose some of the disadvantages within the CALD community [17,38]. Thus, the present study underscores the importance of paying attention to an important but often overlooked aspect -the impact of COVID on emotion and mental health of older women, on top of pre-existing social issues that intersect and compound disadvantage of older women in CALD communities. As shown, although older CALD women faired reasonably well in terms of behavioral coping by adopting measures like self-isolation, social distancing and avoiding social events etc., emotional coping was found to be particularly hard and problematic. As a way of coping in this situation the older women in the CALD community relied heavily on family and friends as a source of emotional support during the difficult and challenging time.

The present study showed that, in pandemic situations like this, access to information was critical, especially for people with low levels of English proficiency and inadequate digital literacy. The study found that inadequate health messaging, together with low levels of English and digital literacy, served as a major impediment to pandemic preparedness and access to available services. It revealed that for some older women information about COVID was inadequate, for others it was too excessive and at times contradictory, which added to their confusions. This was perhaps due to different levels of education and digital literacy [39]. Those with fair amounts of such knowledge experienced a flood of information about COVID on digital platforms, coming from diverse sources with frequent changes [40,41]. Others who relied on more traditional sources may have found information rather limited and inadequate. In both cases, the constantly evolving nature of information and global communication led to confusions especially for those with limited English, as they relied on social media and informal sources for vital information. Some of those interviewed in the study lamented the lack of timely, accurate and adequate, and accessible COVID-19 information, up-dates, and advice in languages other than English for the benefit of the CALD population. This explained why there were people within the community who were not fully aware of the risks involved at that time. Thus, the findings of the study highlight the importance of addressing an obvious gap that exists in terms of communication between older adults in the CALD community, and the public health information dissemination systems and processes [42]. Needless to add that effective communication and access to relevant information about the pandemic could have led to a new level of coping and preparedness by promoting the adoption of problem-focused precautions.

Another notable finding was that although older women perceived COVID-19 as a serious threat and a global challenge, a challenge more serious than the Spanish flu, preparations to deal with the consequences of the pandemic were experienced as inadequate. In other words, the majority of those who participated in the study were un- or under-prepared in terms of their responses. Only a small number of those surveyed and interviewed were sufficiently ready in terms of action plans and contingencies. This suggests that there was work to be done in raising awareness and capacity of relevant groups to undertake appropriate courses of action, especially in the event such emergencies get out of hand requiring immediate and drastic measures than those that were followed.

Conclusions

Older CALD women had high risk perceptions of acquiring COVID-19 and becoming sick from its effects. This high-risk perception prompted them to take strong preventative measures towards contracting COVID-19 and were therefore highly resilient during the crisis. This included washing hands and disinfecting surfaces regularly. The maternal nature of these older CALD women influenced their risk perceptions, placing significant concern towards the safety of their family, followed by their friends, and lastly, themselves. Despite the unprecedented situation of a global pandemic, these women focused on what they could control and not on what they could not. They engaged themselves in positive tasks that kept their minds busy and inspired high morale. This included staying well informed about staying safe during the pandemic and keeping in touch with family and friends. Whilst older women fared well during the pandemic, better social support and less social isolation is a key consideration for the future, as socially isolated individuals did not fare well in comparison to their counterparts who remained surrounded by family. Older CALD women decreased exposure risk by limiting their trips to buy food and following government health advice.

This cross-sectional study provided a “snapshot” of the perceived risk, coping mechanisms, and emergency preparedness of older women from the CALD population. Recent research has concluded that web-surveys are feasible and a suitable alternative for surveying older people [43], however we acknowledge that by not offering paper-based or different language alternatives that this may bias results by excluding subsamples who may lack digital or English literacy. Data recruitment and collection methods were impacted by COVID-19 restrictions, limiting opportunity for distribution of materials via public meetings and snowballing, which will have implicated survey and interview response rates. Other limitations of this study, as in other cross-sectional studies in general, include difficulty in drawing causal conclusions. Identified associations may be difficult to interpret, unable to investigate relationships between outcomes and risk factors, and are also prone to bias. The sample in this study does not represent the entire CALD population in Australia proportionally. In future research it would be interesting to see a larger CALD populations of older women surveyed in additional locations within Australia on disaster issues affecting them. This would yield more meaningful data and allow responses to be compared between other states and territories. The findings of this research may help to determine which CALD communities fared better during natural disaster, helping to guide more effective policies, particularly in terms of preparedness.

Supporting information

Acknowledgments

We are thankful to the participants who provided time and shared their experiences about the COVID-19. We acknowledge the contribution of CALD community organisations that helped the researchers by encouraging people to participate in this study. We thank Judy Baily, Research Assistant at Flinders University Rural Health SA for her valuable support with recruitment of participants and data collection.