Responding to Covid-19: an analysis of position statements of gerontological societies worldwide

Using analysis software (NVIVO), coding involved three systematic steps and three researchers, i.e. first author, senior author, independent researcher. In step one, the first and senior author independently identified text passages representing “calls for action” (CFA) (rather than “background” passages), as they most succinctly represent the statements’ content. A CFA passage was characterised by including modal verbs (e.g. must, should, need to, are obliged to, require) expressing a request, obligation, suggestion, order or advice. In contrast, background passages provided explanations, facts, theory or information, usually pre-empting or reasoning for CFA. Agreement between the two coders on the categorisation of material was almost perfect (98%).

In step two, quantitative content analysis (White and Marsh 2006) was undertaken to determine the frequency of categories and to prepare for subsequent qualitative coding. To do so, we referred to Ayalon et al. (2020) initial coding framework, which identified 39 categories of gerontological research. Using five statements from the sample, the coding framework was pre-tested by coding CFA passages (as identified in step one) using these 39 categories. The test-phase was undertaken by the lead and senior authors, who subsequently developed a common coding manual and systematic decision rules for each category. The initial coding framework was extended by two additional categories (i.e. communication and messaging; unclassified). Three categories were divided into further sub-categories, which we felt were insufficiently represented for the purposes of this research by the categories of Ayalon et al. These were: (1) “long-term care and formal care” with the sub-categories of institutional care; care at home; hospital care; care in the community; health care; social care; (2) “ageism” with the sub-category of heterogeneity and diversity of older people; and (3) “moral and ethics” with the sub-category of human rights. Using the tested and extended coding framework, manual and rules (Supplementary Material A1), data from the entire sample were coded by the lead author. To check reliability of the lead author’s coding, an independent researcher coded five statements (i.e. 22% of the sample). With inter-rater agreement being highly satisfactory (i.e. 85%), the lead author’s coding was accepted. After this step, common and less common topics of interest emerged from the statements as quantified by the number of statements coded per category in the coding framework.

In step three, the CFA content within each main and sub-category in the coding framework was inductively analysed for common themes (summative qualitative content analysis, Schreier, 2012). Data-driven thematic categories arising from this process were subsequently used to interpret the data and report commonalities and differences between statements. Co-authors collaborated in the analytical process through frequent discussion of emerging themes. Supplementary material includes an example of the coding under steps 2 and 3 using one of the statements and an illustration of step 3 using one of the codes (Supplementary Material A2/A3).

The 22 position statements were published by NGGS globally, with most originating in Europe (N = 15, 68%), four in Latin America (N = 4, 18%) and three (N = 3, 14%) in Australia and Canada. No position statements directly published by NGGS in Asia or Africa were located. As such, the proportion of NGGS affiliated to the IAGG with at least one statement is 18%. When taking into account the international position statement and follow-on global “Old Lives Matter” campaign, aimed at combatting ageism and raising awareness of age-based discrimination, and its endorsement by various Asian, African and Eastern European NGGS, the proportion of NGGS with a statement rises to 67%.

The date of publication varied, with most statements (N = 15; 68%) published between March and June 2020 (Fig. 1). No data was collected that explains why NGGS decided to publish at a specific point of time or multiple statements.

Table 1 presents an overview of the prominence of categories in the study’s sample as well as the number of statements and the NGGS that referred to the category at least once within their various CFA. The table compares the ranking to that of Ayalon et al. (2020) categories. Accordingly, the top five categories identified by Ayalon et al. and this study differ significantly with the exception of “long-term and formal care”, which ranked second in both studies. In comparison, the top category of Ayalon et al.—cognitive functioning—ranked twentieth in this study, whilst social relations and interventions were more prominent in this study, together with the new (sub-)categories of human rights and communications and messaging. There was greater agreement between the two studies regarding the 10 least represented categories, with the notable exception of “moral, ethics and human rights”, which was in this study’s top five and in the bottom 10 of Ayalon et al. (2020). Accordingly, the categories of nutrition, suicide, addiction, sleep and immigrants remained some of the least represented topics in this study.

We now report results from the qualitative content analysis of the most common categories amongst position statements, highlighting common themes and differences among the NGGS’ approaches as reflected in their CFA. Results for less common categories, with supporting quotations for each category, are available as supplementary material (Supplementary Material A4).

Overall, this represented the most prominent category.

Measures to prevent infections among older adults requiring care and support, whether at home or in acute or institutional care settings, were frequently demanded (Czech Republic, Finland, Argentina). Interventions to provide personal protective equipment (PPE) for carers and diagnostic tests in care settings featured prominently. Furthermore, calls for the development of information, guidance and learning materials for health and social care staff, older adults and family members included demands for guidance on how to stay healthy, how to effectively self-isolate and treat patients suspected of being infected, as well as clear information for patients to enable informed healthcare decision making. Various NGGS requested concrete support initiatives for community-dwelling older adults. This included financial supports for older adults and their carers or for community-based organisations (Canada, UK), designated shopping times for older adults (Argentina) or establishment of emergency contacts to prevent isolation and maintain social participation and wellbeing (Germany).

This category subsumes three themes. First, broad consensus existed among relevant statements, including in the UK and Czech Republic, that positive family relationships must be supported during the pandemic. This included demands for the promotion of communication and contact between older adults in acute or institutional settings and their families, support for families who were caring for older relatives at home, and support for people ageing without families.

The second theme related to building a fair, cohesive society, in which everyone is aware of and acts on their obligations towards others. Ideas around a fair society centred on mutual respect of rights, mutual support, and promoting older adults’ social participation despite physical distancing and isolation policies and advocacy. Third, various CFA related to the pandemic’s social impacts on older adults, demanding a holistic and integrated treatment of health and social ramification of any policies, research and political responses.

This category encompassed two themes. First, there was broad consensus around a responsible public discourse and the power of language in the media either supporting or challenging ageism in society. NGGS appealed to journalists, politicians and medical experts speaking in public to be aware of the potential impact of their words on exacerbating ageism and to choose non-ageist language. Some NGGS proposed neutral wording, including replacing the term “elderly” with “older adults”.

Commonly, NGGS called for recognition, protection and respect of older adults’ “equal rights” during the pandemic, as either enshrined in international or national law. Codes included references to “human rights”, “rights”, legal rights or “constitutional rights” or concepts linkable to human rights, notably “autonomy”, “equality”, “choice and control” or “self-determination”.

Rather than mentioning rights per se, various CFA referred to rights-grounding values, such as dignity and fairness or autonomy, which according to CFA must be protected in responses to the pandemic. In two cases, there were specific references to particular human rights, notably rights to social participation (Germany) and equal access to healthcare (Portugal). In Germany, the CFA balanced the right to social participation with a need to ensure infection control.

The working conditions and training of people providing health or social care in hospitals or care homes were of shared interest among NGGS. Specifically, there was general consensus that care workers must be afforded safe working conditions during the pandemic, including adequate provision of PPE and access to regular testing for Covid-19, to prevent infection among staff and older adults in acute and/or long-term care settings. Various CFA demanded adequate training for care workers to provide comprehensive care for older adults during and post-pandemic.

Many statements urged governments to balance policy responses with potentially negative consequences for older adults. The NGGS in the UK, for example, called for innovative policies to enable older adults to meet loved ones amidst physical distancing measures, facilitate attendance at funerals, and enable physical exercise as matters of overall wellbeing and health. Various statements rejected policies based on chronological age alone, which societies argued would reinforce ageist stereotypes and deny the heterogeneity of older populations. Two societies (Portugal, Ireland) demanded the creation of government entities for older adults to ensure that older people’s needs were acted upon in government both during and post-pandemic.

General consensus existed among relevant NGGS that the pandemic and the associated situation of older adults had exacerbated ageist practices. Particularly, many NGGS identified a blanket approach to the group of “older adults” with a lack of understanding of the heterogeneity among older age groups as a form and source of ageism. As such, NGGS, including in Argentina and Ireland, called for recognition of the diversity of older people. The international campaign “Old Lives Matter”, initiated by France, and some national societies (UK, Portugal) urged a shift in perspective, away from considering older adults a burden towards viewing them as valuable members of society who contribute to the economy, communities and families.

Various NGGS, including in the UK, Portugal and Canada, called for greater understanding of how multiple economic, socio-structural and social factors may influence health needs and outcomes for older adults in the pandemic including beyond a Covid-19 infection.

CFA of various NGGS (e.g. Germany, France, Finland) focused on the needs and care of older people with multiple or underlying health conditions. The relevant CFA indicated that multimorbidity and underlying health conditions must not be a reason to restrict healthcare, with the society in Germany urging older people with underlying health conditions to continue visiting clinics when necessary, and that in Finland demanding that information on older people’s functional capacity be taken into account when planning treatment after a Covid-19 infection.

Most statements in our sample were produced by European NGGS, with some published by NGGS in other world regions, notably Latin America. African and Asian societies associated themselves with an international statement originating in France. Together, analysis of these statements can indicate shared global interests and values that can inform the discipline of gerontology and future international research collaborations.

Within the context of the public health threat posed by Covid-19, the category of long-term care and formal care with its sub-categories was most widely represented in NGGS statements during the pandemic’s first wave. This reflects the on-average high biological vulnerability of older adults to Covid-19 and the pandemic’s multiple negative consequences on the mental and physical wellbeing of people requiring care and support and their informal carers (Hodgson et al. 2020). Globally, providing health and social care during the pandemic has posed numerous ethical and practical problems. It is, therefore, not surprising that this category featured prominently in this analysis, highlighting a shared importance attributed by NGGS to the topic as the pandemic unfolded.

The next four categories generating most attention in NGGS statements related to provision of targeted interventions to solve problems associated with the pandemic, and issues around social cohesion, quality of communication and messaging, and equality and human rights. The most prominent topics suggest that NGGS continued to show considerable interest in traditional subjects of geriatric inquiry (long-term care and formal care) but also growing recognition of social, cultural and legal topics of gerontological interest. Perhaps surprisingly, comparing our study’s topics of interest with those of Ayalon et al. reveals an under-representation of the area of cognitive functioning and an over-representation of the category of moral, ethics and human rights during the pandemic. Our findings thus depart from what Ayalon et al. (2020) describe as a strong focus on a biomedicalisation of ageing and deficits, cementing gerontology’s central goal of addressing “the problem of aging” (p. 5). Rather, this study’s statements reveal heightened gerontological interest in older adults’ position in society and a forward-looking focus on how gerontology can help to achieve greater age-related equality. This aligns with a reinvigorated debate around an International Convention on the Rights of Older Persons, reflecting Georgantzi’s (2021) argument that gerontological insights into the realities of older adults’ experiences should increasingly inform human rights advocacy, law and policies. However, with dementia identified as one of the main underlying health conditions associated with Covid-19 mortality (Wang et al. 2021) and studies documenting the adverse effects of policies in the pandemic on the wellbeing of people living with dementia and their carers (Giebel et al. 2020), the situation of people with dementia in society as a whole could be considered as a part of this interest in an equitable and inclusive society.

Of the nine categories which remained uncoded among the statements, five (nutrition, suicide, addiction, sleep and immigrants) represent also the least addressed topics in Ayalon et al. (2020) analysis. As argued by Ayalon et al. it is possible that some of these topics, nutrition and sleep specifically, are traditional areas of inquiry in disciplines other than gerontology (p. 6). However, addiction, substance abuse and suicide in older adults who were isolated during the pandemic has been identified as a potential problem (Jemberie et al. 2020; Satre et al. 2020). Some studies also suggest a relatively high psychological resilience among older adults generally, with comparatively less adverse mental health outcomes, including suicidal tendencies, among older than younger adults (Vahia et al. 2020). However, it is yet to be determined whether the relatively high levels of subjective wellbeing have endured over the course of the pandemic (Vahia et al. 2020). Other under-represented categories in NGGS statements, including the situation of immigrants (the category of ethnicity and minorities was also under-represented) or people living in rural rather than urban areas, are also important in the light of available evidence. Carr (2021, p. 2), for example, highlighted a stark racial divide in negative outcomes for health and social welfare related to Covid-19, with black and Latinx older adults in the United States particularly affected. Rivera-Hernandez et al. (2020) reported greater susceptibility to Covid-19 among rural- than urban-dwelling older adults in Mexico. Rather than indicating disinterest, these under-represented topics may have been too specific for NGGS to consider within the timeframe when statements were written. As with cognitive functioning and dementia in particular, these under-represented issues can be considered as important factors for research into inclusivity and equality.

Our findings suggest a high level of agreement within the categories across NGGS and no strong divides between countries or world regions. However, notable differences in statements arose, specifically in the category of “institutional care” and the question of hospitalisation or isolation of care-home residents with Covid-19 infections. This topic was salient across numerous countries, with Burton et al. (2020) indicating the need to shield care homes from introduction of the virus and the requirement for rapid action in the case of first infections to minimise causalities. The most efficient way to protect care-home residents was yet to be determined at the time when most statements were published. Ireland’s position on questioning the desirability of institutional care in society was particularly notable, as was Brazil’s statement on medicating people with Covid-19 infections outside clinical trials, and the prominence of references to human rights in Latin American statements. In Ireland, the national context of abuse in institutional settings (e.g. BBC 2021) potentially influenced its position on care homes for older adults. Latin America is the only world region with a dedicated Convention on Protecting the Human Rights of Older Persons, which may explain this topic’s prominence in relevant statements. While these examples highlight the importance of contextualising NGGS statements according to country of origin, such analysis is beyond the scope of this study.

Reflecting upon our findings, we identify three overarching themes. A first theme concerns the advocacy for equality and inclusion of older adults not only in the immediate pandemic response, but also beyond. Studies show that the pandemic and the contrasting risks to the health of older as compared to younger people without underlying health conditions has led to a global surge of ageism (Ayalon 2020; Aronson, 2020). This includes commonplace use of ageist language, stereotyping and policies either based on ignoring older adults or segregating them from the rest of society (Ayalon et al. 2020). NGGS recognised the surfacing of ageism and discrimination and advocated for equal treatment, non-discrimination and inclusion of older adults and their carers, whether in the community, workplace, media, or health and social care settings.

A second overarching theme is a holistic approach to care of older adults with health and/or support needs. The CFA in NGGS statements suggest an approach in which all stages and actors in an individual’s health and social care journey are equally important and should work in an integrated manner for best personal outcomes. Studies highlight challenges to delivering integrated care during the pandemic and opportunities for learning post-pandemic (e.g. Lindner et al. 2020; Stein et al., 2020). Here, NGGS and their members can continue to make a contribution through research and sharing of best practice.