Clients/collaterals who were reached were more likely to be females (χ2 = 3.86, p < 0.05) or have a confirmed substantiation for physical abuse (χ2 = 7.91, p < 0.05), compared with those who could not be reached. Compared with clients who had a collateral to respond, clients who responded to the phone interview themselves were more likely to be females (χ2 = 7.22, p < 0.05), White (χ2 = 23.46, p < 0.01) and speaking English (χ2 = 17.20, p < 0.01). Interviews conducted with clients also had a lower proportion of confirmed substantiation for neglect (χ2 = 15.22, p < 0.05) and polyvictimization (χ2 = 31.45, p < 0.01), and a higher proportion of confirmed substantiation for financial abuse (χ2 = 19.11, p < 0.01). Sample sizes were too small to interpret for the other cells with significant statistical results (see Appendix for distribution and statistical results).
Quantitative Results from Interview Questions
Clients’ COVID-19 Awareness and Unmet Needs
Results are demonstrated in Figs. 1 and 2. Among the 934 successful contacts, 850 (91%) indicated clients had heard of COVID-19, 853 (91%) were aware of the stay-at-home order (called shelter-in-place in the Bay Area), and 776 (83%) had a doctor to call in case of COVID-19 concerns. A total of 741 (79%) responded positively to all three questions. Clients were more likely to respond that they were aware of COVID-19 (χ2 = 41.17, p < 0.01) and the stay-at-home order (χ2 = 55.28, p < 0.01), while collaterals (client’s family, trusted others, or service provider) were more likely to state clients were not aware of either, or decline responding to the questions. Different ethnic groups did not differ in COVID-19 awareness.
A total of 697 (75%) clients had no unmet essential needs. A total of 843 (90%) had food and ways to get more food, 802 (86%) had access to medication, 778 (83%) could get to medical appointments, 821 (88%) had no other urgent needs, and 678 (73%) did not feel lonely. Compared with collaterals, a higher proportion of clients indicated they had access to medication (χ2 = 17.47, p < 0.01), could get to medical appointments (χ2 = 20.63, p < 0.01), had no other urgent needs (χ2 = 16.74, p < 0.01), did not feel lonely (χ2 = 58.61, p < 0.01), and a slightly higher proportion needed food (χ2 = 16.99, p < 0.01). Interestingly, a higher proportion of clients also stated that they needed help to get to medical appointments and felt lonely, sad, or overwhelmed. On the other hand, collaterals were more likely to decline responding to questions on client’s unmet needs and feelings of loneliness. Overall, when client responded, they were more likely to indicate at least one unmet need (χ2 = 13.51, p = 0.02). Among ethnic groups, African Americans were more likely to need help getting to medical appointments (χ2 = 16.80, p = 0.03), and Hispanics were also more likely to report feeling lonely (χ2 = 15.56, p = 0.05).
Who was not Aware of COVID-19 and had Unmet Needs?
Using victim’s mistreatment type and age as predictors, binary logistic regression models that were firth adjusted were built with each awareness and unmet need question as dependent variable (see Table 2). Substantiation decision for all types of mistreatment were included in each model to identify the mistreatment type associated with COVID-19 unawareness and unmet needs. Only age was included as a predictor among all demographic variables because other variables had too much missing data.
For COVID-19 awareness, older persons (χ2 = 5.03, p = 0.02) and self-neglectors (χ2 = 4.68, p = 0.03) were less aware of COVID-19, but victims of financial abuse were more aware of COVID-19 (χ2 = 4.32, p = 0.04). Older persons (χ2 = 5.70, p = 0.02), self-neglectors (χ2 = 9.02, p < 0.01), and victims of neglect (χ2 = 5.57, p = 0.02) were also less aware of stay-at-home order. No predictor was associated with having a doctor for COVID-19.
Regarding unmet needs, victims of isolation were more likely to have medication/medical supplies needs (χ2 = 4.58, p = 0.03). While victims of emotional abuse were more likely to report feeling lonely (χ2 = 14.12, p < 0.001), victims of physical abuse were less likely to report feeling lonely (χ2 = 4.33, p = 0.04). Surprisingly, victims of financial abuse were more likely to have their food needs met (χ2 = 8.40, p < 0.01). No predictor was found to be associated with transportation to medical appointments and other urgent needs.
Qualitative Results from Case Notes (see Table 1 for Example Quotes)
Theme 1: Clients’ Preparedness for the COVID-19 Pandemic
Qualitative case notes revealed three distinct groups of clients. The first group, well-prepared clients, were aware of COVID-19 and had no unmet needs. “Client reports he is sheltering in place. He is in contact with his primary care physician via the phone. He is getting food delivered to him. He has caregiver services in place. His medications are being mailed to him from [local drug store], and his physical therapist is coming to his home to give him physical therapy each week.” Some clients received meals-on-wheels delivery, and a few mentioned they connected with others via internet. Almost all of these clients mentioned having assistance from family, friends, caregivers, or service providers, and they fared well since the support was in place and not interrupted.
In the second group, clients were aware of COVID-19 but had to leave their home at least occasionally. Most of these clients stated that they need to purchase food and get medication, “I live by myself, I have to eat, I put a mask on and go myself.” Some clients told APS caseworkers that online grocery delivery’s capacity was limited, while others could only use their electronic benefit transfer in certain stores that did not deliver. A few clients were homeless or lived in a hotel. Additionally, some of clients did not have access to facial masks. “Client did ask if we were able to provide masks,” indicating awareness of COVID-19, but lack of resources. Some of these clients might need help if the pandemic does not come to an end soon, “client has food at home right now, but it’s getting harder for her to order grocery delivery or ask her neighbors/friends to help out on a regular basis.”
The last group of clients was not able to comprehend COVID-19 or the stay-at-home order. Collaterals told APS caseworkers that clients had dementia, “Client needs a lot of assistance with personal care and needs to be monitored due to trying to go outside on his on and does not understand shelter-in-place.” Some clients had severe mental health or substance abuse issues. “Client has schizophrenia and won’t follow any direction provided to him. Client stays in the streets and hardly in his room except for sleeping. Client also has a payee representative at [name of service provider]. Client is connected to services but lacks awareness of his situation due to his mental health.”
Theme 2: Unmet Needs during the COVID-19 Pandemic
While well-prepared clients fared well, the latter two groups of clients indicated unmet needs for essentials. Food, medication, and supplies (such as toilet paper and facial masks) were common necessities lacking, even if clients were willing to take the risk and step outside of their homes. “Client [is] in need of one medication but doctor’s office ‘cannot squeeze her in’ to be seen and be prescribed meds, as stated by caretaker. Client has been out [of medication] for past month. Client also received an eviction notice.” The need for personal care was also prevalent. Some collaterals, especially caregivers, seemed to be under stress and requested In-Home Supportive Services (IHSS). Other clients simply did not have anyone to help with personal care needs. “Client and spouse will benefit from IADLs assistance, but they don’t qualify for MediCal/IHSS or affordable support at home due to assets exceeding income requirement for these programs. At the same time they can’t afford private pay home care.” Other unmet needs mentioned included doing laundry, getting transportation to medical appointments, covering pet supplies, and mitigating eviction risk by paying rent, insurance, or other bills.
Theme 3: Loneliness during the COVID-19 Pandemic
Lastly, the stay-at-home order led to feelings of loneliness for some clients. “He is sad that he now has no visitors due to COVID-19.” Quite a few clients said they could not attend adult day care programs; or they do not use the internet to connect with others. Aside from the digital divide in learning to navigate the internet, the cost of acquiring a computer and internet was not always feasible. Clients with history of depression were especially impacted, and they mentioned seeking help from psychiatrists and medication. “Client is greatly concerned with COVID-19. Her psychiatrist is helping her deal with it.” “Client was upbeat during our call, but said that she has been sad, depressed, stressed at times, but takes medications, listens to music, has supportive friends and those things have helped her to not feel all alone.”