The Tamil Nadu Panel Elderly Well-Being at Baseline (2019) COVID-19 Data Collection Well-Being in the COVID-19 Lockdown Counseling Intervention
How Did the Elderly in Tamil Nadu Weather the COVID-19 Lockdown?Evidence from the Tamil Nadu Aging Panel
September 6, 2020
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The Tamil Nadu Panel Elderly Well-Being at Baseline (2019) COVID-19 Data Collection Well-Being in the COVID-19 Lockdown Counseling Intervention
Outline
• The Tamil Nadu Aging Panel and Government Partnership
• What we know about the lives of the elderly (Baseline: Jan - Jun 2019)
• How the elderly are coping with the coronavirus pandemic
• Improving mental health and economic well-being
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The Tamil Nadu Panel Elderly Well-Being at Baseline (2019) COVID-19 Data Collection Well-Being in the COVID-19 Lockdown Counseling Intervention
The Tamil Nadu Aging Panel Government Partnership
• Challenge: Demographic transition, with elderly population (55 years or above) in developingcountries slated to grow more than three-fold between 2011 and 2050
• Tamil Nadu: from 7.2% in 2011 to 22%+ by 2050• Insufficient data to inform policy to address this changing context
• Solution: create a high-quality 7-year-long panel dataset
• Inform design and implementation of social safety schemes (pensions, cash transfers, publicdistribution), health policy, mental health interventions
• Launch an RCT with an intervention to fight loneliness among the elderly living alone
• Collaborating with Government of Tamil Nadu to collect data, part of the larger J-PALinstitutional partnership since 2014
• The Department of Economics and Statistics collected self-reported survey data; medical staff at theDirectorate of Public Health collected health measurements;
• J-PAL provided technical guidance and research support; principal investigators designed and pilotedproject and interventions
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The Tamil Nadu Panel Elderly Well-Being at Baseline (2019) COVID-19 Data Collection Well-Being in the COVID-19 Lockdown Counseling Intervention
A representative sample of TN’s elderly
• Census: 61,954 households (HHs) from 5 state-representative districts, further stratified intodistrict-representative Primary Sampling Units, were surveyed to identify eligible households (thosewith at least one elderly)
• Panel sample: 5,000 HHs with at least one elderly member (55 years or over)• Subgroups of interest
• Elderly living alone (ELA), i.e., single-member HHs (1530)• Elderly potentially eligible for but not receiving Old Age Pensions (OAP) (1279)
• Stratified random sampling, by village/town, identified a panel sample with three subgroups fromthe census listing: a random sample, the ELA, and the OAP
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The Tamil Nadu Panel Elderly Well-Being at Baseline (2019) COVID-19 Data Collection Well-Being in the COVID-19 Lockdown Counseling Intervention
Panel Survey Waves and COVID-19 Update
• Baseline survey: January-June 2019. Future waves: 2021, 2023, 2025.• Economic well-being (consumption, income, food security)• Health (mobility, diagnosed diseases, health-seeking behavior and utilization)• Mental health (depression, loneliness)• Social interaction (community activities, family)• Health measures (blood pressure, diabetes, mobility)
• COVID update: Two short phone surveys. April and July 2020.• Awareness of symptoms/lockdown, prevalence of symptoms• Coping: access to the government’s COVID welfare measures, food security, economic situation,
physical and mental health.
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The Tamil Nadu Panel Elderly Well-Being at Baseline (2019) COVID-19 Data Collection Well-Being in the COVID-19 Lockdown Counseling Intervention
The Elderly Living Alone (ELA) are predominantly female
0
5
10
15
Perc
ent o
f Eld
erly
that
are
ELA
55 - 59 60 - 64 65 - 69 70 - 74 75 - 79 80+Age
Female and ELA Male and ELA
• TN census exercise with 61,954 households
• 13% of households with elderly aresingle-member households, i.e. elderly livingalone.
• 87% of the ELA are female; written anotherway, 15% of elderly females are ELA.
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The Tamil Nadu Panel Elderly Well-Being at Baseline (2019) COVID-19 Data Collection Well-Being in the COVID-19 Lockdown Counseling Intervention
Poverty is very high among the elderly
Extreme poverty:38 Rs or $1.9/day
Low-middleincome poverty:
64 Rs or $3.2/day
0
5
10
15
Perc
ent
0 100 200 300Daily per-capita household expenses (Rs.)
Elderly Living with Others
Extreme poverty:38 Rs or $1.9/day
Low-middleincome poverty:
64 Rs or $3.2/day
0
5
10
15
Perc
ent
0 100 200 300Daily per-capita household expenses (Rs.)
Elderly Living Alone
Notes: Extreme and low-middle income poverty lines are taken from the World Bank. USD coversions are PPP.
• 25% of the elderly livingwith others fall under theextreme poverty line, $1.90per person per day.
• 28% of the elderly livingalone are below the extremepoverty line
• Compared to 12% of thestate as a whole.
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The Tamil Nadu Panel Elderly Well-Being at Baseline (2019) COVID-19 Data Collection Well-Being in the COVID-19 Lockdown Counseling Intervention
Self-described financial situations are worse for the ELA
0
10
20
30
Perc
ent
2 4 6 8 10Self-rated financial health (1-10)
Elderly Living with Others
0
10
20
30
Perc
ent
2 4 6 8 10Self-rated financial health (1-10)
Elderly Living Alone • The average elderly householdrated their financial situation as“difficult,” a 3 on a 1-10 scale.
• 1 reflects an extremely difficultfinancial situation; 10 reflectsextremely comfortable.
• Despite an only slightly higherELA poverty rate, nearly 60% ofthe ELA rated their financialsituation as “extremely or verydifficult.”
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The Tamil Nadu Panel Elderly Well-Being at Baseline (2019) COVID-19 Data Collection Well-Being in the COVID-19 Lockdown Counseling Intervention
Objective disease prevalence is high yet not self-reported
0 20 40 60Percent of all elderly
Hypertension
Diabetes
Cataract
Hearing loss
Kidney disease
Lung or heart disease
Arthritis
Objectively measured prevalence Self-reported prevalence
• Very high disease prevalence among theelderly when medically examined
• Awareness gap: much lower self-reportedprevalence of most diseases.
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The Tamil Nadu Panel Elderly Well-Being at Baseline (2019) COVID-19 Data Collection Well-Being in the COVID-19 Lockdown Counseling Intervention
Disease prevalence increases in age
1.4
1.6
1.8
2
2.2
2.4
55 60 65 70 75 80 85Age
Avg. no. of common diseases - Males
1.4
1.6
1.8
2
2.2
2.4
55 60 65 70 75 80 85Age
Avg. no. of common diseases - Females
Non-ELA ELA
• Of the seven commondiseases listed above,prevalence is increasing inage.
• Particularly steep increaseamong males, as femaleshave higher diseaseprevalence early on,especially the female ELA
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The Tamil Nadu Panel Elderly Well-Being at Baseline (2019) COVID-19 Data Collection Well-Being in the COVID-19 Lockdown Counseling Intervention
Significant functional impairment, especially for the ELA
0 10 20 30 40 50Percent with severe difficulty completing
Climbing a flight of stairsWalking long distances (1km)
Stooping or kneelingStanding for long periods
Carrying thingsLearning a new task
Standing up from sittingUsing transportation
Getting up from lying downSitting for long periods
Walking 100 metersGetting out of home
Joining community activitiesConcentrating for 10 minutesLifting arms above shouldersTending to household dutiesPicking items up with fingers
Getting to and using toiletEating
Washing whole bodyGetting dressed
Moving around at home
Elderly Living with Others Elderly Living Alone
• ELA considerably more likely tohave difficulty completingvarious activities of daily living;
• Disparity grows with activitydifficulty.
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The Tamil Nadu Panel Elderly Well-Being at Baseline (2019) COVID-19 Data Collection Well-Being in the COVID-19 Lockdown Counseling Intervention
Functional impairment increases steeply with age
1
2
3
4
5
6
7
55 60 65 70 75 80 85Age
No. of deficient ADLs - Males
1
2
3
4
5
6
7
55 60 65 70 75 80 85Age
No. of deficient ADLs - Females
Non-ELA ELA
• “Functional impairment” is thenumber of ADLs (of 22 listedpreviously) which respondents haveat least severe difficulty completing.
• Females and the female ELA aremore likely to be functionallyimpaired.
• Functional impairment growssharply with age.
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The Tamil Nadu Panel Elderly Well-Being at Baseline (2019) COVID-19 Data Collection Well-Being in the COVID-19 Lockdown Counseling Intervention
Cognitive impairment is very high for females
20
40
60
80
55 60 65 70 75 80 85Age
Pct. with cognitive impairment - Males
20
40
60
80
55 60 65 70 75 80 85Age
Pct. with cognitive impairment - Females
Non-ELA ELA
• High prevalence of cognitiveimpairment, as measured by theMini Mental State Examination
• Higher for the ELA and far higherfor females, across ages.
• 80% of females over 80 demonstratemild or severe cognitive impairment.
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The Tamil Nadu Panel Elderly Well-Being at Baseline (2019) COVID-19 Data Collection Well-Being in the COVID-19 Lockdown Counseling Intervention
The ELA are far more likely to demonstrate depression
UK Elderly over 65
ELA over 60 in Shanghai
Elderly Prisoners over 60 in the UK
20
30
40
50
60
55 60 65 70 75 80 85Age
Pct. suggestive of depression - Males
UK Elderly over 65
ELA over 60 in Shanghai
Elderly Prisoners over 60 in the UK
20
30
40
50
60
55 60 65 70 75 80 85Age
Pct. suggestive of depression Females
Non-ELA ELA
• High absolute rates ofdepression, as has commonlybeen seen for the elderly.
• More females and many moreELA show symptoms ofdepression depression.
Notes: Depression scores from 15-item Geriatric Depression Scale: scores above 5 (out of 15) are suggestive of depression and scores above 9 are almost always indicative of depression. Values forelderly prisoners from O’Hara et al. 2016, ELA in Shanghai from Chen and While 2018, UK elderly from D’Ath et al. 1994.
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The Tamil Nadu Panel Elderly Well-Being at Baseline (2019) COVID-19 Data Collection Well-Being in the COVID-19 Lockdown Counseling Intervention
We measure loneliness in two ways
• Directly-reported loneliness: “Do you often feel lonely?”
• UCLA Loneliness Scale:• Short-form (four-item) version;
• “I feel in tune with the people around me”• “No one really knows me well”• “I can find companionship when I want it”• “People are around me but not with me”
• Responses on 3-point Likert scale. Items are reverse or forward-scored, depending on direction.• Not validated in the Indian context
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The Tamil Nadu Panel Elderly Well-Being at Baseline (2019) COVID-19 Data Collection Well-Being in the COVID-19 Lockdown Counseling Intervention
Among males, the ELA are especially lonely
10
30
50
70
90
55 60 65 70 75 80Age
Pct. Who Often Feel Lonely - Males
10
30
50
70
90
55 60 65 70 75 80Age
Pct. Lonely from UCLA Scale - Males
Male living with others Male living alone
• Loneliness among males differssignificantly between directreports and that from 4-itemUCLA scale, but considerable rateof loneliness persists.
• Loneliness among the male ELA isextremely high, around 60%.
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The Tamil Nadu Panel Elderly Well-Being at Baseline (2019) COVID-19 Data Collection Well-Being in the COVID-19 Lockdown Counseling Intervention
Among females as well, the ELA demonstrate outsized loneliness
20
30
40
50
60
70
55 60 65 70 75 80Age
Pct. Who Often Feel Lonely - Females
20
30
40
50
60
70
55 60 65 70 75 80Age
Pct. Lonely from UCLA Scale - Females
Female living with others Female living alone
• Among females, the high rate ofloneliness roughly doubled for thefemale ELA.
• Mirrors male loneliness, as doesthe discrepancy between directreports and UCLA loneliness scale.
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The Tamil Nadu Panel Elderly Well-Being at Baseline (2019) COVID-19 Data Collection Well-Being in the COVID-19 Lockdown Counseling Intervention
Social interaction with individuals and community
0 20 40 60 80 100Percent of Respondents
Has someone to call in emergency
Has someone to borrow money from
Talks on phone at least weekly
Can make phone call
Was visited in last week
Visited someone in last week
Had conversation in last day
Interaction with Individuals0 20 40 60 80 100
Percent of Respondents
Feels respected in community
Trusts neighbors considerably
Currently works
Attends cultural events
Meets with community leaders
Community Interaction
Elderly Living with Others Elderly Living Alone
• Elderly report having sourcesof support in times of troubleand feel respected in theircommunity.
• Little in-person and phoneinteraction, as well as lowcommunity engagement.
• For ELA, all forms ofcommunity interaction slightlyless likely, as are phone useand having sources ofemergency support.
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The Tamil Nadu Panel Elderly Well-Being at Baseline (2019) COVID-19 Data Collection Well-Being in the COVID-19 Lockdown Counseling Intervention
The ELA own far fewer assets enabling connection
(1) (2)Living with others Living alone
mean mean
Bicycle 30 3Scooter 47 2Car 4 1Phone 84 36Computer 5 1Internet connection 11 1
Observations 4760 1534
Table: Asset ownership (percentage who own each asset)
• ELA far less likely to ownassets enabling both in-personand remote connection
• Raises concerns about reachingthe ELA in times of crisis
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The Tamil Nadu Panel Elderly Well-Being at Baseline (2019) COVID-19 Data Collection Well-Being in the COVID-19 Lockdown Counseling Intervention
Two waves of COVID-19 phone surveys
• Two waves of phone surveys were planned to understand the effects of COVID-19 and thelockdown on the elderly, specifically:
• Access to government COVID welfare measures, food security, economic situation, physical andmental health.
• The role of state pensions and welfare measures in alleviating the pandemic’s effects over time.
• Target sample: 4,929 elderly with phone access, from the 6,294 baseline sample.
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The Tamil Nadu Panel Elderly Well-Being at Baseline (2019) COVID-19 Data Collection Well-Being in the COVID-19 Lockdown Counseling Intervention
Receipt of government schemes
0
20
40
60
80
Free rations (April) Cash transfer Free rations (July)
Percent of card holders receiving scheme
Elderly Living with Others Elderly Living Alone
Notes: During Wave 1 (April), the ELA were surveyed one week earlier than all others.
• The state of Tamil Nadu launched two schemes forration card holders
(1) Free rations from April to July, doubling therice entitlement
(2) Cash transfer of Rs. 1000 (about USD 14)per ration card for April and May
• The schemes reached most, although not all,intended recipients.
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The Tamil Nadu Panel Elderly Well-Being at Baseline (2019) COVID-19 Data Collection Well-Being in the COVID-19 Lockdown Counseling Intervention
Health challenges and food insecurity at the beginning of the lockdown
0 10 20 30 40 50Percent
Has no resources for food next week
More worried than usual about having food
Had to skip meals
Needed medication but could not buy
Needed to visit doctor but could not
Living with Others April Living Alone April
Notes: During Round 1, the ELA were surveyed one week earlier than all others.
• At the start of the lockdown, theelderly faced significant health andfood-security challenges.
• Nearly 50% reported not havingenough resources for food in thenext week.
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The Tamil Nadu Panel Elderly Well-Being at Baseline (2019) COVID-19 Data Collection Well-Being in the COVID-19 Lockdown Counseling Intervention
Health challenges and food insecurity later in the lockdown
0 20 40 60Percent
Has no resources for food next week
Had to skip meals
Needed medication but could not buy
Needed to visit doctor but could not
Living with Others April Living Alone AprilLiving with Others July Living Alone July
• The number of elderly unable tobuy medicine or see a doctor sinceApril has fallen.
• Food insecurity, however, has risenand is high, particularly among theelderly living alone.
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The Tamil Nadu Panel Elderly Well-Being at Baseline (2019) COVID-19 Data Collection Well-Being in the COVID-19 Lockdown Counseling Intervention
Among the pension-eligible, recipients and non-recipients are equally well-off in April
0 20 40 60Percent
Has no resources for food next week
Needed to visit doctor but could not
Had to skip meals
Needed medication but could not buy
Assigned OAP Control April Assigned OAP Treatment April
• Not all eligible for the Old Age pensionreceive it.
• In the census exercise, a group of 1,124individuals were identified as OAPeligible but not receiving it. Theseindividuals were randomized into atreatment group or a control group forreceiving the pension. 42% of thetreatment group, compared to 8% ofthe control group, now receive thepension.
• Those in the treatment and controlgroups were of equal financial stabilityin April, when pension payouts weredelayed.
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The Tamil Nadu Panel Elderly Well-Being at Baseline (2019) COVID-19 Data Collection Well-Being in the COVID-19 Lockdown Counseling Intervention
Those randomized to receive the pension fare better as the lockdown progresses (July)
0 20 40 60 80Percent
Has no resources for food next week
Needed to visit doctor but could not
Had to skip meals
Needed medication but could not buy
Assigned OAP Control April Assigned OAP Treatment AprilAssigned OAP Control July Assigned OAP Treatment July
• By the July survey, Old Agepension payments had resumed fora number of weeks.
• The treatment group, relative tocontrol, was now much less likelyto report having not having enoughresources for food in the next week.
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The Tamil Nadu Panel Elderly Well-Being at Baseline (2019) COVID-19 Data Collection Well-Being in the COVID-19 Lockdown Counseling Intervention
Most elderly with COVID symptoms did nothing or self-medicated
0 10 20 30 40Actions taken by elderly with COVID-19 symptoms (%)
Self-medicated
Did nothing
Saw government health provider
Saw private doctor
Called government helpline• 1.4% of the elderly reported having COVID-19
symptoms during the April phone surveys.
• Of the elderly reporting symptoms, nearly 80% didnothing or self-medicated.
• No one reported calling the government helpline inApril; only 0.1% reported having called thegovernment helpline in July.
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The Tamil Nadu Panel Elderly Well-Being at Baseline (2019) COVID-19 Data Collection Well-Being in the COVID-19 Lockdown Counseling Intervention
COVID-19 awareness
0 20 40 60 80 100Percent
Knew COVID-19 precautions
Knew COVID-19 symptoms
Knew how COVID-19 spread
Living with Others April Living Alone AprilLiving with Others July Living Alone July
Notes: During Round 1, the ELA were surveyed one week earlier than all others.
• Awareness of COVID-19 spread,symptoms, and precautions ismoderate.
• Awareness has grown among the elderlyliving alone, presumably as informationpercolates through networks.
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The Tamil Nadu Panel Elderly Well-Being at Baseline (2019) COVID-19 Data Collection Well-Being in the COVID-19 Lockdown Counseling Intervention
Social connection was very low early lockdown (April)
0 10 20 30 40 50Percent
Had regular phone calls in last week
Had regular visits in last week
Living with Others April Living Alone April
Notes: During Round 1, the ELA were surveyed one week earlier than all others.
• At the beginning of the lockdown, socialinteraction was low for the elderly, both in-personand remote.
• Early on, the ELA were less likely to have regularphone calls.
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The Tamil Nadu Panel Elderly Well-Being at Baseline (2019) COVID-19 Data Collection Well-Being in the COVID-19 Lockdown Counseling Intervention
Social connection increased mildly throughout lockdown (July)
0 20 40 60Percent
Had regular phone calls in last week
Had regular visits in last week
Living with Others April Living Alone AprilLiving with Others July Living Alone July
• By July, both regular in-person visits and calls hadpicked up moderately for the elderly living aloneand elderly living with others.
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The Tamil Nadu Panel Elderly Well-Being at Baseline (2019) COVID-19 Data Collection Well-Being in the COVID-19 Lockdown Counseling Intervention
The ELA demonstrate outsized loneliness and depression early lockdown (April)
0 5 10 15 20Percent
Often felt lonely
Felt their situation was hopeless
Afraid bad thing would happen to them
Living with Others April Living Alone April
Notes: During Round 1, the ELA were surveyed one week earlier than all others.
• At the beginning of the lockdown, the elderlyliving alone were about twice as likely toindicate feelings of loneliness and depression.
• These indicators reflect lower loneliness anddepression than those at the baseline survey.This may be due to nature of the COVIDsurvey - shorter and via the phone - beingless conducive to rapport-building betweensurveyors and respondents.
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The Tamil Nadu Panel Elderly Well-Being at Baseline (2019) COVID-19 Data Collection Well-Being in the COVID-19 Lockdown Counseling Intervention
Loneliness and depression spike significantly during the lockdown (July)
0 10 20 30Percent
Often felt lonely
Felt their situation was hopeless
Afraid bad thing would happen to them
Living with Others April Living Alone AprilLiving with Others July Living Alone July
• As the lockdown progressed, all elderlybecame far more likely to expressfeelings of loneliness and depression.
• This was especially true for the ELA,32% of whom reported often feelinglonely, when asked in July.
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The Tamil Nadu Panel Elderly Well-Being at Baseline (2019) COVID-19 Data Collection Well-Being in the COVID-19 Lockdown Counseling Intervention
Improving mental health, food security, and health access: background
• We were on the cusp of starting an in-person therapy and group counseling intervention whenCOVID-19 crisis began.
• But, it is obviously no longer safe to have older people meet together and to have young peopletravel from village to village to spend extended periods of time with them.
• The elderly are most vulnerable to COVID-19, and those living alone are completely left alone fromany support system: starkly more likely to report being lonely (32% vs 15%) and having to skipmeals in last week (20% vs 15%)
• Suggestive indication that pension receipt mitigates food insecurity and health access.
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The Tamil Nadu Panel Elderly Well-Being at Baseline (2019) COVID-19 Data Collection Well-Being in the COVID-19 Lockdown Counseling Intervention
Improving mental health, food security, and health access: proposed intervention
Cross-randomized RCT with a therapy and a cash component for 1,530 participants across 5 districts
• Therapy: Delivered over the phone for 6 weeks (meticulous IRB-approved protocol to ensure safetyof the elderly and interviewer)
• Counseling to address depression• Companionship to address loneliness• Self-efficacy and problem-solving for addressing financial and/or health concerns• Follows non-specialist therapy approach that was found highly effective in low-resource settings
(Singla et al. 2017)
• Cash transfer: One-time, Rs. 1000, equivalent one-time government COVID-19 cash transfer forration-card holders
• Enable elderly to meet immediate needs: health, food• Delivered after therapy sessions• Considerable evidence that cash and other transfers improve mental health (Ridley et al. 2020)
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The Tamil Nadu Panel Elderly Well-Being at Baseline (2019) COVID-19 Data Collection Well-Being in the COVID-19 Lockdown Counseling Intervention
Main intervention outcomes
• Depression: geriatric depression scale
• Food security: Skipping meals in the last week or month
• Mobility and health (access and adherence)
• Social interaction with family members and other community members
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The Tamil Nadu Panel Elderly Well-Being at Baseline (2019) COVID-19 Data Collection Well-Being in the COVID-19 Lockdown Counseling Intervention
Conclusion
• The elderly living alone are not assumed to exist in India; they constitute a blind spot in economicpolicy-making.
• The COVID-19 crisis has given new urgency to monitoring what is happening to the elderly andELA and helping them, as they are particularly vulnerable both in terms of their health and thefinancial situations.
• At the same time, COVID-19 makes any intervention for this group more difficult to implement; itis a unique opportunity to see what might work.
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The Tamil Nadu PanelElderly Well-Being at Baseline (2019)COVID-19 Data CollectionWell-Being in the COVID-19 LockdownCounseling Intervention