Bouncing back from the pandemic? A psychosocial analysis of older adults in urban areas of Malaysia

Abstract As of 8 October 2021, the COVID-19 pandemic had caused over 236.6 million confirmed cases and 4.83 million deaths globally. The pandemic has quickly spread across the world, with only five countries being COVID-free. The outbreak has also had a significant impact on people’s lifestyles and daily interactions in Malaysia. Malaysian cities have been tremendously affected, with social distancing transforming people’s way of life and impacting their wellbeing. This study investigated the extent to which city inhabitants, particularly those who are more vulnerable, are adapting to these changes. In particular, it sought to identify the psychosocial impact of COVID-19 on the older adult population in George Town (Penang), and Kuala Lumpur with a focus on behavioural changes, anxiety, and adaptation. A total of 100 older adult respondents were recruited to complete the questionnaire survey using purposive sampling, with five respondents also participating in telephone interviews. The findings revealed that despite the social distancing rules that were in place, the participants’ adaptive responses, access to their surrounding environment, and maintenance of social networks had reduced the psychosocial impact of the pandemic. Thus, measures that ensure access to the environment and strengthen social support should be sustained, in parallel with actions to enhance community resilience and wellbeing.


PUBLIC INTEREST STATEMENT
Older adults are by far the most vulnerable population group affected by COVID-19 and the most robust consensus captured about this pandemic is related to this group. Hence, most countries have targeted this group to protect them. However, little is known about older adults' resilience and psycho-social health. In this paper, we aim to enhance our understanding of older adults' responses to the pandemic in Malaysian cities using data from questionnaire surveys and interviews. The findings provide a clear description of the behavior in a comparative perspective between two large cities and advocates possible government intervention in protecting and empowering this group. The response and compliance of the elderly is evidently positive, although findings are slightly different with studies elsewhere. The psycho-social health is quite a concerning issue, however the importance of social support/network as well as contribution of spirituality have been increasingly strong and appealing.

Introduction
The current global pandemic has had a huge impact on global public health and wellbeing. As of 8 October 2021, there had been 236,599,025 confirmed cases of COVID-19, with 4,831,486 deaths (WHO, 2021). With many nations now lifting the lockdown restrictions imposed to contain the spread of the virus, there is an increased focus on the long-term psychosocial impact of COVID-19.
Since the beginning of the pandemic, Malaysia has recorded a total of 2, 323,478 cases and 27,191 deaths (DG of Health, 2021). On 8 October 2021, Malaysia reported its increase in infections, with a total of 9,751 new cases and 78 deaths (44 male, 34 female) (DOSM, 2021b;MOH Malaysia, 2021;DG of Health, 2021). This significant growth was caused by the spread of the Delta variant of the virus (Anand, 2021). On the same day, Kuala Lumpur (KL) recorded 313 new cases (reaching a total of 187,864 cases), while George Town recorded 632 new cases (reaching a total of 135,800 cases). The first case in Malaysia was reported on 24 January 2020, but the number of cases only began actively increasing in March 2020. At that time, the Malaysian government introduced a Movement Control Order (MCO) to mitigate the adverse impacts of the pandemic. The MCO order has been extended multiple times and has been switched to either the Conditional Movement Control Order (CMCO), the Recovery Movement Control Order (RMCO), or the Enhanced Movement Control Order (EMCO). Following the completion of the MCO stages, the National Recovery Plan (NRP) was implemented on 1 June 2021. The NRP is a four-phase recovery plan designed to steer Malaysia out of the pandemic. The three key conditions for progressing to the next phase are related to daily COVID-19 cases, the rate of ICU bed use, and the percentage of the population fully vaccinated (MDBC, 2021). The pandemic has affected society as a whole but has had a particular impact on vulnerable communities and lower-income groups. According to the Economic Action Council (EAC), more than 600,000 households that were previously in the middle 40% income group have fallen into the bottom 40% category (Yeo, 2021). The psychological and emotional impacts of the pandemic are significant, with the spread of the virus causing great concern and leading to increased levels of anxiety (Roy et al., 2020).
The older adult population is particularly vulnerable to the impacts of the COVID-19 pandemic and thus requires special attention. Vulnerability is a function of exposure, sensitivity, and adaptive capacity: low adaptive capacity, relative to exposure and sensitivity, contributes to high vulnerability. In contrast, higher adaptive capacity helps to reduce the effects of exposure and sensitivity, and, in turn, reduces vulnerability (Thomas et al., 2018). Older adults are the most at-risk group for COVID-19 because the mortality risk of the virus increases with age, particularly for those with chronic conditions (Cheung et al., 2020;Lloyd-Sherlock et al., 2020;Meng et al., 2020;Mustaffa et al., 2020). In Malaysia, the risk of infection rises with age. People with chronic or non-communicable diseases such as diabetes, hypertension, heart or kidney disease, and cancer are also at higher risk (Harun & Othman, 2020). This is in line with a statement given by the Health Director-General of Malaysia: This is based on information from the COVID-19 mortality review, in which the Ministry established that 32 out of 99 reported COVID-19 deaths in the country are of those aged between 61 and 70, while 19 deaths involved those aged between 71 and 80. (Harun & Othman, 2020) Although government regulations have aimed to guarantee public safety, there is currently no direct strategy that aims to mitigate the psychosocial impacts of the COVID-19 crisis on the community. Many studies of the psychosocial effects of pandemics have focused on patients and healthcare workers (Chandrasekaran & Fernandes, 2021;Dong et al., 2021;Fadiloglu et al., 2021;Joisten et al., 2021;Olagunju et al., 2021;Phuc et al., 2021. Very little research has explored the pandemic's effects on the broader population, including older adults (Hughes et al., 2021;Krendl et al., 2021;Lind et al., 2021;Seethaler et al., 2021). Thus, there is a gap in the literature concerning the impact of the pandemic on older adults' mental health, social support and social networks, as well as the effectiveness of the assistance provided by the public health system. Accordingly, this paper offers some insights into the response to the pandemic among the older adult population in the urban areas of George Town and KL, Malaysia. The research investigated the extent of the participants' resilience and the coping strategies they have utilised to manage this challenging period, with a focus on participants' behavioural changes, anxiety, and adaptation. The results concerning the impact of the pandemic on the wellbeing of older adults provide guidance on the measures that should be taken to create better and more sustainable support for this population.

Pandemics in urban areas and older adult population
Since the dawn of human civilisation, people have faced pandemics. Cities and human health are closely interconnected, with cities being transformed in response to health threats. The Cholera epidemics in the 19th century, the Spanish flu in the 20th century, and the Severe Acute Respiratory Syndrome (SARS), Ebola, and COVID-19 pandemics in the 21st century each illustrated the severe consequences of major global threats to public health. In light of the increasing urbanisation around the world, it is critical to understand the responses of cities, as well as the resilience of urban citizens, to pandemics. This must include a consideration of the psychosocial attributes of people living in urban environments, as well as an investigation of the notion of resilience and its reciprocal relationships with other factors in the urban living environment.
Numerous studies have examined the relationship between urbanisation and the spread of pandemics (see, for example, Keil & Ali, 2007, 2018Pyle, 1986;Acuto et al., 2020). Keil & Ali, (2007, 2018 for instance, addressed the network connectivity of Toronto in the global city hierarchy and the influence of infectious disease like SARS outbreak. They advocate the rescaling of health governance system in cities, particularly the role of urban municipalities. Wheaton and Thompson (2020), in their study of cities in Massachusetts, found that population density has an economically and statistically significant effect on disease incidence. Meanwhile, Almagro and Orane-Hutchinson (2020) investigated New York City and discovered a significant positive relationship between population density and the proportion of positive COVID-19 tests, although this relationship diminished over time. Carozzi et al. (2020) recently showed that density affected the timing of outbreaks in each county, with denser locations being more likely to have an earlier outbreak. Wong et al. (2020) also found that population density as an effective predictor of cumulative infection cases in the US. They stressed that population density and sizes of vulnerable population subgroups should be explicitly included while predicting the impact of the pandemic, particularly at the county level.
Although the COVID-19 pandemic remains a public health threat, many countries are gradually trying to restore social and economic activities. In the recovery process, the resilience of a community or country may lead to different outcomes that deserve further attention. The 2030 Agenda for the Sustainable Development Goals (SDGs) sets out a universal plan of action to achieve sustainable development and realise the human rights of all people. The Agenda emphasises ensuring that the SDGs are met for all segments of society and for people of all ages, with a particular focus on the most vulnerable, including older adults (UN, 2016).
However, older adults should not be treated as passively vulnerable; rather, they should be recognised as active agents of societal change that are crucial to achieving truly transformative, inclusive and sustainable development. The ageing population is a major global trend affecting all countries, albeit at different paces and extents (Dugarova, 2017;Dugarova & Gülasan, 2017;World Bank Group, 2016), and it reflects significant development achievements such as improved health, greater longevity and lower mortality (UN (United Nations), 2017; UNDESA (United Nations Department of Economic and Social Affairs), 2007). Between 2015 and 2030, the number of adults aged 60 years and over is projected to grow by 56%, reaching 1.4 billion (nearly 16.5% of the global population) in 2030. There are currently an estimated 3.5 million people over the age of 65 in Malaysia, accounting for 7 per cent of the population. This group is the most vulnerable in terms of maintaining a subsistence lifestyle until the age of 77, which is the average lifespan for a Malaysian man. In 2020, Malaysian women (1.2 million) outnumbered Malaysian men (1.1 million) in the 65-and -over age group.
Malaysia's older adult population is growing year after year, contributing to an ageing population. According to the Malaysian Department of Statistics, the percentage of the population aged 0-14 years old dropped from 23.5% in 2019 to 23.3% in 2020, while the percentage of people aged 15-64 declined from 69.8% to 69.7%. The percentage of people aged 65 years and over increased from 6.7 per cent to 7.0 per cent during the same period. Older adults in Malaysia include those aged 60 years and over, based on the definition developed by the World Assembly on Ageing (United Nations, 1982, p. 50). The percentage of the Malaysian population aged 60 years and over has increased from 3.5 million (10.7%) in 2020 to 3.6 million (11.2%) in 2021 (DOSM, 2021a). By 2056, Malaysia will be a "super-aged society", with more than 20% of its population over the age of 65 (The World Bank, 2020). Accordingly, as stated by the chairman of Alliance for a Safe Community: In just 20 years, the ageing population will increase to 20%, proving an even greater challenge to today's generation. (The Star, 2021)

Psychosocial health, resilience and social support during COVID-19
The adaptation and response of older adults to COVID-19 has greatly impacted this group's level of mortality during the pandemic (Daoust, 2020). The public health approach remains the most important strategy for control of the virus, with key measures including social distancing, lockdowns, movement restrictions within cities and across borders, face mask usage, and quarantine. However, these public health actions have disproportionately impacted older adults that are vulnerable in health, social, and economic dimensions (Lloyd-Sherlock et al., 2020). Social isolation can adversely affect the mental health of such people, due to a lack of interaction (García-Fernández et al., 2020). Beyond illness and fear of contracting COVID-19, mandatory restrictions on freedom of movement, social distancing, isolation, and quarantine all have negative implications for psychological wellbeing (Holmes et al., 2020;Marroquín et al., 2020;Qiu et al., 2020;Wang et al., 2020). Consequently, social isolation can be a very serious public health issue, with significant psychosocial impacts if not addressed (Banerjee, 2020).
Many countries, including Malaysia, have adopted social distancing as a public health measure to reduce the transmission of COVID-19 within the community. Further, the measures taken to curb the pandemic, such as movement restrictions and lockdowns, have also resulted in social isolation. Such isolation is closely linked to feelings of uncertainty about the future and fear of infections, resulting in an increased level of anxiety (Khan et al., 2020). Quarantine and social isolation pose a threat to overall wellbeing (Wang et al., 2019) and cause distress for many people, particularly older adults . Older adults in isolation may become more anxious, angry, stressed, agitated and withdrawn during the COVID-19 pandemic or while in isolation (WHO, 2020b).
In addition, Wu (2020) recently found that social isolation and loneliness are major risk factors for poor physical and mental health. This may include health problems such as increased blood pressure, obesity, heart disease, diminished immune system functioning, depression, poor cognitive functioning, anxiety, Alzheimer's disease, and mortality. According to the National Academy of Sciences, Engineering and Medicine, social isolation is associated with an approximately 50% increased risk of developing dementia, a 29% increased risk of coronary heart disease and a 32% increased risk of stroke.
According to Barbisch et al. (2015), and Serafini et al. (2020), psychological reactions to COVID-19 vary from panic or hysteria to pervasive outcomes including suicidal behaviour and elevated anxiety due to compromised health measures. Long-term behavioural changes, including careful handwashing and avoidance of crowds, have also been reported, as well as delayed return to normality, even after many months after quarantine (Cava et al., 2005). Thus, social isolation, particularly isolation associated with quarantine, has important psychological consequences for individuals' short-and long-term mental health. Anxiety, in addition to affecting mental health, can affect the broader population. Increased anxiety can lead to maladaptive behaviours, such as panic-buying, resulting in an overburdening of community resources due to a disproportionate increase in help-seeking behaviour (Garfin et al., 2020;Lim et al., 2021;Roy et al., 2020).
Furthermore, early research on the effect of COVID-19 has found that the grief associated with COVID-19 deaths and the anxiety of testing positive also have severe implications for mental health. In Malaysia, fear and anxiety concerning COVID-19 have had a significant impact on the mental health of individuals and society (Serafini et al., 2020;Shanmugam et al., 2020). In a UKbased study, a survey of the general population found that symptoms of depression and anxiety were elevated compared to pre-pandemic data (Shevlin et al., 2020). Meanwhile, in China, a study conducted in Yunnan province reported higher depression and anxiety among those who were quarantined (Lei et al., 2020). Stress, frustration, depression, anxiety, and uncertainty can emerge progressively during an outbreak, impacting the psychological health of those affected. Earlier pandemics have also led to elevated symptoms of depression and anxiety, as reported by Chan et al. (2006). For example, in Hong Kong, the SARS epidemic of 2003 was associated with a 30% increase in suicide rates among older women 65 years and over.
In addition, building resilience is important to surviving uncertainty and coping with pandemicrelated psychological stress at both the societal and individual levels (Vinkers et al., 2020). People with higher levels of trait resilience were shielded from psychological distress during the COVID-19 quarantine period . Lower psychological resilience has been linked to negative mental outcomes such as severe anxiety (Killgore et al., 2020). Furthermore, protective behaviours may help to reduce anxiety levels, as greater engagement in such behaviours may reassure people that they are less likely to become infected with COVID-19, easing their anxiety (Lim et al., 2021). According to Kobori and Salkovskis (2013), reassurance aids in the control of people's sense of a threat, which is a useful mechanism for anxiety regulation. Further, compassion has a potential role in assisting people to understand the feelings and suffering of others related to COVID-19. Ultimately, compassion motivates people to reduce the burden on the public health system by practising protective health behaviours to prevent the spread of infection (Doraiswamy et al., 2020;Galea, 2020;Gillies, 2020;Zaki, 2020). The adoption of recommended protective health behaviours by the general public is critical to slowing the spread of COVID-19 and facilitating a return to normal activities (Lim et al., 2021).
Perceived support quality is strongly related to mental health and, thus, the social environment is increasingly implicated as the cause of mental health issues. As stated by McKenzie and Harpham (2006), it is vital to have a clear understanding of the social factors that cause psychological problems so that preventive strategies can be developed to counter these factors. Drageset (2021) also stressed the importance of social support as a vital salutogenic resource that enhances individuals' wellbeing. Social support occurs through a social network (Kent De Grey et al., 2018;Langford et al., 1997) and refers to any process by which social relationships provide improved health and wellbeing. This might include emotional support, belonging to a social community, being valued (i.e., esteem support), practical help, social integration or network support, and the provision of information and tangible assistance (Cutrona & Russel, 1987. McKenzie et al. (2002 also defined in ecological manner, the concept of social capital in terms of a person's social relationships with others, including other individuals, groups, and abstract bodies such as the state or city, that allow access to resources such as healthcare and education. Several studies have concluded that the mortality rates for people with few social relationships are higher than for those with larger social networks, with small social networks being correlated with an increased risk of accidents, suicide and cardiovascular disease (McKenzie & Harpham, 2006). Furthermore, social capital also includes trust, a sense of belonging and civic engagement. Such capital can also serve to prevent isolation and alienation. Thus, individual social capital can promote access to social support and social networks. Social capital has been classified into three dimensions: structural/cognitive, bonding/bridging and horizontal/vertical.
In general, perceived social support can come from many sources, such as family, friends, romantic partners, pets, community ties, and co-workers (Li et al., 2021). In one study, Killgore et al. (2020) asked 1,004 adults to complete assessments of their resilience, mental health, and daily behaviours and relationships during the first weeks of the nationwide lockdown in the US. They found that perceived and actual social support from family, friends and significant others contributed to greater psychological resilience. Later, Cugmas et al. (2021) identified the various types of personal social support networks that are available to the older adult population during the pandemic. Cugmas et al. (2021) discovered that social support is critical to establishing and maintaining physical and, more importantly, psychological health in both the general population and older adults specifically (Cugmas et al., 2021). Similarly, Kelley et al. (2000) and Alcover et al.
(2020) each found that social support helps older adults to cope with stressful experiences and contributes significantly to physical and psychological wellbeing.
Furthermore, perceived social support can act as a potential resilience factor, as it can lower depression and anxiety. Killgore et al. (2020) found that social support from family, friends, and loved ones were associated with greater resilience during the lockdown. As a result, people must cultivate such relationships and find innovative ways to stay emotionally connected with loved ones. In addition, one study found that undertaking religious activities and coping strategies within communities led to fewer depressive symptoms during the pandemic (Pirutinsky et al., 2020). Killgore et al. (2020) also highlighted the importance of spiritual health, particularly a greater frequency of prayer, as another important aspect of wellbeing. Spiritual health is associated with greater resilience to the challenges to mental health imposed by COVID-19. Various other studies have also stressed the significance of spirituality. For instance, Durmus and Durar (2021) noted that individuals with stronger spirituality are less afraid of coronavirus. Roberto et al. (2020) found that spirituality has a positive influence on resilience, hope, optimism, peace, and comfort, suggesting that spirituality is a vital dimension of managing people's health as the pandemic continues to unfold across the globe. Positive religious coping methods are associated with improved wellbeing and individual growth amid life stressors (Prati & Pietrantoni, 2009) and the use of such strategies enables people to imagine the possibility of overcoming the challenges of the pandemic (Pargament et al., 2020). Hence, religious coping, together with hopeful thinking, is a psychological resource that can support people's wellbeing and help them to overcome setbacks or maintain progress towards their goals while subject to lockdown orders (Schwarzer & Luszczynska, 2008). In addition, Kirby et al. (2004) found that spirituality as a routine activity among older adults leads to marked benefits in psychological wellbeing. Spirituality is also one component of the bio-psycho-social-spiritual model for medical research and treatment in clinical settings, emphasising the value of an integrated approach to the unique and holistic needs of patients with COVID-19 (Beng, 2004;Galbadage et al., 2020).
Meanwhile, online communities and social networks, which are components of the broader technological toolset known as information and communication technologies (ICT), have grown in popularity among older adults in recent years, particularly since the outbreak of the pandemic (Lawless et al., 2020). The pandemic has intensified the use of technology to support social interaction in the general population. Older adults are also increasingly using mobile technology, including smartphone apps, to access healthcare and other resources and stay connected during this time (Banskota et al., 2020;Quinn et al., 2019). Thus, mobile technology may be beneficial for those who wish to avoid leaving their homes while remaining connected and maintaining access to healthcare services, medications, groceries, and other resources. Recent studies have investigated the benefits of online peer-to-peer communities for older adults, particularly in this time of increased social isolation and disconnectedness. Meanwhile, Mackey et al. (2020) found that technology has a short-term positive impact on social support, social connectedness, and social isolation for older adults. Generally, online communities connecting older adults to their peers enable participants to share information and experiences regarding health conditions, as well as exchanging peer support for those with common interests (Lawless et al., 2020).

Research design, sampling procedure & data collection
This study employed a survey research design, with a questionnaire being used as the tool for data collection. The research aimed to assess the psychosocial impact of COVID-19 on older adults in George Town and KL, including their behavioural changes, anxiety, and adaptation. The study used purposive sampling by only selecting respondents aged 60 years and above. This meets the definition of "older adults", as stated by the Malaysian Department of Social Welfare. The selection of this group of respondents was also based on statistics released by the Malaysian Ministry of Health, which stated that almost 70% of the COVID-19 deaths in the country were among those aged 60 years and above (Rosli, 2020).
Part 1 of the questionnaire collected demographic data on the respondents. Next, Part 2 investigated behavioural changes, Part 3 analysed participants' pandemic-related anxiety, and Part 4 gauged the respondents' adaptation to the pandemic. The items in the questionnaire were measured using the Binary or Dichotomous Scales (1-Yes, 0-No) and 5-point Likert Scale (1-Very Disagree, 2-Disagree, 3-Uncertain, 4-Agree, 5-Very Agreeable). The study was conducted in George Town and KL, with 50 respondents being selected to represent each study location. These number of respondents were decided due to movement restrictions during the pandemic. Thus, 100 questionnaires were distributed during the last quarter of 2020. All the respondents (100%) validly completed the survey. The process of distribution and collection of questionnaires and subsequent telephone interviews (discussed below) took almost one month.
In this study, a descriptive analysis method was used to analyse the obtained data, which were mostly categorical. Other than frequencies and percentages, which were used to understand the general trend of answers for all parts of the questionnaire, the means of each variable were generated by applying descriptive statistics. The data analysis was conducted using IBM SPSS ® Statistics (version 26). Landell's (1997) interpretation scale was used to determine the score for each mean value: low (1.0 to 2.33), medium (2.34 to 3.67) or high (3.68 to 5.00).
In addition to the descriptive quantitative survey instrument mentioned above, the study also incorporated the qualitative method, with telephone interviews being conducted with five informants to gain further insights regarding the interviewees' strategies to cope with and adapt to the pandemic. The data from the interviews were transcribed and the content was analysed based on selected themes identified in the study. In doing this research, all appropriate ethical considerations were carefully observed by the authors; consent was required to participate in the study and approval was obtained from the ethics committee (JEPeM Code: USM/JEPeM/19070406).
Since this study included a questionnaire, it was essential to ensure that every variable in the survey instrument accurately measured the concept it was supposed to measure. Thus, the reliability of the questionnaire was tested. Cronbach's alpha test was performed to ensure that the items were homogeneous and measured the concept of interest (Taber, 2018). As shown in Table 1, t was between 0.762 and 0.850. Therefore, the instrument was reliable and no item needed to be removed. The items were used to form concrete concepts for further analysis.

Findings
This section describes the statistics of the participants in this study. As shown in Table 2, the largest proportion of participants were aged from 60 to 65 years (52%), followed by 66 to 70 years (38%) and 71 to 75 years old (10%). In terms of gender, 51% of the respondents were women, while 49% were men. The majority of the respondents were Malay (65%), followed by Chinese (25%), and Indian (10%). In addition, 70% of respondents are married, while 30% were divorced. A quarter of the respondents had completed primary school, 35% had completed some secondary school, 22% had a secondary school diploma, and 18% had completed a bachelor's degree.
More than half of the respondents (55%) were pensioners, 23% were working in the private sector and 22% were unemployed. In terms of monthly income, 25% of the respondents had zero income and 28% earned MYR1001-2000 (USD240.37-480.25). Moreover, 20% of the respondents earned MYR 2001-3000 (USD480.49-720.38), 15% earned MYR3001-4000 (USD720.62-960.50) monthly, and 12% earned MYR4001-5000 (USD966.71-1208.08). Table 3 shows the behavioural changes reported by the older adult participants during the pandemic, covering the seven items in Part 2 of the survey. The table incorporates a comparison of behavioural changes between older adults in George Town and KL. The mean value of "I have improved my spiritual practices during the pandemic" was the highest among all items in this part, at 4.32 in George Town and 4.52 in KL. The respondents agreed that they had engaged in spiritual activities during the MCO period because they were able to focus their time and energy on worship. However, they were also preoccupied with world affairs. Therefore, they took the opportunity during the pandemic to perform spiritual activities such as additional prayers, fasting, and reciting the holy Quran.

Behavioural changes during COVID-19 pandemic
Meanwhile, the item "I do sports activities, entertainment, meditation and so on in my house during the pandemic" had the second-highest score of all items, with a mean value of 4.18 in George Town and 3.48 in KL. This was due to the respondents' preference for performing such activities in the early morning and late afternoon. Respondents stressed that the pandemic period should be used wisely to perform various activities that could not be done while they were busy with other tasks. Among the activities mentioned by the participants were the SENAMAS (Exercise for older adults), which is carried out individually within the house, meditating in a natural setting to increase peace of mind, gardening vegetables and herbs, planting various flower trees, fishing in ponds and trenches, rearing chickens, ducks and geese, keeping fish and birds, and playing board games such as "dam aji" [checkers], chess and others.
Next, the item "I frequently use the Internet, WhatsApp and my phone to contact family, relatives and friends during the MCO" had a mean score of 3.92 in George Town and 4.06 in KL, the third highest among all items. The respondents reported having personal interactions with their family members, relatives and friends during the pandemic. The respondents stated that they had maintained regular contact with family members who were staying with them. For those who were living apart from them, they could still communicate via telephone and the Internet. Thus, the pandemic had not prevented them from interacting and connecting with their distant family members, relatives or friends. Table 4 summarises the 10 items concerning anxiety among older adults in George Town and KL during the pandemic. The findings showed that overall, the level of anxiety among the respondents in George Town was moderate. Conversely, the respondents from KL recorded high mean values for six items. The item with the high mean value in KL was "I often think about the COVID-19 outbreak", with a mean value of 4.24. The respondents stated that they were nervous about the outbreak and were constantly watching the news and browsing the Internet to get the latest information regarding COVID-19.

Anxiety related to COVID-19 pandemic
The second highest item was 'I often worry about getting infected with COVID-19ʹ, with a mean value of 4.14. The KL respondents reported feeling that they were particularly vulnerable to the virus because they were in the centre of the capital city of Malaysia. The third-highest item was "I feel afraid when one of my relatives/contacts gets sick during the pandemic", with a mean value of 3.94. The respondents stated that they felt uncomfortable and worried every time they were informed about the health problems of people they knew.
The fourth-highest item was "I feel sad about not being able to meet my children who live far away during the pandemic", with a mean score of 3.84. As discussed above, all communities in Malaysia were subject to an extended period of home quarantine to curb the spread of the pandemic. As a result, the respondents were sad and concerned about not being able to visit their children who lived outside their homes. Some children even lived nearby but were unable to meet with their parents due to the lockdown order. The fifth highest item was "I often worry about financial resources during the pandemic", with a mean value of 3.78. The respondents were concerned about their economic situation due to the high cost of urban living, as well as other financial problems affecting both them and their children.
The sixth highest item was "I often feel anxious about the statements made about COVID-19 in the media and on social media", with a mean value of 3.70. The respondents reported feeling uneasy when watching the news regarding the rise and fall of COVID-19, as such trends impacted them even more than those living in high-risk areas. They were sometimes so concerned that they called their children, relatives, and friends living in high-risk areas to remind them to be cautious of their surroundings and avoid going to public places. Table 5 demonstrates the 10 items used to measure the degree of adaptation among the older adults in George Town and KL during the COVID-19 pandemic.

Adaptation during COVID-19 pandemic
The results showed that respondents from both George Town and KL had adapted well to the COVID-19 pandemic, based on the high mean values across most items. The item with the highest mean score was, "I always stay at home for safety purposes during the pandemic", with The respondents considered that they must remain at home to prevent COVID-19 from spreading widely, as recommended by the Ministry of Health. The second-highest item was "I avoid being in public places and attending social events, including weddings and reunions", with a mean score of 4.34 for respondents in George Town and 4.68 for respondents in KL. The respondents stated that they would not leave their homes if they did not have essential needs. They also did not attend social events to protect their safety and health, as the COVID-19 outbreak in Malaysia has not yet subsided.
The third-highest item was "I always wear a face mask outside", with a mean value of 4.26 for George Town respondents and 4.66 for respondents in KL. Although respondents were rarely able to leave their homes due to age and environmental factors, when they did need to go outside to manage important matters, they always wore facial masks to protect their health. The respondents also stated that they had practised hand washing and personal hygiene throughout the pandemic and continued to apply such practices. This was reflected in the results for the item "I regularly practice handwashing and personal hygiene", which was the fourth-highest mean value, as 4.22 for respondents in GT and 4.56 for respondents in KL. The fifth-highest item, "I practice social distancing", recorded a mean score of 4.14 for respondents in George Town and 4.52 for respondents in KL. This was due to compliance with safety guidelines issued by the Ministry of Health. The respondents stressed that they knew that they should follow the Standard Operating Procedures to avoid health risks.
The sixth-highest item, 'I am always aware of the current news about COVID-19ʹ, recorded a mean score of 3.90 for George Town respondents and 4.50 for KL respondents. Most of the respondents stated that they were constantly following the latest developments concerning the pandemic so that they could combat the virus and take appropriate precautions. The seventhhighest item was "I always think positively to motivate myself during the pandemic", with a mean score of 3.74 for respondents in George Town and 4.30 for respondents in KL. This indicates that respondents from both urban areas have adopted a positive attitude during the pandemic to motivate themselves to survive this difficult period.
The final item was "I interact with family, relatives and friends to reduce stress", registering a mean score of 3.68 for respondents in George Town and 4.06 for respondents in KL. Interacting with family members, relatives, and friends to ensure they were all in good health enabled the respondents to gain peace of mind. The majority of respondents stated that interacting with family members, relatives, and friends alleviated their anxiety and made them feel more at ease.

Discussion
Based on the results of this investigation, older adults in George Town and KL have changed their behaviour during the COVID-19 pandemic. The respondents placed the greatest importance on their "improvement in terms of spiritual practices during the pandemic". This aligns with the results of previous studies and supports the bio-psycho-social-spiritual model, which advocates taking a humanistic and holistic view of human wellbeing during this time. The results of this study are also consistent with Killgore et al. (2020), whom found that those who actively engage in spiritual health and nurture their relationships have tended to be the most resilient to the mental health challenges posed by the COVID-19 pandemic.
Next, the respondents reported engaging in sports, entertainment, meditation, and other activities in their houses during the pandemic. Such activities not only occupied the respondents' leisure time but also increased their physical activity, resulting in improved fitness. Meanwhile, the results also align with the goals of the WHO's #HealthyAtHome campaign, which encourages staying physically active, looking after one's mental health, quitting tobacco, healthy parenting and eating healthily (WHO, 2020a).
The older adults in George Town and KL also reported that they had "engaged with the Internet, WhatsApp and phone frequently to contact family, relatives and friends during the MCO". A recent study found that increased communication with regular support partners and connecting to new or infrequent social contacts through new communication technologies are effective ways to increase resilience, thus reducing levels of depression and anxiety (Fuller et al., 2021). This aligns with Hajek and König (2021), who found that one solution for managing the pandemic and staying in touch with others is to use video conferencing programs (e.g., Skype) or online social media (e.g., Facebook). These solutions may, at least temporarily, replace physical contact with friends, acquaintances, children, and grandchildren, and have the potential to alleviate feelings of social isolation or loneliness. Moreover, the use of social networking has increased feelings of connectedness, supporting the notion of social capital as defined by McKenzie and Harpham (2006). Consistent with previous studies, the results of this study indicate that social support is a protective factor in resolving psychosocial issues (McKenzie & Harpham, 2006). Lehtisalo et al. (2021) agreed that engagement in cognitive stimulation activities such as using the Internet, doing handicrafts, and solving crosswords has increased during the COVID-19 lockdown period. During the pandemic, the Malaysian government has taken action to show its concern to the citizens. The People-Centric Economic Stimulus Package (PRIHATIN) was announced by the Prime Minister on 27 March 2020, shortly after the onset of the pandemic, and was the nation's largest-ever economic stimulus, with a total value of RM250 billion. Several packages of RM1 billion have also been offered in collaboration with various telecommunications companies, supporting efforts to improve telecommunications networks. The government has also promised to offer free Internet access from 1 April 2020 until the end of the MCO period, at a cost of RM600 million (MCMC, 2021).
This study also considered the anxiety faced by the older adults in George Town and KL concerning the COVID-19 pandemic. The issue causing the highest anxiety among older adults in KL was "too much thinking about the COVID-19 pandemic". The respondents were concerned not only about becoming infected with the virus but also about the impact of the pandemic on their daily lives (e.g., not being able to see their friends). Fear and anxiety about COVID-19 can be overwhelming, increasing mental stress concerning individual and social safety (Shanmugam et al., 2020). However, the respondents were optimistic that the outbreak would soon be over. This is in line with a study conducted by Lim et al. (2021), which found that greater fear predicts higher anxiety levels. However, fear does not significantly influence an individual's engagement in protective behaviours. The findings also revealed that compassionate older adults engage in protective behaviours more frequently. Furthermore, frequent use of protective behaviours and higher resilience predicts lower anxiety in older adults.
Meanwhile, 'worry about getting infected with COVID-19ʹ was the second most significant anxiety-related concern for older adults in KL, given that they were living or staying in the capital city of Malaysia. KL has reported the second-highest number of COVID cases and deaths in Malaysia, as compared to Penang at the seventh highest. KL also has the highest population density in the country, at 7,188 people per square kilometre. In contrast, the population density of Penang is 1,691 people per square kilometre (DOSM, 2021a). COVID-19 spreads via human contact, with denser areas providing more opportunities for such contact (Carozzi et al., 2020;Wong et al., 2020). Highly concentrated and densely populated urban areas have a greater risk of virus transmission between their inhabitants. Furthermore, most respondents reported feeling worried about anyone they met and feeling afraid of being a close contact of a patient or carrier of the virus. Feeling afraid of relatives or contacts getting sick was one of the top three anxiety-related concerns experienced by older adults in KL. There are two types of worry expressed: the first was that relatives or contacts would be virus carriers, and the second was that the respondents would be unable to visit the patients due to the restrictions in place. Throughout the pandemic, the respondents have been plagued by a variety of worries about the health of those around them.
Vaccines are one of the most effective ways of protecting people from COVID-19 and controlling the pandemic, and they are particularly important for older adults. Since the emergence of COVID-19, various efforts have been made around the world to develop a vaccine for the virus. In Malaysia, the Special Committee for Ensuring Access to COVID-19 Vaccine Supply, which is co-chaired by the Malaysian Ministries of Health and of Science, Technology and Innovation, was established to ensure immediate, safe and effective access to the COVID-19 vaccine (JKJAV, 2021). As of 27 July 2021, 19,919,192 Malaysians had registered for vaccination, with 11,797,708 Malaysians having received their first dose. The Special Committee on COVID-19 Vaccine Supply has also reported that, as of 4 July 2021, over 65% of older adults in Malaysia had received at least one dose.
Finally, this study examined the adaptation of older adults in George Town and KL to the COVID-19 pandemic. The respondents reported three key ways in which they have adapted to the pandemic. The highest preference was for staying at home for safety purposes. According to the Ministry of Health, older adults are more susceptible to the pandemic as they are categorised as high-risk. Given this, the respondents felt safer staying at home during the outbreak. This was followed by "avoiding public places, including attending social events". This aligns with the government's approach since March 2020, when the MCO was imposed to prevent people from moving outside their homes (Rahim, 2020). The third most common way to adapt to the COVID-19 pandemic was "wearing a face mask outside".

Conclusion
This study investigated the behavioural changes, anxiety, and level of adaptation related to psychosocial issues experienced by older adults in George Town and KL during the COVID-19 pandemic. Comparing both cities, KL recorded higher mean values for most of the items.
There is no doubt that the pandemic has profoundly affected most people, and has had a particular impact on the health and wellbeing of older adults. Providing the older adult population with means of engagement, support and connection with other individuals, groups and networks is crucial to their overall wellbeing. Although there have been increasing numbers of hospitalisations and deaths as a result of the pandemic, this study highlighted the previous underrecognised resiliency and capacity of older adults to respond effectively to this crisis. The results also highlight opportunities to elevate various issues in the recovery efforts.
Staying physically active and alert, as well as engaging in spiritual activities, has been shown to contribute significantly to uplifting the wellbeing of this vulnerable group. The results suggest several approaches to address the issue of isolation, including promoting the maintenance of social support and ensuring that older adults can interact and connect with their family, relatives, friends, and community networks. Developing technology-based interventions can also improve social connections and psychosocial wellbeing.
The results suggest that while geography-based associative behaviours are important, people are also likely to belong to several different communities, both geographical and non-spatial. This reflects their strength of social capital and level of access to social support and social networks. Nevertheless, government interventions should continue to address the need to engage the healthcare system, incorporate methods to identify social isolation among older adults, and define key policy priorities and actions, particularly in healthcare settings.
This study also illustrates that ICT is a critical tool for both living and working during the pandemic, not only for the younger generations and working adults but also for older adults. More efforts should be made to promote and support physical, social, and cognitive activities for older adults, leveraging relationships with family members, caregivers, volunteers and others. The study highlights some opportunities for future research, including investigation of the mental health of older adults, the support provided by multigenerational living arrangements and family structures, and the role of technology in improving older adults' quality of life. Moving forward, pandemic responses should strongly focus on issues of urban inequality, and authorities should take proactive measures to develop the required social capital and infrastructure to engender healthier and more sustainable communities.