A critical discourse analysis of the Quebec media’s portrayal of older adults in residences and long-term care homes pre- and peri-COVID-19

Introduction

Heterogeneity in the aging population includes variability in social structure, genetics, and personality (Light et al., 1996; Ehni & Wahl, 2020). It may also reflect the outcome that some older adults will be independent while others will depend on support from their relatives, community services, or a residence or long-term care (LTC) home as they have higher care needs (Grigsby, 1996; Nguyen et al., 2021). In 2019, adults aged 65 and older in Quebec represented 19.2% of the population, making it the Canadian province with the highest proportion of older adults in its population (Statistics Canada, 2021; Institut de la statistique du Québec, 2019). It is estimated that for those older adults that do not live independently in the community, 85,000 live in private residences while 46,000 live in publicly funded LTC homes in Quebec (Bravo et al., 2014). Within this categorization, Quebec further differentiates its LTC homes into three types based on the level of care provided: (1) “centres d’hébergement de soins de longue durée” (CHSLD), (2) “résidences privée pour aînés” (RPA) and (3) “ressources intermédiaires” (RI) (Commissaire à la santé et au bien-être (CSBE), 2021). Older adults who need the highest level of care, in that they require help with daily tasks, are typically placed in CHSLDs (CSBE, 2021). In contrast RPAs are homes in which residents may require some care but the focus is more on providing a support system and a community (CSBE, 2021). The intermediate type of home is considered RI, where older adults need some assistance with their daily activities but not to the extent of older adults in CHSLDs (CSBE, 2021). It should also be noted that RIs are not limited to older adults but also include persons of all ages who have severe disabilities (CSBE, 2021). Currently in Quebec, there are 412 CHSLDs (private, private subsidized and public), 1791 RPAs and 1835 RIs (Lavoie, 2020).

COVID-19 is an infectious disease caused by a coronavirus, first discovered in Wuhan, China (World Health Organization, 2020). The first COVID-19 case in the province of Quebec was confirmed on 27 February 2020 (Olson, 2020). During the first wave, adults aged 60 years and above represented 36.8% of confirmed cases and 97.7% of deaths resulting from COVID-19 in the province (Gouvernement du Québec, 2020). During the crisis, Quebec became one of the top ten epicenters in the world largely due to the spread within the LTC homes (Bérubé, 2020). The pandemic served to highlight the already fragmented system serving LTC residents from years of understaffing and mismanagement of funds (le ministère de la Santé et des Services sociaux, 2021; CSBE, 2021). More than ever, people have been turning to the media to be informed of daily updates regarding the pandemic. In 2014, more than 57% of Quebecers said that they read print newspapers at least once a week (Siag, 2016). Adults over 50 years old make up the largest demographic of print newspaper readers in Quebec (Centre d’études sur les médias, 2019). The Journal de Montréal reported a 91% increase in readership compared to the year prior to the pandemic (Robitaille, 2020). As such, the media has been given a significantly larger role in public life, making its depiction of older adults during these unprecedented times not only more prominent but reaching a much larger audience. The degree of influence of the media on the perception of older adults during COVID-19 is therefore considerably higher.

The media has the power to influence the public’s opinion based on the ideas it presents as well as the many ideologies it supports (Happer & Philo, 2013). The media can act as a vector for the dissipation of stereotypical views that can make their way into societal perceptions (Happer & Philo, 2013). When the media creates and propagates stigma, the more neutralized the stereotypes become, thus making it easier to adopt these views into popular culture (Ross, 2019). Mainstream news media typically focuses on populations in power and often portrays institutional leaders, such as the government, positively (Ross, 2019). This consequently results in populations deemed less important and sometimes already marginalized, to receive less favorable and stereotypical portrayal (Ross, 2019).

Positive and negative ideas of aging have been presented in the media, but many tend to reinforce ageist stereotypes (Fraser, Kenyon, Lagacé, Wittich & Southhall, 2015; Milner, Norman & Milner, 2012). Aging is often seen as a phenomenon that should be avoided, where older people create a burden on social and economic resources of the society (Milner et al., 2012). News and social media reinforce the ageist stereotypes where older adults are ultimately waiting to get sick and are helpless against illness (Ayalon et al., 2021; Bacsu et al., 2022; Fraser et al., 2020; Lagacé, Laplante & Nahon-Serfaty, 2013). Occasionally, aging is perceived positively by the media, but this is often in the form of an underlying anti-aging campaign (Milner et al., 2012).

One model that has attempted to explain why society, including the media, conveys stereotypes about older adults is the Stereotype Content Model (Fiske et al., 2002). This model identifies two categories in which groups may be stereotyped, according to: warmth and competence (Chasteen & Cary, 2015). Older adults may be described using this model, scoring high for warmth yet low for competence (Chasteen & Cary, 2015). Although scoring high for warmth may be perceived positively, it is typically paired with scores of low competency and this may contribute to the undermining of older adults in the society and consequently, to lowered self-esteem and decreased social participation (Chasteen & Cary, 2015). In fact, when older adults living in LTC are treated as able-minded and -bodied, positive health outcomes can be observed (Chasteen & Cary, 2015). Direct (e.g., old people are fragile) or indirect (e.g., walking canes are ugly) stereotypes can have a profound impact on the way not only society views a group of people but how the members of that group perceive themselves (Kang & Chasteen, 2009).

One way of critically examining, interpreting, and explaining how discourses create and reinforce social inequalities is critical discourse analysis (CDA) (Mullet, 2018). This method acknowledges the power of language on perception and social relations (Mullet, 2018). CDA also helps present a global context on what is happening in the society in terms of economic, historical, and governmental interactions in terms of the group of interest (Fraser et al., 2015). This method has been used before to examine differences and similarities in the ageism present in public discourse in a study related to the older population living in Ireland (Phelan, 2018). Semi-structured interviews were conducted with nurses who were asked their views on older adults. Many of the ageist stereotypes found within the oral discourse of the nurses were reaffirmed by older adults themselves when interviewed separately (Phelan, 2018). One older adult even said that living in her own home would be too dangerous, as older people are very vulnerable to violent break-ins and assault, as portrayed by the media (Phelan, 2018). Here, the older adult accepted and applied the stereotype of being vulnerable to her own life, demonstrating the power of language in public discourse (Phelan, 2018).

Since one of the populations most affected by COVID-19 is older adults living in LTC homes, it is of interest to examine their portrayal in the media prior to and during the pandemic. This will allow for the exploration of existing issues of neglect in the care and quality of life outcomes of older adults in residences or LTC homes (Estabrooks, Squires, Carleton, Cummings, Norton, 2015; Katz, 2011), as well as their contribution to the poor health outcomes and mortality seen in the wake of COVID-19. Therefore, the goal of this study was to examine the Quebec mainstream print and online media material about older adults living in LTC homes pre- and peri-COVID-19 using critical discourse analysis.

Methods

Search strategy: It is estimated that the Journal de Montréal and Journal de Québec reach 2.83 and 1.48 million readers per week respectively, making these the two newspapers the most dominant media platforms in Quebec, both in print and their online form (Québecor, 2019), and therefore these two newspapers were targeted in our search. In addition, with the goal of capturing media from as many regions and perspectives as possible, the following French-language news sources were included based on readership: Le Devoir, Le Soleil, La Presse.ca, La Tribune, Le Quotidien, and La Voix de L’ Est (Jacques, 2017). Using the Factiva database, these sources were searched on 13 May 2020, and the 6 previous months were examined. This allowed us to capture media texts from 3 months before the first confirmed COVID-19 case in Quebec to 3 months after. A preliminary database search was conducted using a list of basic search terms related to the research question (e.g., “aînés” [older adults] and “centres d’hébergement de soins de longue durée (CHSLD)” [long-term care homes]). This search was amended as it was found that several additional terms emerged that reflected the residences/care homes available in Quebec in a more concise manner. Each type of residence involved care services provided to older adults, but they varied in the number of hours of care and services provided. In addition to CHSLD, other search terms that related to LTC homes in Quebec were used, these included: “résidence pour aînés”, “résidence privée pour aînés” or RPA, and “ressource intermédiaire” or RI.

Inclusion/exclusion criteria: Selected articles had to include one of the type of residences in Quebec and health/quality of life outcomes of older adults. Any type of article (i.e., opinion, news, life, etc.) was eligible for inclusion and articles were coded according to type in order to better understand where in the newspaper the targeted discourse was emerging (i.e., front page news or life). Articles were excluded based on two criteria: (1) Unrelated and (2) Duplicates. Articles falling into criterion (1) did not include information pertaining to direct or indirect impact on the lives of older adults living in LTC homes. For example, the article was excluded if it only mentioned the word “CHSLD” without explaining the impact on the lives of older adults. Lastly, articles containing identical content with or without identical titles to previously included or excluded publications were considered duplicates.

From 1413 generated articles, two authors determined that 316 fit the inclusion criteria for all search terms based on the immediate content surrounding the search term. The same authors screened the full texts of the 316 articles, discussed any conflicts and determined by consensus that an additional 108 articles be excluded. For the 208 included articles, a coding grid was created that included information about: (a) the newspaper (Journal de Montréal or Journal de Québec), (b) type of article (i.e., news, opinion, etc.), (c) author, (d) date of publication and (e) length of the article in words. The two authors then collaboratively coded 35 articles to discover common themes arising from the text. The coding of this subset was completed over a 2-week period, where discussion led to the formal definition of codes and a preliminary code book. Subsequently, the next 33 articles were coded with the code book and then discussed to make any final adjustments to the coding. All remaining articles were coded with the final code list (25 codes) by the first author. Codes were applied to different passages and the frequency of each code was quantified in Microsoft Excel.

During the iterative coding process, OA and SF found that certain codes reflected emergent categories (or themes). For example, the codes: social isolation, neglect, abuse, and reduced autonomy (by others) were all found to reflect the category of mistreatment. The advocacy category emerged with respect to the codes: support and protection (from the public), family support, moral responsibility and justice system. After reviewing the data, seven conceptual categories emerged by author consensus. These categories were (i) mistreatment, (ii) positive care procedures, (iii) negative care procedures, (iv) communication, (v) stigma, (vi) government and (vii) advocacy. The minimum length of text coded was one sentence. Representative passages were selected and the first author, a bilingual researcher, translated the passages from French to English for reporting purposes. The code list, specific definitions and categories can be found in Figure 1. Once the sample (208 articles) was coded completely, thematic analysis was used to uncover themes from interacting codes. Thematic analysis helps identify themes from the text by the grouping of several categories that convey a similar meaning through the use of inductive analysis (Mogashoa, 2014). The recurring themes (or interactions between codes/categories) can help explain what is being said in the text in a more cohesive manner (Mogashoa, 2014).

Figure 1. A representation of the 25 final codes used during the critical discourse analysis (CDA), organized by category.

Results

Close examination of the texts revealed that there were interactions between the different categories identified during coding, leading to two important themes emerging. The first theme, (1) Resources, health and government, represents the intersection between lack of resources, negative health outcomes and government action during the pandemic, encompassing categories (iii) and (vi). The second theme, (2) Social isolation and advocacy, represents the relationship between negative health outcomes and advocacy during the pandemic, encompassing categories (i), (ii) and (vii). The results of these two themes will be presented immediately after the reporting of the summary quantitative data comparing the code frequency in the pre- and peri-COVID-19 timeframes. These findings will be followed by additional results surrounding the discourse around the different types of residence and ageist language that are indirectly related to the research question.

Summary and quantitative data

Data collection yielded a total of 316 articles, of which 108 were excluded based on exclusion criteria, and the remaining 208 article contents were critically analyzed. A distribution of articles published per month during the selected time period can be found in Figure 2. Ninety-one percent of articles analyzed discussed the situation in LTC homes during the pandemic (peri-phase), the remaining 9% belonged to the pre-pandemic phase. The most common newspaper section reporting on older people in LTC homes was the news section, followed by opinion pieces. Most of the articles (87.5%) focused on CHSLDs while the remaining covered other types of residence, with private residences being the second most prevalent.

Figure 2. The distribution of articles regarding older adults living in long-term care facilities published per month in the Quebec media during the timeframe of this study.

Discussion

The goal of this study was to examine the Quebec media’s portrayal of older adults living in LTC before and during the first wave of COVID-19. The similarities and differences between the pre- and peri-COVID-19 phases highlight which aspects of LTC were problematic even before the pandemic and which aspects were exacerbated by the pandemic, resulting in poorer outcomes for older adults. The media presentation of the pandemic also fostered strong social advocacy for older adults living in LTC homes.

Firstly, it is clear from the findings that there has been and still is a need for more resources in Quebec LTC homes. These resources can come in the form of staffing, training, equipment and most importantly, funds. From the data, a strong association between lack of resources in these homes and negative health outcomes for older adults was clear. A majority of older adults residing in CHSLDs require extensive amounts of care for daily living tasks (CSBE, 2021). Therefore, insufficient funds or staffing can have a profound impact on their quality of life and overall well-being. This was recognized by the Quebec government when preparing the 2018-2019 budget, as they allocated $378 million for services in all types of LTC homes, and specifically $96 million to improve the province’s CHSLDs (Gouvernement du Québec. 2018). However, despite the government’s budget plan, CHSLDs made up the largest proportion of deaths per living arrangement during the pandemic, largely because they were lacking resources (Gouvernement du Québec, 2020).

The findings highlighted that the relationship between lack of resources and negative health outcomes is further exacerbated by disasters (e.g., a pandemic) that limit access to informal care such as visits from family members, and can cause stressful conditions. Informal care provided by family members and non-professionals can facilitate a continuity of care as well as maximize the care (by providing additional assistance) and psychological support of the older adult (Triantafillou et al., 2010). The need for government reform was acknowledged more urgently during the peri-COVID-19 phase once the role of informal caregivers was finally recognized as an essential part of the continuity and quality of care among older adults. The reform calls for increased staffing and valuing the work of health care practitioners in LTC homes by increasing their salary and level of training. In May 2020, the Quebec government announced a plan to increase the staff working in CHSLDs by 10,000, increase the yearly salary of an orderly by 9,000 CAD and provide a 3-month training program for all new employees (Shingler, 2020). Although the need for distributive reform was addressed immediately during the pandemic, the lack of resources was evident before it. Perhaps the dependence of Quebec LTC homes on informal care was significant enough to mask the urgent need for government intervention prior to the pandemic. In comparison to the rest of the country, Quebec is not the only province that struggled with the effects of the pandemic on their LTC facilities (Holroyd-Leduc & Laupacis, 2020). Long-term care is a sector in Canada that has been historically overlooked, which contributed to the high mortality in these residences when faced with COVID-19 (Holroyd-Leduc & Laupacis, 2020). Many deaths in LTC homes across the nation were preventable if similar measures put into place in hospitals were implemented in care homes (Holroyd-Leduc & Laupacis, 2020). This pandemic has resulted in many provinces reevaluating the delivery of care in their LTC homes and planning for necessary reform (Holroyd-Leduc & Laupacis, 2020).

The pandemic highlighted and perhaps contributed to a rise in advocacy for older adults by those who value their lives and contributions. Advocates in Quebec society spoke out and defended those living in LTC. Other studies found that some older adults living in the community distanced themselves from those living in a CHSLD (Lagacé et al., 2021). As social isolation grew strong among the residents of various LTC homes and certain deleterious living conditions were exposed, some individuals demonstrated their advocacy directly, with deliberate acts of kindness, while others acted indirectly, challenging the underlying ageist views that are present in the public discourse. The extent of loneliness became more apparent not only in Quebec residences but in LTC homes across the world (Wu, 2020). Since the level of communication older adults maintained with their family during COVID-19 was a good predictor for their overall psychological wellbeing, a program that emphasizes communication would have a significant impact on the lives of older adults who are self-isolating. A Texas nursing home was popularized online for its pen-pal initiative (Henney, 2020). The latter provided older adults with a means of feeling connected to their society outside of their residential community. Social integration, exhibited by the pen-pal initiative, is a key factor to successful aging as a result of increasing life satisfaction, dissipating the extent of isolation older adults experience during a pandemic, and improving both physical and mental health (Vitman, Iecovich & Alfasi, 2014).

Many Western societies view negative health consequences as resulting from an individual’s actions (Blanchard-Fields, Chen, Horhota & Wang, 2007). Furthermore, this cultural practice plays into the stereotype of aging, that individuals in better health are more valuable to the societies and those who are not considered burdens to social and economic systems (Milner et al., 2012). The discourse surrounding older adults often uses the words “burden” and “vulnerable”, creating negative attitudes towards aging that may promote the social exclusion of older adults, leading to negative health outcomes in this population (Vitman et al., 2014; Lagacé, Doucet, Dangoisse & Bergeron, 2021). Recognition of the latter in the media during COVID-19 raised public awareness over what was really happening in Quebec LTC and the years of neglect these institutions had endured. In this way, the media was a catalyst for a rise in social advocacy and people challenging stereotypical views of aging. This hopefully will promote a new culture that will facilitate social integration among older adults, thus creating an environment where all members of a society, regardless of age, feel a sense of belonging.

Despite a growing number of advocates countering ageist views, the media continues to use language that undermines the status and self-image of older adults living in LTC. Though sometimes used in a compassionate or protective way, the use of ageist terms such as “vulnerable” reinforces a stereotypical view of aging, that all older adults must be vulnerable and taken care of (Fraser et al., 2015; Lagacé et al., 2013). In line with previous research in this area (Phelan, 2018), prejudicial speech can influence the way members of the stigmatized group perceive themselves. When confronted with stereotypes or consistently exposed to age-related stigma, older adults may use problem-focused or emotion-focused coping strategies (Chasteen & Cary, 2015). As age-related stereotypes are highly prevalent in our society, some older adults may not even recognize compassionate ageism having an impact on their self-esteem (Chasteen & Cary, 2015). This would, in turn, render problem-focused coping an imperfect strategy to reduce bias. Additionally, problem-focused coping may contribute to a stigmatized group being perceived as overly sensitive and reactive towards remarks made (Chasteen & Cary, 2015). Emotion-focused coping, however, enables older adults to recognize ageist remarks and dissociate them from their self-concepts (Chasteen & Cary, 2015). With this strategy, the stigmatized group can construct a barrier between prejudicial speech and how the group views themselves (Chasteen & Cary, 2015). Emotion-focused coping goes hand-in-hand with the increased mental adaptability that accompanies natural aging (Chasteen & Cary, 2015).

Using a technique such as critical discourse analysis (CDA), it was possible to unravel the specific social relations between the aging population and the media by looking at the language present in print newspapers (Mullet, 2018). Additionally, this CDA captures the modern context of the Quebec health, economic and governmental interactions in terms of older adults living in LTC facilities. Media outlets should consider that the majority of their readers are older adults (50 years and older; Centre d’études sur les médias, 2019) and may be significantly impacted by the language chosen to portray their age group (Chasteen & Cary, 2015).

Conclusion

The goal of this study was to examine the media discourse concerning older adults living in LTC homes prior to and during the COVID-19 pandemic. The findings support that COVID-19 served to exacerbate existing issues in LTC homes in Quebec while also attracting public attention and advocacy for older adults through the media reports. The findings highlight that there is a clear need for government reform regarding LTC residences and the resources attributed to them. With a larger audience reading media during the pandemic, the ideologies and language presented may have a wide impact, influencing the public, and older adults specifically. The dominant francophone newspapers in Quebec continue to use stigmatizing language when referring to older adults living in LTC, which can make its way into mainstream dialogue and further undermine the position of older adults in the Quebec population. It follows that it is imperative to counter these stereotypes using anti-stigma strategies to minimize the extent of the harm done to older adults in the province. It remains to be seen if the advocacy found for older adults in this discourse analysis has truly led to policy change to improve outcomes for older adults living in CHSLDs and residences.

Data availability

All data underlying the results are available as part of the article and no additional source data are required.