Perceived Fear of COVID-19 and its Associated Factors Among Nepalese Older Adults in Eastern Nepal: Findings From a Cross-Sectional Study

Background Coronavirus disease 2019 (COVID-19) has impacted all age groups, but older adults may have greater distress given their increased risk for severe illness and mortality. In Nepal, most stories of older adults are untold (cid:0) both in pre-COVID-19 and the COVID-19 era. In this study, we aimed to assess the perceived fear of COVID-19, and associated factors, among older adults in eastern Nepal. Methods A cross-sectional study was conducted between July and September 2020 among 847 older adults ( ≥ 60 years) residing in three districts of eastern Nepal. Perceived fear of COVID-19 was measured using the seven-item Fear of COVID-19 Scale (FCV-19S). In order to examine the factors associated with the COVID 19 fear, a generalized estimating equation, adjusting the sampling design was used. STATA 15 and JASP 0.13.1 were used for data analyses.

12%-34%, agreed to the seven items of the fear scale. Increasing age, Dalit ethnicity remoteness to the health facility, and being concerned or overwhelmed with the COVID-19 were associated with greater fear of COVID- 19. Surprisingly, pre-existing health conditions were inversely associated with fear of COVID-19.

Conclusion
Greater fear of the COVID-19 pandemic among the older population suggests that during unprecedented times such as the current pandemic, the psychological needs of most vulnerable groups should be prioritized. Fear among the most vulnerable groups could be reduced with the ow of adequate genuine information as well as better preparedness and psychosocial interventions.

Background
As of 29 September 2020, there were over 33 million con rmed cases and over one million deaths from novel coronavirus disease-2019 (COVID-19) (1). By the same date, Nepal reported 76,258 con rmed cases and 491 death from COVID-19 (2). The ongoing COVID-19 pandemic has been the center of focus globally and covered extensively in local and international news outlets. Much of the global and regional focus has been on disease prevention of transmission and therapeutics, which are undoubtedly pressing public health needs during a pandemic. However, one understudied, nevertheless not a less important aspect of COVID-19, is its mental health impact in the general population and, more importantly, among high-risk groups.
The oating information related to COVID-19 rapid transmission, swamping infection rates, and mortality globally has led to the development of stress, anxiety, and fear among the population at the ground level.
Over 100 countries worldwide (3), including Nepal a south-Asian country between India and China imposed partial and complete lockdown to curb the transmission of the virus. Consequently, social isolation, coupled with economic loss, may have serious impacts on the mental health of individuals (4). Life has been disrupted in most parts of the world, and the anxiety is common among people to accept the increasing cruelty of COVID-19 and to become accustomed to the new norm of life. Although most people seem to be physically, mentally, socio-economically impacted by the COVID-19 pandemic, the impact may be greater for certain groups such as the older population who are at an elevated risk of severe illness and mortality (5); the fatality rate for those over 80 years of age is ve times the global average (6). COVID-19 may have disrupted everyday life, jeopardized the needs and rights of older people around the world, and exposed the deep-rooted ageism. Given the increased risk of infection and mortality, it is obvious that older adults are more vulnerable to fear and worry due to the current unprecedented pandemic condition. Fear may affect older people's feeling, mood, or behavior, which may impact their ability to function physically, socially and cognitively each day (7,8).Speci cally, in Nepal, most stories of older adults are untold in both pre-COVID-19 as well as COVID-19 era.
The Senior Citizen Act of Nepal de nes individuals aged 60 years and older as senior citizens or older adults (9). The average life expectancy at birth in Nepal has increased from 49.6 years in 1981 to 70.6 years in 2016 (10), resulting in a burgeoning population of older adults. According to recent estimates for 2019, there were 2.67 million older adults in Nepal, representing 8.6% of the total population (11). The growth rate for the older population is 3.5% per year, which is greater than the national average of 1.35% (12).
There is scarce data on fear and its predictors among older adults in south Asian countries, mainly from a resource-limited country like Nepal. To the best of our knowledge, this is the rst study ever been conducted to assess feer of COVID-19 and associated factors among the older adults at the community settings in Nepal amid the COVID-19 pandemic.. Hence, the objective of this study is to assess the perceived fear of COVID-19, and associated factors, among Nepali older adults.

Methods
A cross-sectional study was conducted between July and September 2020, among the older adults (≥ 60 years) residing in three districts (Morang, Pachthar, and Terathum) of Province 1 in eastern Nepal. The sample size of 847 was calculated considering the following parameters: unknown prevalence = 50%, CI = 95.0%, sampling error = 5.0%, design effect = 2, and non-response rate = 5.0%. Multi-stage cluster sampling recruited the study participants. In the rst stage, three districts from Province 1 were selected purposively. Then, one urban and one rural municipality in each districts were selected randomly.
Subsequently, from each municipality, three wards (lowest administrative units in Nepal) were randomly selected. In the nal step, a proportionate simple random sampling technique was used to recruit participants from each ward. Representatives from the municipalities provided the list of eligible older adults in the selected wards. Eligibility criteria included age ≥ 60 years, Nepali nationals with a minimum of one year of residence in the community. The exclusion criteria included residing in nursing care, and mental conditions (clinically proved schizophrenia, bipolar mood disorder), a hearing disability, or unable to communicate.

Data collection and study variables
Data were collected by semi-structured interviews using a validated survey questionnaire (13). Surveyors were 12 trained health care providers working for the government of Nepal in the selected districts. Prior to data collection, surveyors were trained through the Zoom meeting facilitated by ve authors (UNY, OPY, DRS, SKM, SM). Surveyors were trained on study tools, participant recruitment, ethical aspects, and data collection techniques. Surveyors visited the households and collected the data using the KoBo Toolbox mobile app (14).

Dependent variable measurement
COVID-19 related fear was the primary outcome, which was measured using the seven-item Fear of COVID-19 Scale (FCV-19S) developed and validated by Ahorus et al. among the general Iranian population (13). Participants' agreement/disagreement with the seven items was assessed using a vepoint Likert-scale (ranging from 1= "strongly disagree," 3= "neither agree nor disagree," and 5= "strongly agree"). Hence, the cumulative score ranged from 7 to 35, where the higher the scores, the greater the fear of COVID-19.

Independent variable measurement
Independent variables included age group, gender, marital status, family type, ethnicity, education, occupation, urban/rural residence, walking distance to the nearest health facility, any pre-existing chronic health problems, any current medications, nancial hardships with health care access, need of additional care from family members/caregivers, social security allowance, source of COVID-19 information, and feeling overwhelmed and concerned because of COVID-19 pandemic. These co-variates de nition and measurements are described in our previous work (16,17). For the variable "sources of COVID-19 information", in multiple response questions, we asked participants to list their source of information for COVID-19. Participants were also asked "How overwhelmed are you feeling in this corona pandemic (Yes/no/not sure) and How concerned are you because of this coronavirus pandemic (Not at all/Somewhat concerned/Very concerned)".
The English version of the tool was rst translated to Nepali and then back-translated to English by three researchers to ensure the contents' consistency. Piloting of the tool among a small sample (n = 10) of older adults helped to re ne the nal version by considering the remarks from the older population.
Following piloting, minor editorial issues were resolved, such as "COVID-19" was replaced with the term coronavirus throughout, and the question that aimed to capture proximity to the health facility was clari ed by specifying "walking distance to the nearest health facility."

Statistical analyses
Mean (SD) and frequency (%) are used to depict participants' characteristics. Independent t-tests and ANOVA evaluated the mean differences in the FCV-19S score by participants' characteristics. The bar graph shows the participants' agreement with the seven items of FCV-19S. In order to examine the factors associated with the COVID 19 fear, a generalized estimating equation, adjusting the sampling design was used. The variables with p < 0.1 in the bivariate analyses were included in the nal multivariate model. STATA 15 and JASP 0.13.1 were used for data analyses. Table 1 describes participants' characteristics overall as well as in bivariate association with COVID-19 fear. Among 843 participants, 45% were aged 60-69 years, 49% were female, 76% were married, and 87% lived in joint families. Similarly, the majority of them had no formal education (68%), had pre-existing conditions (64%) or under any medications (51%), and had nancial hardships to access health care (55%) ( Table 1). Factors associated with the fear of COVID-19 among Nepali older adults Table 2 presents factors associated with the fear of COVID-19 among study participants. Increasing age, Dalit ethnicity, remoteness to the health facility, and being concerned or overwhelmed with the COVID-19 pandemic were associated with greater fear of COVID- 19. Surprisingly, pre-existing health conditions were inversely related to fear of COVID-19.

Discussion
This study assessed the perceived fear of COVID-19 and factors associated with the fear among Nepali older adults.The increasing problem of COVID-19 wordwide has led to increasing levels of stress, anxiety, and fear, in particularly among the older populations. Nepali older adults experienced different levels of COVID-19 fear on the seven items of the fear scale developed by Ahoruset al. (13). A sizable proportion of participants reported an agreement (ranging between 12%-34%) on the seven items of FCV-19S. Although the literature on fear of COVID-19 among the older population lacks from Nepal, experts opine that COVID-19 has heavily affected the mental health of older adults across the globe as they are more susceptible to fear and anxiety problems during the pandemic (18,19). Our ndings aligned with the recently published evidence that reported fear, psychosocial effects, and uncertainty due to COVID-19 (20,21). The ongoing fear among the general Nepali population is also corroborated by the media reports of residents protesting against the building of quarantine centers near their community settlement, evicting health workers from their rented units, non-attendance at the funerals, entry blockades to outsiders into their local areas, demonstrations and protests against the insu cient government's responses and so on. All these acts reveal the degree of fear perpetrated on the social fabric of Nepal. Moreover, the infodemics and misinformation spreading from fake and unauthorized news portals, and also from social media might have created additional fear among the general population (22).
Fear can be explained by a myriad of predictor variables. Increasing age, Dalit ethnicity, remoteness to the health facility, and being concerned or overwhelmed with the COVID-19 pandemic were associated with greater fear of COVID-19. The increasing fear of COVID-19 with increasing age was expected for two reasons. First, the impact of COVID-19, in terms of the hospitalizations, ICU admissions, and fatality rate, is highest among those ≥ 85 years of age (23). Notably, chronic disease or multimorbidity increases with age (24), which is one of the factors that make older people more vulnerable to the cruelty of COVID-19. Relatedly but surprisingly, our participants with prevalent chronic conditions perceived lesser fear than those without such conditions. This could be because people with pre-existing conditions have already navigated health services, and thus they know where and how to access health care. Additionally, they may also have received reliable information about COVID-19 and its prevention from their healthcare provider. Another possible explanation could be that those with chronic conditions have already developed resilience to dealing with major disease conditions which may have helped to develop perceived con dence to managing COVID-19, should they be infected. Furthermore, motivation and support from family members are important in chronic disease management in Nepal (25). Thus our participants with pre-existing conditions may have bene ted from their social support, which may have made them feel safer and consequently lessen the fear. However, we suggest the need for further study to explore the reasons. Despite the unexpected nding, we still believe that the increased risk of severe outcomes and death is one reason to increase the fear among older ages. Second, low health literacy among older adults in Nepal, speci cally the oldest age groups (26), may avert their ability to access, analyze, and appraise the information on COVID-19. Furthermore, a metanalysis on aging and the misinformation effect found that older adults above the age of 65 are more vulnerable to misinformation (27). Misinformation could aggravate fear and increase the sense of helplessness (28). Misinformation and ageism have prevailed during the current pandemic, and reports of older adults perceiving that COVID-19 had periled their existence (29) is an example that emphasizes the negative mental health impact of COVID-19 among the most vulnerable group. Such misinformation and ageism may make older adults very concerned and overwhelmed about the pandemic, which eventually can accumulate stress, fear, panic, and depression (30). As COVID-19 rapidly spreads around the world, adverse mental health effect among the older population is a global health issue. Subsyndromal mental health consequences have spiked among the older population due to isolation and loneliness (31). So, we should pay more attention to the old-age population who need more care and psychological support during the pandemic (32,33).
Another notable nding was the greater perceived fear among Dalits( low caste ethic minority as per traditional hindu caste system) compared to the Brahmin/Chhetris. Notably, the Dalit ethnic group were historically considered "untouchables" until the recent past and are still disadvantaged in terms of opportunities. The role of social determinants of health and their linkage to poor health outcomes among minorities is well documented (34). Although the socio-economic and health inequalities between the upper caste group and Dalits have been existent historically, even in the pre-COVID era, nevertheless, the current pandemic, by disproportionally affecting marginalized communities (35), has led us to rethink and revisit the disparities by ethnicity. Unfortunately, the COVID-19 case or mortality counts by ethnicity is unavailable in Nepal, but the greater perceived fear among Dalit ethnic groups could be attributed to the relative disadvantages they may have in terms of access to health care and other resources.
The results of this study revealed that being distant from health facilities was positively associated with COVID-19 related fear. This is reasonable because most of the local health care facilities have halted their services due to fear of COVID-19 transmission (36), and older adults who reside farther away from the health facility may think that it would be di cult to reach health facilities/centers for testing or COVID-19 related health care on time. On the same line, fear and uncertainty of the COVID-19 may have increased in the minds of older people as they are conscious of their effete immunity. Our study identi ed that the participants who were overwhelmed and concerned about the effect of the COVID-19 were more fearful than those who were indifferent to it. This is anticipated as fear of COVID-19 cripples when people become more concerned about its lethal outcomes, which triggers psychological distress (29). Mass media, including social media, also play a pivotal part in this regard as they are providing up to date information of this deadliest disease and making the people concerned about its negative outcomes (37). One of the ways forward could be increasing the conversation about mental health and dissemination of messages portraying self-care and coping strategies.
One of the strengths of this study is that it is the rst of its kind to assess the level of COVID-19 related fear among older adults in Nepal. A limitation is that the study conducted in three districts of Nepal in Province 1, which limits the generalizability to other provinces and/or settings of Nepal. The crosssectional study design doesn't suggest any causal relationship between fear and its correlates observed in this study. Additionally, we relied on the information provided by participants, where social-desirability bias could have occurred.

Conclusion
Despite the global burden of mental health, its importance has been relatively less recognized. The losses of the ongoing pandemic should not only be understood in terms of the loss of lives and economy, but the underlying psychosocial morbidities and their consequences, which may linger around even the pandemic is curbed, should be acknowledged. The greater fear of the COVID-19 pandemic among the older population suggests that during unprecedented times such as the current pandemic, due care of the psychological needs of most vulnerable groups needs to be taken. Thus, addressing the mental health needs of the most vulnerable group should be one of the priorities of pandemic management. Fear among the most vulnerable groups could be reduced with the ow of adequate genuine information as well as better preparedness and psychosocial interventions. Mobilizing the existing ones or setting up new mental health services is needed. Given the infodemics that heighten during the crisis, which may further aggravate the fear among the general public or among the most vulnerable groups, dissemination of appropriate information related to pandemic management as well as self-care and management of psychosocial health should be more frequent. Funding: The authos received no nancial support for the research or publication of this article.