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 findings 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 insufficient 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 confidence 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 benefited 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 finding, 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, specifically 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 finding 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 difficult 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 identified 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 first 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 cross-sectional 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.