The threat of COVID-19 that still lingers in the air, which has been associated with the unknown and carries an element of mystery, requiring a rapid and constant capacity for change and adaptation, and the consequences of the disease have acquired an uncontrollable magnitude, mainly among the most vulnerable groups, including older people, especially those who are institutionalized. The COVID-19 pandemic had important effects on the daily lives of most individuals starting on the first half of 2020, and many of these effects persist in the daily lives of all, especially those caring daily for older people. Many of these effects are directly or indirectly associated with the need to maintain measures to minimize the spread of the virus, and the others are associated with their psychological impacts, which continue to be felt, especially in terms of the fear generated by possible individual or family or caregiver contamination. Health workers became afraid of contaminating others or being contaminated. Health workers directly involved in the care of infected patients have a higher risk of contracting COVID-19, which can trigger feelings of apprehension or fear of being infected or infecting other people, including family members15. Fear is an emotional response to a threat, as COVID-19 still is. In fact, the fear of unpredictability and of the unknown, as COVID-19 was and still is, was felt by the workers at care homes for older people.
These feelings emerged because of the need to deal with the fear of contracting the disease during the pandemic and may also influence their behaviors. In the case of nurses16, the fear of COVID-19 decreased job satisfaction and increased the organizational and professional turnover intention among frontline nurses. According to some authors 17, the coronavirus required new behaviors and precautionary measures that resulted in the repulsion of physical contact, since this is the cause of viral spread.
The caregivers of older people in the analyzed institutions who had completed more schooling showed less fear of COVID-19. The fact that caregivers with higher education showed less fear of the health crisis they faced in older people care institutions may reveal of their ability to understand and analyze all the information produced and disseminated about contamination, the disease, and its side effects. It also suggests that higher education gave workers a greater critical capacity to protect themselves from the fake news that was spread worldwide minimizing the disease and its consequences. Higher educational levels usually correspond to higher levels of health literacy and consequently of mastery of skills of accessing, understanding, evaluating, and applying health information. Health literacy goes beyond knowledge and involves motivation and personal skills to access, understand, evaluate, and apply health information, as knowledge was significantly lower among older, less educated, low-income, and rural-dwelling participants; participants with higher education had significantly higher levels of knowledge18. Some studies19 found, that knowledge about the infection were significantly lower among older, less educated participants with low incomes living in rural areas, and participants with higher education had significantly higher levels of knowledge. Our study also corroborates other authors20 who found that most Chinese residents of relatively high socioeconomic status, particularly women, have more knowledge about COVID-19, which leads them to maintain optimistic attitudes and adopt appropriate practices in relation to COVID-19.
The mastery of this information seems to allay the fear of COVID-19 among female caregivers of care homes for older people with higher education. Conversely, a lower level of education, mainly among women, generates greater fear of COVID-19. For them to exercise their traditional role as “health managers”, both in the family sphere and in the work context, these women need to be able to access the successive waves of information about the disease and the pandemic, understand it, evaluate it, and apply it. A lower educational level may hinder the operationalization of this set of skills, which can generate fear, both of contamination and of the disease itself, and of the inability to perform their role as caregivers. It could therefore be stated that this is not only a fear of the unknown (in its full sense) but also a fear where the unknown still has a strong presence, despite the daily and unprecedented advances in scientific knowledge over these two years of fighting the pandemic. The scientific advances, scrutinized at each moment, seem not to have been sufficient to allay the fears that the different waves of the disease resurfaced or the complications that the disease causes, which began to gain visibility soon after the first year of the pandemic. Those with less schooling will have greater difficulty in daily monitoring the reliable information about each new advance and/or retreat of the pandemic waves, the evolution of treatments, the advances obtained in terms of vaccines, or prevention and containment measures. Previous studies identify higher levels of fear of COVID-19 in women, as well as more negative expectations regarding the consequences of the disease21. Although controversial, as women take more preventive measures, it is perhaps the perception of a threat to personal and collective health that generates strong emotions, reaching situations of greater anxiety associated with gender21,22.
Another important finding is that caregivers who were vaccinated against the flu were 1.16 times more afraid of COVID-19 infection than those who were not vaccinated. The explanation for this finding may come from the health information available to them, as they will know that the vaccine (in both the case of influenza and SARS-CoV-2) does not completely prevent infection. In contrast, studies that have related the flu vaccine with COVID-19 have concluded that flu vaccination is associated with improved clinical outcomes and prevention of complications associated with COVID-1923, and suggested that the administration of the flu vaccine, even before the typical flu season24 may help prevent the most severe forms of the disease and death. Thus, people who are more concerned with or more afraid of the disease may have resorted to flu vaccination to prevent COVID-19, or at least in the expectation that if they become infected, they will develop less severe forms of the disease. In fact, the people who are most afraid and consider themselves at high risk for COVID-19 are those who express their intention to receive the flu vaccine25. However, in other people, the feeling of invincibility sometimes sets in, which leads to self-exclusion from risk. These are people who overestimate their body's capabilities, discredit the guidelines of health institutions, and have a low perception of susceptibility. This concurs with other studies, where it was found that subjects who did not want to be vaccinated also doubted the safety conferred by vaccination, considering it superfluous for their person26.
In the case of caregivers who had more symptoms similar, to COVID-19 in the last two weeks and who were more afraid than those who did not have these symptoms, the explanation for the fear may come from having lived with an uncertain diagnosis, combined with the discomfort of the symptoms they experienced. This fear may also be associated with the images and news disseminated by the media about severe COVID-19 cases, which have always been given a prominent place, in addition to the official daily numbers of intensive care unit hospitalizations. Individuals saw and heard about patients in a coma, in need of oxygen therapy, on extracorporeal membrane oxygenation, and experiencing a set of serious situations that were typically not associated with diseases caused by respiratory viruses. COVID-19 has a variety of signs and symptoms, with the most frequent being fever, cough, and shortness of breath (compatible with other pathologies). However, these symptoms may be absent in COVID-19, which makes it more difficult to identify the disease. Gastrointestinal symptoms and changes in smell and/or taste have been identified in less severe cases and shortness of breath in more severe cases, the latter possibly progressing to death. Infection by SARS-Cov2, manifesting itself in a symptomatic or asymptomatic condition, giving rise to uncertainties in personal health, which both contribute to regulatory cognitive representations of the threat, and emotional representations, in the evaluation and management of feelings. Health care seeking behavior is thus influenced by representations about the disease, beliefs regarding the symptoms and the perception of severity/virulence27.
Limitations and strengths. In methodological terms, the assumptions of the multiple linear regression were met. The number of respondents was beyond 10 to 20 for each predictor variable, or at least 17514,28. Thus, there was sufficient statistical power for the analysis using the stepwise method. The stepwise method was the option chosen given that each iteration tests variables that can be removed. The convenience sample prevents generalization of the results. The study addresses an emotion, which is why the cross-sectional approach provides insights about the present moment. Further studies could benefit from samples with a stratified proportional distribution, according to the functions performed by the professional caregivers or the length of contact with the older people. In addition, the study deals with an emotion, which is why the cross-sectional approach offers the results of the moment. Later studies could benefit from samples with stratified proportional distribution, according to the functions performed by professional caregivers, or time of contact with the older people.
The FCV-19S scale has a good Cronbach's alpha coefficient (0.870)14, suggesting that it is a robust and adequate measure. As far as it was possible to observe, the FCV-19S was the first instrument, which addresses fear of COVID-19, validated for Portuguese13. The limitations of the instrument still lie in the character of the evaluated concept, fear, since it is an emotion, thus possessing some inconsistency, both influenced by internal factors and by the surroundings. The date of data collection may also have influenced the level of fear revealed by the participants. In fact, the deflation was starting gradually, based with caution, on the casuistry of 105 new cases per 100 thousand inhabitants29.
Reporting missing data became a recommendation in 1999, occurring more frequently from this year onwards. It is an improvement in the presentation of the research process that should be encouraged to authors30. Missing data leads to several problems, namely reduced statistical power, estimation bias, low sample representation31. The treatment of missing data is done through elimination or imputation techniques. While elimination excludes subjects or omits cases, mean imputation is a more conservative technique. The imputation of the average, in the missing data, calculated from the available scores, is a simple method since the missing data are filled in and subsequently analyzed. Thus, the assumption is made that they would not be absent. The main advantage is that it recognizes the differences between cases, using data provided by the case itself, to estimate the missing data32. This method has, however, some weaknesses, namely because when imputing missing values, through the average, it can affect the variance of the variable, as well as the co-variance with the remaining variables30,32. However, it is believed that the estimate through the average was an adequate resolution, as it is based on the theoretical foundation that it is reasonable for a distribution close to normal31.
Implications for Practice. This study presents contributions to rethink the importance of the role of caregivers of the older people (mostly women), namely the need for an early diagnosis of caregivers' feelings and emotions, through appropriate instruments and the training and preparation of these same caregivers in the management of feelings and emotions (fear) and the acquisition of skills in situations of global health crisis. Also, specific health literacy actions must be directed to caregivers to mitigate fears and simultaneously increase the safety of all those who live daily in these institutions (caregivers and older adults). Indeed, health literacy should be systematically promoted in care homes through short weekly training sessions on the central health themes that are dominant at any given time. A health literacy program must be able to develop in each worker the constant need for a systematic “epistemological alert” regarding general health information.
Implications in gerontology. Institutional caregivers are the people who most interact with the older people, so they identify their fears regarding the transmissibility of diseases and promote their knowledge, to overcome beliefs or prejudices, and can contribute to improving the quality of gerontological care.
Implications for nursing care with older people. Institutionalized older people have restricted contact with the family (a fact made worse by the pandemic), assuming the relationship with professional caregivers to be enormously resistant, due to the level of fear of the professional, to understand the risks of user-professional or professional-to-professional transmission. user, can be a destabilizing factor in care for the older people.
Implications for policy, practice, research, or education. Institutions for the older people are excellent contexts for the clinical practice of nursing students, whether with a healthy person or a dependent and vulnerable person. Thus, in situations of Public Health crisis, it is necessary to assess how students and professionals position themselves in relation to fear, through appropriate scales, in the sense of better management of this emotion.