Abstract

Introduction

Today, society and healthcare systems across the globe are being challenged by the emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In December 2019, Hubei province in China reported the first cases of a novel coronavirus and the disease now called COVID-19. Not long after, cases appeared all over the world, and on April 7th, 2020, World Health Organization (WHO) conferred it the status of pandemic ¹1. World Health Organization. Coronavirus disease 2019 (covid-19). Situation report, 78. Geneva: World Health Organization; 2020.. Up to August 21, 2020, there were over 22.5 million confirmed cases of COVID-19 in 216 countries and over 789,000 related deaths. In Brazil, the first confirmed reported case was on February 26th, 2020, and the count is already at almost 3.5 millions cases and 111,00 deaths (World Health Organization. WHO coronavirus disease (COVID-19) Dashboard. https://covid19.who.int/).

In the early phase, COVID-19 resembles a simple upper respiratory infection and in most cases, it will have few or no symptoms. SARS-CoV-2 can cause severe acute respiratory syndrome (sars) and can affect other physiological systems, similar to MERS-CoV (middle eastern respiratory syndrome coronavirus) ²2. Badawi A, Ryoo SG. Prevalence of comorbidities in the Middle East respiratory syndrome coronavirus (MERS-CoV): a systematic review and meta-analysis. Int J Infect Dis 2016; 49:129-33.. Older people and those with previous chronic diseases are more likely to develop a more severe form of COVID-19 ³3. Banerjee A, Pasea L, Harris S, Gonzalez-Izquierdo A, Torralbo A, Shallcross L, et al. Estimating excess 1-year mortality associated with the COVID-19 pandemic according to underlying conditions and age: a population-based cohort study. Lancet 2020; 395:1715-25.^,44. Shahid Z, Kalayanamitra R, McClafferty B, Kepko D, Ramgobin D, Patel R, et al. Covid-19 and older adults: what we know. J Am Geriatr Soc 2020; 68:926-9.^,55. Bello-Chavolla OY, González-Díaz A, Antonio-Villa NE, Fermín-Martínez CA, Márquez-Salinas A, Vargas-Vázquez A, et al. Unequal impact of structural health determinants and comorbidity on COVID-19 severity and lethality in older Mexican adults: considerations beyond chronological aging. J Gerontol A Biol Sci Med Sci 2020; glaa163. [Online ahead of print].^,66. Jordan RE, Adab P, Cheng KK. Covid-19: risk factors for severe disease and death. BMJ 2020; 368:m1198.^,77. Richardson SJ, Carroll CB, Close J, Gordon AL, O'Brien J, Quinn TJ, et al. Research with older people in a world with COVID-19: identification of current and future priorities, challenges and opportunities. Age Ageing 2020; afaa149.. Multimorbidity (defined as 2 or more chronic conditions in the same person at the same time) is an important risk factor, since it is in itself a predictor for risk of death ⁵5. Bello-Chavolla OY, González-Díaz A, Antonio-Villa NE, Fermín-Martínez CA, Márquez-Salinas A, Vargas-Vázquez A, et al. Unequal impact of structural health determinants and comorbidity on COVID-19 severity and lethality in older Mexican adults: considerations beyond chronological aging. J Gerontol A Biol Sci Med Sci 2020; glaa163. [Online ahead of print].^,88. Iaccarino G, Grassi G, Borghi C, Ferri C, Salvetti M, Volpe M, et al. Age and multimorbidity predict death among COVID-19 patients: results of the SARS-RAS Study of the Italian Society of Hypertension. Hypertension 2020; 76:366-72.. Studies of the Brazilian adult population show that the prevalence of multimorbidity is 22.2% (≥ 2 morbidities) and 10.2% (≥ 3 morbidities) ⁹9. Nunes BP, Chiavegatto Filho ADP, Pati S, Cruz Teixeira DS, Flores TR, Camargo-Figuera FA, et al. Contextual and individual inequalities of multimorbidity in Brazilian adults: a cross-sectional national-based study. BMJ Open 2017; 7:e015885.. About 67.8% of Brazilians, over 50 years of age, live with multimorbidity ¹⁰10. Nunes BP, Batista SRR, Andrade FB, Souza Junior PRB, Lima-Costa MF, Facchini LA. Multimorbidity: the Brazilian Longitudinal Study of Aging (ELSI-Brazil). Rev Saúde Pública 2019; 52 Suppl 2:10s..

Multimorbidity and COVID-19 have important correlations with health inequities, and people with worse socioeconomic status seem to be more affected ¹¹11. Calderón-Larrañaga A, Vetrano DL, Ferrucci L, Mercer SW, Marengoni A, Onder G, et al. Multimorbidity and functional impairment-bidirectional interplay, synergistic effects and common pathways. J Intern Med 2019; 285:255-71.^,1212. Guimarães RM, Andrade FCD. Healthy life-expectancy and multimorbidity among older adults: Do inequality and poverty matter? Arch Gerontol Geriatr 2020; 90:104157.^,1313. Oronce CIA, Scannell CA, Kawachi I, Tsugawa Y. Association between state-level income inequality and covid-19 cases and mortality in the USA. J Gen Intern Med 2020; 35:2791-3.. Some authors have revisited the term syndemic (i.e. synergistic pandemic - originally used in the 1990s on the discussions of the AIDS pandemic and its correlation with substance abuse or violence in the USA) to show inequality in chronic conditions and in social determinants of health and the impact they have on the rates of infection and mortality by COVID-19 ¹⁴14. Bambra C, Riordan R, Ford J, Matthews F. The COVID-19 pandemic and health inequalities. J Epidemiol Community Health 2020; 74:964-8.. This adds to the fact that Brazil is one of the most unequal countries in the world and in the last 4 years has had a 33% rise in poverty and the highest ¹⁵15. Kalanche A. Coronavirus makes inequality a public health issue. World Economic Forum, 2020. https://www.weforum.org/agenda/2020/04/coronavirus-makes-inequality-a-public-health-issue/ (acessado em 05/Jul/2020).
https://www.weforum.org/agenda/2020/04/c... . We observed the robustness of this association in the last months, with the change of the epicenter of the pandemic to the poorer North and Northeastern states of the country, where infection and lethality by COVID-19 have been disproportionately high ¹⁶16. Baqui P, Bica I, Marra V, Ercole A, van der Schaar M. Ethnic and regional variations in hospital mortality from COVID-19 in Brazil: a cross-sectional observational study. Lancet Glob Health 2020; 8:e1018-e1026.^,1717. Hallal P, Hartwig F, Horta B, Victora GD, Silveira M, Struchiner C, et al. Remarkable variability in SARS-CoV-2 antibodies across Brazilian regions: nationwide serological household survey in 27 states. medRxiv 2020; 30 mai. https://www.medrxiv.org/content/10.1101/2020.05.30.20117531v1.
https://www.medrxiv.org/content/10.1101/... .

As mitigation strategies for the outbreak of COVID-19, many countries have repressed the movement of its citizens and protected the higher risk groups in an effort that these measures, especially in the elderly, could minimize the number of cases and deaths ¹⁸18. Daoust J-F. Elderly people and responses to Covid-19 in 27 Countries. PLoS One 2020; 15:e0235590.^,1919. Utych SM, Fowler L. Age-based messaging strategies for communication about Covid-19. J Behav Public Adm 2020; 3(1). https://journal-bpa.org/index.php/jbpa/article/view/151.
https://journal-bpa.org/index.php/jbpa/a... ^,2020. Mesa Vieira C, Franco OH, Gómez Restrepo C, Abel T. Covid-19: the forgotten priorities of the pandemic. Maturitas 2020; 136:38-41.. In Brazil, the Ministry of Health declared that there was community transmission of COVID-19 in the entire country as of March 20th, 2020 ²¹21. Brasil. Ministério da Saúde. Portaria nº 454, de 20 de março de 2020. Declara, em todo o território nacional, o estado de transmissão comunitária do coronavírus (COVID-19). Diário Oficial da União 2020; 20 mar.. In an attempt on non-pharmacological measures, they tried to implement social distancing (especially for those above 60 years old - who were told to only leave their homes in extreme necessities), banned crowd gatherings and encouraged face masks and correct hand washing techniques.

Thus, in face of the high prevalence of chronic morbidities and multimorbidities, mainly in older Brazilians, combined with social inequalities and the recognition of the community transmission of the new coronavirus; we aimed with this study to measure the prevalence of protective protective behaviors for COVID-19, sociodemographic factors and multimorbidity in a cohort of Brazilians above 50 years of age.

Methods

Sample

Individual data was used from the participants of the Brazilian Longitudinal Study of Aging (ELSI-Brazil) ²²22. Lima-Costa MF, Andrade FB, Souza Jr. PRB, Neri AL, Duarte YAO, Castro-Costa E, et al. The Brazilian Longitudinal Study of Aging (ELSI-Brazil): objectives and design. Am J Epidemiol 2018; 187:1345-53.. This is a longitudinal study with a population design, started in 2015-2016, intending to represent the population of 50 years and older in Brazil. The second wave of the cohort started in August 2019, but it was interrupted on March 17th, 2020 due to the SARS-CoV-2 pandemic. We have at the moment data on 9,177 people.

We started a telephone inquiry, as a complement of the initial study, specifically to understand COVID-19 in this population. All participants of the 2nd wave of ELSI-Brazil were eligible for this telephone inquiry, called ELSI-COVID-19 initiative and the interview lasted approximately 5 minutes. We sought to understand: protective non-pharmacologic behaviors for COVID-19 (staying home, face masks usage and hand hygiene); reasons for leaving home (going out); social or family support for the purchase of food and medication; medical diagnosis of COVID-19 (and confirmatory testing); healthcare usage and mental health issues. Telephone interviews took place between May 26th and June 8th, 2020 and further methodological details of ELSI-COVID-19 initiative is described elsewhere ²³23. Lima-Costa MF, Macinko J, Andrade FB, Souza Jr. PRB, Vasconcellos MTL, Oliveira CM. ELSI-COVID-19 initiative: methodology of the telephone survey on coronavirus in the Brazilian Longitudinal Study of Aging. Cad Saúde Pública 2020; 36 Suppl 3:e00183120..

Hence, we got information on 6,149 participants (67% of the 2^nd wave of ELSI-Brazil). Of these, 27.8% had an informant as primary responders. We calculated the sociodemographic characteristics of our sample and they did not differ to the Brazilians older than 50 years in all the analyzed factors.

Variables

The outcome variable of our study was “protective behaviors for COVID-19”. We asked about: going out (frequency and motives); face masks usage when going out and hand hygiene (water and soap or hand sanitizers with alcohol). We then categorized reasons for going out: essential (buying food or medication, working, paying bills, and health-related) and non-essential (gathering with friends or family, physical activities, and others).

For evaluation of multimorbidity we asked and counted the following conditions ²⁴24. Clark A, Jit M, Warren-Gash C, Guthrie B, Wang HH, Mercer SW, et al. How many are at increased risk of severe COVID-19 disease? Rapid global, regional and national estimates for 2020. medRxiv 2020; 22 abr. https://www.medrxiv.org/content/10.1101/2020.04.18.20064774v1.
https://www.medrxiv.org/content/10.1101/... : (1) hypertension; (2) stroke; (3) heart attack; (4) angina; (5) heart insufficiency; (6) chronic kidney disease; (7) Alzheimer’s disease; (8) Parkinson’s disease; (9) Chronic obstructive pulmonary disease (COPD); (10) diabetes; (11) rheumatoid arthritis; (12) asma; (13) cancer; (14) depression; and (15) obesity. All these conditions had a weighted count of one (1) for every instance and were self-reported (based on a previous medical diagnosis); except for obesity (where the body mass index - BMC cutoff: ≥ 30kg/m² for below 60 years, and ≥ 27kg/m² for those older) ²⁵25. Lippi G, Mattiuzzi C, Sanchis-Gomar F, Henry BM. Clinical and demographic characteristics of patients dying from COVID-19 in Italy vs China. J Med Virol 2020; 10.1002/jmv.25860.^,2626. World Health Organization. Obesity: preventing and managing the global epidemic. http://www.who.int/entity/nutrition/publications/obesity/WHO_TRS_894/en/index.html (acessado em 05/Jul/2020).
http://www.who.int/entity/nutrition/publ... . We considered the following categories: no chronic morbidity; at least 1 chronic morbidity; and multimorbidity (≥ 2 chronic conditions). We classified individuals who did not know the answer or did not respond to any of the questions on morbidities (1.3%) as no morbidity.

Major exposures were: sex (man, woman); age (50-59; 60-69; 70-79 and ≥ 80) and years in formal education (never went to school; 1-4; 5-8 and ≥ 9 years). the covariates were self-reported skin color/race (white, black/pardo, Asian, indigenous); marital status (married, widowed, single); the number of people who lived in the house (1, 2 and ≥ 3); urban or country dwelling; and geopolitical region in Brazil (North, Northeast, Central, Southeast, South).

Statistical analysis

We used Stata SE 15.0 (https://www.stata.com) and we conducted prevalence calculations (%) coupled with 95% confidence intervals (95%CI). We estimated the prevalence of protective behaviors in each morbidity category. Then we did a multivariate analysis using Poisson regression with backward elimination so we could consider the variables that were confounders in the analysis. We stratified the multivariate analysis by morbidity number (0, 1, and ≥ 2) and analyzed the outcome “not going out” with sex, age, and formal education. For each stratum, we included all other covariates (skin color, number of people living in the house, urban or country, and geopolitical region) in the model at each hierarchy level. After the first fit, we excluded the variable with the highest p > 0.20 and ran the analysis again; we repeated this as long as there were in the resulting model variables with p > 0.20. The prevalence rates (PR) and the 95%CI presented on the table reflect the model fit for all variables with p < 0.20. We considered statistically relevant the correlations with 95%CI that did not include the number 1. We considered the sample parameters and weights obtained by telephone inquiry of every individual, in all analyses.

Ethical aspects

The Oswaldo Cruz Foundation (Fiocruz) Research and Ethics Committee of Minas Gerais approved the ELSI-COVID-19 initiative inquiry (under CAAE: 34649814.3.0000.5091).

Results

Our sample of 6,149 represented 54 million Brazilian nationals aged 50 and older. Of those who had multimorbidities (45.8%), the majority were female (61.6%), married (58.9%), between 50-59 years (36.7%), self-reported as white (52.2%) and residents in the Southeast region (42.3%). When we tested for formal education, 40.6% had 9 or more years in school. The majority lived in urban dwellings (87.1%) and more than half shared their home with 2 or more persons (Table 1).

The prevalence of protective behaviors for COVID-19 in our population in the morbidities strata is in Table 2. Most had gone out 1 or 2 times in the last week or did not go out at all. The number of morbidities correlated with “never going out”; from 22.3% in those with no morbidities to 38% in those with multimorbidities. “Going out every day” was higher in those without morbidities (21.1%) and lower in those with multimorbidities (10.3%). The primary reasons for going out (independent of morbidity category) were: to buy medication or food, for work, and for paying bills. In those with multimorbidity, 9.3% reported leaving the home in the last week to seek help with their health issues; while 9.1% of those without morbidities reported going out to gather with friends or family.

“Wearing face masks always” when going out was above 96% across all morbidity categories. In those with multimorbidity, the prevalence of “never wearing” and “sometimes not wearing” were lower than in the groups with 0 or 1 morbidity. We observed the same trend with hand hygiene; overall 98% the individuals adhered, and it was higher in those with multimorbidity (Table 2).

Persons with less formal education years stayed more at home across all morbidity categories. In those that went out only for essential reasons, we observed higher years in school (Figure 1a). Women reported that they got out less than men, but in the multimorbidity group there is a difference between sexes in going out. Men in this group had a higher prevalence of going out for essential reasons compared to women. And both men and women with 1 or ≥ 2 morbidities had lower “going out for essential reasons” than those with no morbidities (Figure 1b). Older persons reported less “going out” (for any reason) across all morbidity strata. We saw an inverse relationship in the subclass of “going out for essential reasons”, where younger persons were more likely to go out for this reason, and this was also across all morbidity strata (Figure 1c).

When analyzing the outcomes adjusted by sociodemographic characteristics, we found that social distancing (“never going out”) was higher in women with multimorbidity compared to men (PR = 1.49; 95%CI: 1.23-1.79). It also had a positive correlation with age and an inverse correlation with formal education (Table 3).

Discussion

Multimorbidity correlated with the adoption of current protective behaviors for COVID-19; mainly social distancing in the week previous of the inquiry. People with multimorbidity stayed home almost twice as much as those with no morbidities. The reasons for going out were more because of essential necessities (buying medication, food, and working) in the multimorbidity subgroup than in those without health conditions. Only going out for health reasons was higher in the multimorbidity strata, showing the relevance in organizing the health system to prioritize and prepare for the higher healthcare needs and burdens of this population. Women, older and less formal educated persons left their homes less in all morbidity strata. Face masks and hand sanitation were almost universal.

In our sample, most of the interviewed did not leave their home, or left 1 or 2 times in the last week. It is very plausible to expect that older persons should be the ones to better self implement the protective measures, as the evidence on worse prognosis in the elderly infected with SARS-CoV-2 brought clear government responses in this population all over the world ⁶6. Jordan RE, Adab P, Cheng KK. Covid-19: risk factors for severe disease and death. BMJ 2020; 368:m1198.. Yet a Malaysian study showed that although citizens were adopting these measures, these were less adopted in the 50 or older and the wealthier subgroups ²⁷27. Azlan AA, Hamzah MR, Sern TJ, Ayub SH, Mohamad E. Public knowledge, attitudes and practices towards COVID-19: a cross-sectional study in Malaysia. PLoS One 2020; 15:e0233668.. In the Philippines, 62.9% of the interviewed avoided gatherings ²⁸28. Lau LL, Hung N, Go DJ, Ferma J, Choi M, Dodd W, et al. Knowledge, attitudes and practices of COVID-19 among income-poor households in the Philippines: a cross-sectional study. J Glob Health 2020; 10:011007.. In German elders, although the level of knowledge was high, the perception of risk and the adoption of preventive measures were very low ²⁹29. Betsch C. How behavioural science data helps mitigate the COVID-19 crisis. Nat Hum Behav 2020; 4:438.. Australian avoided gatherings as the most common behavior (66.7%) and elders were 4 times more represented in those that said they were (highly/very highly) preoccupied with COVID-19 ³⁰30. Seale H, Heywood AE, Leask J, Sheel M, Thomas S, Durrheim DN, et al. COVID-19 is rapidly changing: examining public perceptions and behaviors in response to this evolving pandemic. Tu W-J, editor. PLoS One 2020; 15:e0235112..

In contrast, a study that analyzed 27 countries of high, middle and low income, found that elderly people could not do more social distancing than those aged 50 or 60 years ¹⁸18. Daoust J-F. Elderly people and responses to Covid-19 in 27 Countries. PLoS One 2020; 15:e0235590.. The authors show that there was high adherence to the sanitary recommendations across all age categories, and there was no increase in this adherence with age. They also concluded that the elderly are not, necessarily, more respondents to self-imposed isolation and willfulness to isolation, they are not the most disciplined in preventive measures, especially face masks usage out of the home. Last, as a recommendation, they hypothesize that the adoption of individual-centered care and empathy could be fundamental for adherence to the preventive measures focused on these more vulnerable individuals ³¹31. Pfattheicher S, Nockur L, Böhm R, Sassenrath C, Petersen MB. The emotional path to action: Empathy promotes physical distancing and wearing face masks during the COVID-19 pandemic. PsyArXiv 2020; 23 mar. https://psyarxiv.com/y2cg5/.
https://psyarxiv.com/y2cg5/... .

Our study showed higher adherence to social distancing (“never going out”) in women with multimorbidity when compared with men, there was a positive correlation with age and inversely with formal education levels. We hypothesize that the highest frequency of preventive behaviors in women arose by their higher consciousness on the importance of healthy habits related to the prevention of diseases and health promotion in this population ³²32. Brito A, Camargo B. Representações sociais, crenças e comportamentos de saúde: um estudo comparativo entre homens e mulheres. Temas Psicol 2011; 9:282-303.. Epidemiologic policy, including the closing of schools to stop transmission of COVID-19, which occurred in China, Hong Kong (SAR China), Italy, South Korea and also in Brazil, can have different effects in women, in so far as they are responsible for the informal care of the families, diminishing their working and economic prospects ³⁴34. Davies SE, Bennett B. A gendered human rights analysis of Ebola and Zika: locating gender in global health emergencies. Int Aff 2016; 92:1041-60.. During the outbreak of Ebola in Western Africa in 2014-2016, women had a higher propensity of infection because of their predominant roles as caregivers in families and health professionals in the front line ³⁴34. Davies SE, Bennett B. A gendered human rights analysis of Ebola and Zika: locating gender in global health emergencies. Int Aff 2016; 92:1041-60.. Incorporating gender in the analysis of health research, with support for past studies in epidemics, is paramount for identifying health interventions with high effectiveness and to promote equity.

Individuals with multimorbidity left less the home when compared to those with no morbidity (28% versus 22.3%, respectively). This can represent good adherence to protective measures, but can also overload the capacity of Emergency Rooms if they only appear in advanced stages of decompensation of their chronic illness. When the reason “health-related” for going out appeared in the research in the multimorbidity strata, it seems more research on this topic is necessary. Finding a balance between social distancing and the need for follow-up of the health issues of multimorbidities can be challenging in this population, in the families, and in health care services alike ³⁵35. Kohli P, Virani SS. Surfing the waves of the COVID-19 pandemic as a cardiovascular clinician. Circulation 2020;142:98-100.. Hence, Primary Care is indispensable for the promotion of adequate geriatric care, as close to their homes as possible, and enabling telehealth in all forms (anywhere and in any instance that is feasible) as long as social distancing measures are in place ³⁶36. Daumas RP, Silva GA, Tasca R, Leite IC, Brasil P, Greco DB, et al. O papel da atenção primária na rede de atenção à saúde no Brasil: limites e possibilidades no enfrentamento da COVID-19. Cad Saúde Pública 2020; 36:e00104120.^,3737. Greenhalgh T, Choon Huat Koh G, Car J. Covid-19: avaliação remota em atenção primária à saúde. Rev Bras Med Fam Comunidade 2020; 15:2461.^,3838. Sarti TD, Lazarini WS, Fontenelle LF, Almeida APSC. Qual o papel da Atenção Primária à Saúde diante da pandemia provocada pela COVID-19? Epidemiol Serv Saúde 2020; 29:e2020166..

The lower formal education subgroup also stayed at home more, independently of morbidity strata. Previous research also showed that those with higher incomes were less prone to obey the health recommendations and had a lower fear and more control over their pandemic situations ³⁹39. Wong KK, Cohen AL, Norris SA, Martinson NA, von Mollendorf C, Tempia S, et al. Knowledge, attitudes, and practices about influenza illness and vaccination: a cross-sectional survey in two South African communities. Influenza Other Respir Viruses 2016; 10:421-8.^,4040. Raude J, Setbon M. Lay perceptions of the pandemic influenza threat. Eur J Epidemiol 2009; 24:339-42.. Formal education represents a relevant socioeconomic indicator with the impact of elderly health and correlates with a higher occurrence of multimorbidity, and nowadays with social distancing ⁴¹41. Pathirana TI, Jackson CA. Socioeconomic status and multimorbidity: a systematic review and meta-analysis. Aust N Z J Public Health 2018; 42:186-94.. This occurrence can lead to worse outcomes if the care for these individuals, mainly in mental health, are ineffective in reaching the more vulnerable in the present context ⁴²42. Fiorillo A, Gorwood P. The consequences of the COVID-19 pandemic on mental health and implications for clinical practice. Eur Psychiatry 2020; 63:e32.. Before the pandemic the more frequently multimorbid profile was that of women, older people, and those with less formal education, and we found that that is the same profile of those who mostly stay at home ¹⁰10. Nunes BP, Batista SRR, Andrade FB, Souza Junior PRB, Lima-Costa MF, Facchini LA. Multimorbidity: the Brazilian Longitudinal Study of Aging (ELSI-Brazil). Rev Saúde Pública 2019; 52 Suppl 2:10s.. Beyond the “risk groups” for infection and prognosis for SARS-CoV-2, including the elderly and those with chronic illness, a comprehensive approach towards the vulnerable population by the health care system and policymakers has the potential to better respond to the pandemic’s socially determined health problems (historic, current or future) ⁷7. Richardson SJ, Carroll CB, Close J, Gordon AL, O'Brien J, Quinn TJ, et al. Research with older people in a world with COVID-19: identification of current and future priorities, challenges and opportunities. Age Ageing 2020; afaa149..

Among participants, we observed that most only left their homes when the need arose for buying food or medication or for work or paying bills. It is noteworthy that fear of scarcity in essential provisions is an important concern in the elderly ⁴³43. Lloyd-Sherlock P, Ebrahim S, Geffen L, McKee M. Bearing the brunt of covid-19: older people in low and middle income countries. BMJ 2020; 368:m1052.. Going out every day was less frequent in those with multimorbidity, but among those, 9.3% reported having gone out because of health issues.

It is of major importance to maintain adequate follow-up of the health issues of the population, since there are already projections of new waves, especially those related to decompensation of chronic health problems ³⁵35. Kohli P, Virani SS. Surfing the waves of the COVID-19 pandemic as a cardiovascular clinician. Circulation 2020;142:98-100.. In one study most people could have self-isolated with help and support of family and friends. However, they were very preoccupied: with possible difficulties in buying food and supplies (48%) and with health care access (39%). Being responsible for children, family members with disabilities and elderly parents were the greatest impeditives for those who declared that they could not self isolate at home (8%) ³⁰30. Seale H, Heywood AE, Leask J, Sheel M, Thomas S, Durrheim DN, et al. COVID-19 is rapidly changing: examining public perceptions and behaviors in response to this evolving pandemic. Tu W-J, editor. PLoS One 2020; 15:e0235112..

Broadening this analysis, 9.1% of those with no morbidity reported going out to gatherings with their family or friends, may reflect that social distancing and isolation measures disproportionately affect older individuals. Elders have routine social contact out of their homes, by entertaining in community centers or religious temples and centers. If addressed, these necessities could reduce loneliness, depression, and cardiovascular morbidity ⁴⁴44. Berg-Weger M, Morley JE. Loneliness in old age: an unaddressed health problem. J Nutr Health Aging 2020; 24:243-5.. People 50 years or more have less than half the number of close contacts when compared with those aged 18-29 and the number continues to drop with ageing ⁴⁵45. Canning D, Karra M, Dayalu R, Guo M, Bloom DE. The association between age, COVID-19 symptoms, and social distancing behavior in the United States. medRxiv 2020; 23 abr. https://www.medrxiv.org/content/10.1101/2020.04.19.20065219v1.
https://www.medrxiv.org/content/10.1101/... .

In those that responded going out in the last week, wearing face masks was a behavior adopted by the large majority (96%) across all morbidity strata. In Malaysia, as many as 50% reported not using it ²⁷27. Azlan AA, Hamzah MR, Sern TJ, Ayub SH, Mohamad E. Public knowledge, attitudes and practices towards COVID-19: a cross-sectional study in Malaysia. PLoS One 2020; 15:e0233668.. It is noteworthy that neither in Malaysia nor in Brazil (before the current pandemic), was the habit of wearing face masks routine, not even when sick. Moreover there was a shortage of personal protective equipment at the beginning of the pandemic. In the Philippines, only 28% of the population used it, probably for the same reasons as the Malaysians ²⁸28. Lau LL, Hung N, Go DJ, Ferma J, Choi M, Dodd W, et al. Knowledge, attitudes and practices of COVID-19 among income-poor households in the Philippines: a cross-sectional study. J Glob Health 2020; 10:011007..

Among those with multimorbidity, the prevalence of “never using face masks” and “using sometimes” are smaller than those with 0 or 1 morbidity. Granted that there are feasibility in predicting increased protective behavior adherence in those with a higher risk of hospitalization and death by COVID-19. There are signs that we should review these expectations, primarily when thinking of softening sanitary measures ¹⁸18. Daoust J-F. Elderly people and responses to Covid-19 in 27 Countries. PLoS One 2020; 15:e0235590.. Effective communication on risk mitigation strategies for specific populations (e.g. the elderly or the multimorbid) would be crucial.

The prevalence of hand sanitization (water and soap or hand sanitizers with alcohol) was approximately 98% in our population, and it was even higher in those with multimorbidity, following the same trends in other countries ²⁷27. Azlan AA, Hamzah MR, Sern TJ, Ayub SH, Mohamad E. Public knowledge, attitudes and practices towards COVID-19: a cross-sectional study in Malaysia. PLoS One 2020; 15:e0233668.^,2828. Lau LL, Hung N, Go DJ, Ferma J, Choi M, Dodd W, et al. Knowledge, attitudes and practices of COVID-19 among income-poor households in the Philippines: a cross-sectional study. J Glob Health 2020; 10:011007.. In an Australian study, hand sanitization was hygiene’s most adopted behavior (76.6%). Those who most feared COVID-19 had higher adoption of hand sanitization. Hand hygiene is an easily adopted strategy; it is easy to comprehend, easily engaging, and available, and it is one of the primary focuses in many governmental communications internationally ³⁰30. Seale H, Heywood AE, Leask J, Sheel M, Thomas S, Durrheim DN, et al. COVID-19 is rapidly changing: examining public perceptions and behaviors in response to this evolving pandemic. Tu W-J, editor. PLoS One 2020; 15:e0235112.. A study showed that in the U.K. and the U.S.A., up to 92% of residents would adopt hygiene behaviors ⁴⁶46. Geldsetzer P. Use of rapid online surveys to assess people's perceptions during infectious disease outbreaks: a cross-sectional survey on COVID-19. J Med Internet Res 2020; 22:e18790..

The present study has some limitations. Morbidities were self-reported (except obesity), even if asked to report on those medically diagnosed. This is prone to skew the real prevalence of multimorbidity. However, this bias tends to under-represent the prevalence of illnesses. If this error was not present in the sample, we could have an increase in behavior differences since some individuals of those with 0 or 1 morbidities would then be multimorbid. But we predict that this bias would be small in our population, since we included the most prevalent chronic morbidities in this population and only 1.3% responded they did not know or did not respond to the morbidity questions. We also analyzed self-reporting preventive behaviors, and there was no methodological strategy to test the quality of this reporting. And finally, in our inquiry, we defined social isolation as “not leaving home”, but we did not gather information on having guests coming over, for example.

In the present context, new challenges arise from our study. Research on COVID-19 and its impact on health care systems and on the individual person must be paired with inclusion and social responsibility, mainly in the elderly. Future research should look in more depth at aspects such as the complexity of care in the elderly (multimorbidity, frailty, cognitive decline, and living in homes for the elderly) ⁷7. Richardson SJ, Carroll CB, Close J, Gordon AL, O'Brien J, Quinn TJ, et al. Research with older people in a world with COVID-19: identification of current and future priorities, challenges and opportunities. Age Ageing 2020; afaa149.^,4747. Aprahamian I, Cesari M. Geriatric syndromes and SARS-Cov-2: more than just being old. J Frailty Aging 2020; 9:127-9.^,4848. Chan EYY, Gobat N, Kim JH, Newnham EA, Huang Z, Hung H, et al. Informal home care providers: the forgotten health-care workers during the COVID-19 pandemic. Lancet 2020; 395:1957-9.. The correlation of morbidity with sanitary measures aimed at protective behaviors for COVI-19 should consider the social determinants of health in Brazil. These factors that influence the adoption of protective behaviors have the potential to affect people with higher vulnerability and are in greater need of care.

Acknowledgments

The ELSI-Brazil baseline study and the 2nd waves are supported by the Brazilian Ministry of Health: Department of Science and Technology of the Secretariat of Science and Technology and Strategic Inputs (processes 404965/2012-1 and 28/2017) and Elderly Health Coordination of the Secretariat of Health Care (TED: 20836, 22566, 23700 and 77/2019). The ELSI COVID-19 initiative is financed by DECIT/SCTI and the Brazilian National Research Council (CNPq). M. F. Lima-Costa is a CNPq research productivity scholarship holder. B. P. Nunes receives funding from the CNPq (process 432474/2016-1) and the Research Support Foundation of the State of Rio Grande do Sul (FAPERGS - 19/2551-0001231-4) related to research on occurrence of multimorbidity.

References

Publication Dates

History