Elderly people's knowledge and preventive practices about COVID-19* pessoas idosas sobre a COVID-19

Objective: to understand the knowledge and preventive practices of elderly people about COVID-19. Methods: qua- litative research developed with 11 elderly people living in a condominium for the elderly. Data were obtained using the technique of individual interviews and then submitted to le- xicographic analysis by means of the Descending Hierarchical Classification using the software IRaMuTeQ®; and discussion in the light of the literature on COVID-19. Results: six clas- ses emerged: Building knowledge and preventive practices about COVID-19; Emotional consequences; Preventive and control practices; Recognition and importance of prevention strategies; Physical, social, and economic impacts; and In - dividual and collective risk factors. Conclusion: the elderly understands the negative consequences of COVID-19, identi fying the individual and collective risk factors, learned based on experiences during the pandemic, previous experiences, dialogues, and sources of information. They recognize the importance of preventive practices, carrying out care in the home and urban environment. Descriptors: Aged; RESUMO Objetivo:


Introduction
In the year 2020, the world was hit by the Coronavirus Disease-19  pandemic, caused by the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) virus (1) . Regarding elderly people (in Brazil, those aged 60 years or more), they are considered the most vulnerable population group for this disease, presenting higher rates of infection, worsening and lethality (2)(3) .
There is a higher mortality rate in elderly people when compared to the general population, since the risk of dying from COVID-19 increases with advancing age, especially in those with chronic diseases (4) . Until August 17, 2022, Brazil had a total of 34,148,131 million notified cases of the disease and 681,253 thousand deaths. In the state of Paraná, 44,875 thousand people died, representing 6.58% of the total number of deaths (5) .
In this context, the Elderly Community emerges as a favorable scenario for the spread of the virus among the elderly, as well as for the development of preventive practices. The Elderly Community is a modality of assisted housing for low-income elderly people in situations of social vulnerability, offered by the public authorities and coordinated by the Social Assistance and Citizenship Secretariats of the municipalities. The residents are autonomous elderly people, who are functionally independent and live alone or with their partners, who are also elderly (6) .
The adoption of effective measures for the protection of the elderly population is necessary, especially behavioral preventive practices in the daily lives of these people. However, we know little about the practices and adherence of the elderly to preventive care for COVID-19 as well as their knowledge about the disease (2)(3) .
Developing a study on the knowledge and preventive practices of elderly people who live in condominiums of the elderly about COVID-19 is a way to identify their knowledge, individual and collective behaviors. In addition, it makes it possible to unders-tand their perception of the disease and preventive practices, which may be related to the adoption of preventive behaviors. This information can impact the practice of health professionals in Primary Health Care by serving as a basis for the development of health education practices based on the identification of educational demands, aiming at the improvement of preventive practices (7) .
This study was justified by the need to investigate what elderly people know about COVID- 19 as well as what preventive strategies they practice, making it possible to increase studies of this nature and the gaps in the literature, since no research on the subject was found, besides the fact that it was carried out with elderly people who live in condominiums for the elderly.
It was believed that this unprecedented research could contribute to the social and health reality about the prevention of the disease in the elderly by allowing the unveiling of the theme and, thus, collaborating with the construction of knowledge and future development of effective problematizing educational practices in a condominium for the elderly aiming at the prevention of COVID-19 based on the change of individual and collective behaviors, by strengthening pandemic prevention actions among the elderly with the support of health professionals through extension activities.
Given the above, this study was based on the following question: what is the knowledge and preventive practices of elderly residents in a condominium for the elderly about COVID-19? The objective was, therefore, to understand the knowledge and preventive practices of elderly people about COVID-19.

Methods
This was a qualitative research study, which used the Consolidated Criteria for Reporting Qualitative Research (COREQ) guideline to guide the study, to understand what elderly people, know about COVID-19 and how they act when faced with prevention.
The target audience of the study consisted of 47 elderly residents in a condominium for the elderly in a city located in the North Central region of the state of Paraná, Brazil. This was a convenience sample due to the condominium's previous partnership with the teaching institution in which the main researcher performs her teaching and extension activities to collaborate for the future development of educational practices on this theme.
Elderly people who lived in the above-mentioned condominium and had preserved cognitive ability according to the Mini-Mental State Examination (MMSE) (8) were included in the study. Exclusion criteria were not being located at home after two attempts of contact by home visit at the time of data collection. Meeting the criteria, 11 elderly people participated in the research, and the number of participants was defined by exhaustion.
Data collection occurred during the month of May 2022, through individual semi-structured interviews conducted via home visits, using a script prepared by the researchers and composed of 20 guiding questions about the knowledge and preventive practices of the elderly about COVID-19. The script was about the knowledge of the disease, its severity, causes, consequences, prevention and risk factors, sources of information and previous experiences, prevention strategies for COVID-19 practiced by them, besides questions for sociodemographic characterization (age, sex, education, marital status, occupation) and health characterization (self-perception of health, vaccination history, and previous COVID-19).
The interviews were audio recorded, using a cell phone recorder, conducted by two previously trained and qualified researchers, on scheduled days and times and with an average duration of 16.16 minutes. The scheduling of the interviews occurred in person, through the director responsible for the elderly people's condominium, and the elderly people were approached at their homes by the researchers during the scheduled days.
To organize the data obtained, the interviews were transcribed in full by a researcher, and the material was organized into a corpus about the knowledge and preventive practices of older people about COVID-19. The corpus was processed using lexicographic analysis from the software Interface de R pour lês Analyses Multidimensionnelles de Textes et de Questionnaires (IRaMuTeQ®) through the Descending Hierarchical Classification (DHC) (9) . The lexicographic analysis was presented in a table format (Figure 1) based on the DHC about the knowledge and preventive practices of the elderly about COVID-19 and organized by the researcher according to the classes in descending order of Elementary Context Units (ECU) and according to the breakdowns and sub breakdowns of the originated dendrogram. The classes were interpreted, analyzed, named, and constituted by the interviewees' words and statements that illustrated each class. For the characterization of the elderly people, these data were organized in an electronic spreadsheet and analyzed using descriptive statistics. The findings were discussed using current and pertinent literature on COVID-19.
All ethical precepts governing research with human beings in Brazil were respected. The research was submitted to an Ethics Committee for Research with Human Beings and could only be initiated after obtaining the favorable opinion, number 5,344,026/2022 (Certificate of Presentation for Ethical Appreciation: 56913122,5,0000,0105) and the signature of the participants in the Informed Consent Form in two copies. To ensure the confidentiality of their identity, the statements were coded with the acronym EP, referring to the term "Elderly Person", followed by sequential Arabic numbers according to the order of the interviews.

Results
Eleven elderly individuals, with ages ranging from 65 to 79 years, mean 74.8 years, participated in the research. Most were female (n=7), married (n=6), lived alone (n=7), had incomplete primary education (n=7), were retired (n=6) and, in addition, reported negative self-perception of health (n=7). All elderly people had already been vaccinated against COVID-19, and five had already had the disease.
The corpus processing took 25 seconds, identified 12,449 words, of which 1,039 were distinct words with 861 active forms and distributed in 363 ECUs. Of these, 260 were classified, representing 71,63% of the total corpus utilization. Six analysis classes were derived from the DHC dendrogram. The dendrogram was initially divided into two partitions. The first partition split into two sub-partitions: from the first sub-partition, class 1 (ECU=14.6%) was obtained, and the second sub-partition split and generated class 6 (ECU=15%) and classes 5 (ECU=18.9%) and 2 (ECU=18.1%). The second split generated two classes: class 4 (ECU=18.9%); and class 3 (ECU=14.6%) ( Figure 1).
(the Figure 1 continue in the next page...)  The classes obtained by the Descending Hierarchical Classification allowed us to understand the knowledge of the elderly about COVID-19, manifested by knowledge about the consequences of the disease (physical, emotional, social, and economic impacts), the individual and collective risk factors, the sources of information, in addition to knowledge about the importance and forms of prevention of COVID-19. We also understood the preventive practices used by them during the pandemic period in the home and urban environment.

VID-19: physical, social, and economic impacts
Class 5 (ECU = 18.9%) showed the knowledge of the elderly about the negative consequences of CO-VID-19, manifested by the impacts on the health of the population as well as social and economic impacts. According to the elderly, the physical health impacts are related to the signs and symptoms presented during the acute phase of the disease and are manifested in different ways. Weakness, headache, diarrhea, cough, sore throat, and fever were reported as well as the need for social isolation during this time, impacting also on the social aspects: Knowing about the emotional consequences of COVID-19: divine deliverance, feelings of fear, anguish and uncertainty experienced during the pandemic Class 2 (ECU = 18.1%) corroborated the previous class when exemplifying the knowledge related to the emotional consequences of COVID-19 from the perspective of the elderly, manifested by feelings of fear, anguish and uncertainty experienced during the period of the pandemic. Feelings of fear and concern were reported regarding the possibility of contracting the disease, fear of the symptoms they might have in case of a positive COVID-19, the severity of the disease, hospitalization, and death. Still, the fear of transmitting the disease was reported and, therefore, the necessity and importance of preventive practices and care:

Knowing about individual and collective risk factors for COVID-19 and its complications: health conditions and lack of preventive practices
Class 6 (ECU = 15%) showed that older people understand the main individual and collective risk factors that can increase the chance of contracting COVID-19 and the severity of the disease, causing possible health complications. The health conditions of the individual and the presence of chronic diseases and comorbidities were highlighted, such as obesity, diabetes, hypertension, cardiomyopathies, and lung diseases, besides the fact of being elderly, attributing fragility to the elderly person but understanding their vulnerability to COVID-19:

Building knowledge and preventive practices about COVID-19: experiences of the pandemic, previous experiences, dialogues, sources of information, and educational actions
Class 1 (ECU = 14.6%) clarified that the knowledge and preventive practices of the elderly about COVID-19 were learned based on experiences during the pandemic as well as previous experiences with the disease, dissemination and sharing of information through sources of information and dialogues. It was observed the importance of sharing knowledge between health professionals and the elderly for the encouragement, guidance and implementation of preventive practices, which occurred during the realization of educational activities, lectures and/or consultations held in the condominium of the elderly, in the Basic Health Unit and in the hospital during hospitalization: Professional guidance on COVID, only in the post office, which always when we go, they explain to us elderly people how to do, how we should do it (EP2). Talking to professionals is important, yes. They explained it to me (EP9). The professionals helped with the information. It started in the hospital, because I had COVID and in the hospital they oriented me a lot. Talking to health professionals helps a lot, asking for orientations too (EP4). I learned with our counselor.
She is a health professional, she gives lectures (EP10).
In addition, the dialogue about the disease was reported, informally, among the elderly, their relatives, and people who had already been affected by the coronavirus. As sources of information for COVID-19, the educational materials, booklets, and leaflets were mentioned, as well as the media, such as television, radio, and internet: I learned on television, on the radio, they warn people a lot, only those who don't want to take care of themselves don't do it. The coordination team is always here looking and asking. The family members too. Health professionals came to the condominium to orient and talk about COVID. Talking to people and professionals helps a lot. Through the TV, through the radio, we are listening (EP8). I learned with life, but also with television, and radio.
The children also, always talked. Health professionals also (EP4). I learned from the media, day-to-day, in contact with people, because you don't talk about anything else for two years. And, the primers that the professionals gave, we read them (EP5). I learned a lot through television. Those leaflets that they gave to us elderly people, we read them. There were two meetings here in the condominium. This is how we learned (EP9). We listened a lot on the internet (EP10).

Recognition and importance of prevention strategies: avoiding COVID-19
Class 4 (ECU = 18.9%) demonstrated the recognition and importance of preventive practices and ways to prevent COVID-19 from the perspective of the elderly, who understand that the disease can be avoided. In their reports, they pointed out the use of protective masks, vaccination, distance, and social isolation. Besides these strategies, the importance of hand hygiene and the use of alcohol gel was mentioned, as well as avoiding crowds and ventilating the home environment: Prevention is not to stop wearing the mask, and to take the vaccines (EP2

Preventive and control practices for COVID-19 in the home and urban environment
Finally, class 3 (ECU = 14.6%) corroborated the previous class by exemplifying the preventive and control practices of COVID-19 practiced and recognized by the elderly in the home and urban environment. It portrayed that the elderly practiced them mainly at the beginning of the pandemic, losing the habit and dispensing such care over time.
In addition to social isolation, mentioned in the previous class, the practices were manifested by the care performed at home, especially when leaving and returning to it through hand hygiene and use of alcohol, hygiene of market purchases and food, cleaning the home, washing clothes and bathing. The elderly people also left their shoes outside the house when returning home from the street: When

Discussion
All the elderly people participating in the study knew someone -close elderly people, friends or family members -who were victims of COVID-19, and almost half of them had already been affected by the disease. This fact allows us to infer that previous lives and experiences, combined with sources of information and educational practices, enable knowledge about the subject and drive the development of preventive practices, favored by the reality of the pandemic experienced around the world. The knowledge and preventive practices of the elderly about COVID-19 were permeated with risk factors and the recognition of prevention, the physical, social, emotional, and economic consequences, as well as the preventive strategies used by them in the home and urban environment.
Class 5 outlined the knowledge of the elderly in relation to the physical consequences of COVID-19 for the health of the population, in which death was seen as the consequence of greater aggravation. In the municipality of the present study, by the month of June 2022, 1,777 deaths had occurred, that is, 4.08% of the deaths in the state of Paraná (10) . In the year 2021 alone, there were 1,282 deaths, of which 801 were of people aged 60 years or more, in other words, 62.50% of the deaths in the city were of elderly people in that year (11) .
The elderly population has a higher risk of mortality by COVID-19 when compared to other age groups, especially those with multiple comorbidities, presenting an increase in mortality rate with increasing age. Elderly people are more likely to progress to severe forms of the disease due to the fragility of the immune system, the so-called immunosenescence (12) , although the mortality of elderly people by COVID-19 in Brazil is also related to demographic and income distribution aspects (13) .
Regarding the physical consequences of CO-VID-19 from the perspective of the elderly and evidenced in class 5, it was found that they are related to the signs and symptoms presented during the acute and late phase of the disease. A literature review pointed out that flu-like symptoms such as fever, cough, and sore throat were commonly presented by elderly people with COVID-19, such as were experienced and understood in the present study (12) .
The clinical aspect of the disease is heterogeneous and, although fever, cough and dyspnea are often the main signs and symptoms presented by those infected, others may be present, such as altered smell, taste, and gastrointestinal symptoms (14)(15) . Severe cases of the disease represent about 20% of the total number of cases, requiring hospitalization and/or intensive care unit, and may cause death (14) as mentioned above.
The elderly people interviewed also presented knowledge related to the physical consequences of post-COVID. Approximately, 80% of those recovered have sequelae up to four months after infection. The sequelae include the worsening of pre-existing comorbidities, besides respiratory problems, fatigue, joint pain, hair loss, mental disorders, heart palpitations and cognitive difficulties (16) .
It is worth noting that in addition to the physical consequences, another understood and relevant aspect of COVID-19 was the impact on the income and socioeconomic status of the elderly (class 5). The pandemic impacted financially and increased unemployment among the elderly population. A survey of 9,173 elderly people found that only 8.3% of those who were employed continued to work normally during the pandemic. The income of elderly people decreased by almost half, and in 23.6% it was drastically reduced, or they had no income at all (17) .
Besides the physical, social, and economic consequences, class 2 represented the knowledge about the emotional consequences of COVID-19 on the health of the elderly population. The pandemic of CO-VID-19, being responsible for countless deaths worldwide, generated increased feelings of fear, worries and anguish in the population, feelings that were also experienced by the elderly in the present study (12) .
Corroborating the authors, a study identified that the main factors associated with depression symptoms among elderly people during the pandemic of COVID-19 were female gender, low socioeconomic status, and low education. In addition, elderly people who had occupations that directly exposed them to COVID-19 showed higher depression scores (18) .
To protect the elderly from the disease, many family members and friends stopped visiting and re-mained distant, increasing considerably the feelings of loneliness and even abandonment, affecting the mental health of the elderly (19) . This fact has repercussions, especially in those who live alone -as is the case of most elderly people in this study who live in a condominium for the elderly -as well as those who are institutionalized, live in a rural community, are widowed and/or have mental disorders (12) .
Among the various measures taken in Brazil and worldwide to prevent the disease, one of the most widespread was the use of protective masks, distance and social isolation, preventive practices, also practiced by the elderly in this study (class 4). A survey conducted virtually in Brazil during the pandemic pointed out that elderly people who do not work and/or are retired have a higher rate of adherence to this last measure (17) .
Social isolation was a prevention strategy recommended by public agencies, collaborating with the reduction of the contagion curve in the country. Although effective, it also had a negative impact on people's lives, interfering with mental health by collaborating to the increase in cases of mental disorders such as anxiety and depression, bringing physical and emotional consequences to the health of the entire population (12,17,19) .
The religious dimension of the elderly was also evidenced in class 2. Religiosity was seen as a coping strategy for COVID-19 by the elderly and can contribute to minimize emotional and mental suffering during the pandemic period due to social distance and should be encouraged (20) .
Comorbidities are risk factors for severe cases of COVID-19 and were uncovered in the present study (class 6), being in accordance with the literature. The most prevalent pre-existing diseases in elderly individuals are hypertension, diabetes mellitus and cardiovascular disease (16) , besides other comorbidities such as liver, kidney and hematological diseases, obesity, cancer, HIV infection, autoimmune and pulmonary diseases (15)(16)21) .
Regarding the sources of information about COVID-19 (class 1), the use of television, radio, digital social media, and also educational materials to access information about the pandemic were mentioned. Digital social media are associated with increased levels of anxiety and stress in the population, and these are the information sources most used by the general population to access information about the pandemic (22) . Contrary to the results of this study, despite being mentioned in class 1, digital social media were not the majority, and this fact may be related to the low education and socioeconomic status of the elderly participants in this study. Among the preventive practices of the CO-VID-19 evidenced in classes 4 and 3 and practiced by the elderly, the social distancing and isolation, vaccination, hand washing, cleaning the environment, food hygiene and the use of protective masks were highlighted, corroborating another study that presented the most used preventive strategies against COVID-19, including by health professionals (23) . Such measures are necessary for the health care of the elderly population, can reduce the risk of infection and are in accordance with the recommendations of the Ministry of Health (24)(25) , and should be practiced daily during the pandemic (3) .
Regarding this issue, class 4 outlined the recognition and importance of these practices from the perspective of the elderly to prevent COVID-19. The prevention measures practiced by the elderly individuals were like those found in a related study, which analyzed how the population enrolled in a Family Health Strategy (FHS) team perceives and adopts measures to prevent the contagion of COVID-19. The most adopted was the use of protective mask with 68.57%, followed by hand washing (37.14%), use of alcohol gel (37.14%) and social isolation (11.43%) (26) .
Although essential and of great importance for the collective health, these preventive measures still encounter barriers to their implementation and, when added to the dissemination of false news, the so--called "fake news", they make it even more difficult to perform and sustain (27) . The false information about COVID-19 sought to soften the severity of the disease and disqualify the prevention and control measures as well as propagate the use of medication without scientific evidence (28) .
The pandemic of COVID-19 has increased, not only the need for educational strategies that embrace scientific evidence (28) but also the beliefs and the historical, cultural, and social factors, given that they determine individual choices, attitudes, and behaviors, directly implicating the development of prevention actions (29) .
The preventive practices practiced by the elderly were made possible by dialogue, sharing of experiences in an informal way, but also formally with the support of health professionals. A similar study pointed out that when they exist, the educational practices developed by the FHS professionals for the COVID-19 are manifested through orientations (carried out in the Basic Health Unit and at home), distribution of pamphlets and posters. Most FHS teams did not perform Health Education actions for the prevention of COVID-19 during the pandemic, and only 18.57% did (26) .
Elderly people need attention and care, including strategies for support and warning signs and symptoms (3) . Special attention should be given by FHS professionals to collective housing as well as to condominiums of the elderly. In the occurrence of a case, intensive care should be dedicated to the affected elderly person and other residents, monitoring them frequently, providing information and guidance on ways to prevent COVID-19, restricting collective activities and social interaction.
Gerontological care practiced by nurses and other health professionals in the pandemic should be based primarily on prevention and also on health promotion and self-care of the elderly through the encouragement of physical exercise, proper nutrition, quality of sleep, sun exposure, leisure, mental health, religiosity, and spirituality, which can enable the pre-servation and promotion of health of the immune and respiratory systems, and can be addressed in the educational activities (30) of the FHS along with care strategies at home and in the urban environment.
Given this, it is up to health professionals of the FHS teams to perform and adapt their actions and educational practices, aiming to strengthen the community approach to promote the reduction and dissemination of the COVID-19 virus in the community, contributing to improve individual and collective health conditions, besides including the care mentioned to the elderly people who reside in condominiums of the elderly, especially during the pandemic. To this end, problematizing educational practices emerge as indispensable for the prevention of health problems (6) , as in the case of COVID-19 in elderly people living in the community, including those living in elderly condominiums.

Study limitations
As a limitation of the study, it is emphasized that the research was conducted in only one elderly person's condominium, so it is limited to a restricted local context.

Contributions to practice
This research contributes positively to the care of the elderly population with the construction of knowledge about COVID-19, sensitizing and grounding health professionals to plan and develop problematizing educational actions, considering the knowledge and reality of life of the elderly, impacting on professional practice. It is noteworthy that Health Education actions can be important tools for the transformation of knowledge and preventive practices, which can contribute to the prevention of new cases of COVID-19 (and other respiratory diseases that manifest themselves in the same way) and to the end of the pandemic.

Conclusion
It was possible to understand the knowledge and preventive practices of the elderly about the CO-VID-19 and point out that they have knowledge about the negative consequences of the disease, manifested by the physical, social, and economic impacts, as well as the emotional consequences, permeated by fear, anxiety, and uncertainty. It was also verified that the elderly understood the individual and collective risk factors for the COVID-19, learned through experiences during the pandemic, previous experiences, dialogues, and sources of information, recognizing the importance of preventive practices and performing care in the home and urban environment.