Elderly individuals living by themselves: knowledge and measures to prevent the novel coronavirus

Objective: to describe the occurrence of COVID-19 and the health services used by elderly individuals living by themselves; identify the knowledge held by elderly individuals regarding the transmission, signs and symptoms of COVID-19, as well as factors associated with poor knowledge of preventive measures according to sociodemographic and clinical variables. Method: cross-sectional survey conducted by telephone or mobile with 123 elderly individuals living by themselves in the Health Macro-Region of Triângulo Sul in the state of Minas Gerais, Brazil. Descriptive analysis was performed along with bivariate and multiple linear regression (p<0.05). Results: most elderly individuals did not present COVID-19 signs and symptoms (97.5%), were aware of how it is transmitted (86.6%), and of its signs and symptoms (90.8%). The elderly individuals were familiar with four preventive measures on average. After social distancing began, 85.7% of them left home and implemented three preventive measures on average, the most frequent of which was the use of face masks (99.0%). Being a man (p=0.001), 80 years old or older (p=0.045), and having fewer years of schooling (p=0.010) were associated with having less knowledge regarding the COVID-19 preventive measures. Conclusion: the elderly individuals were knowledgeable on COVID-19, but did not implement all the preventive measures. Male elderly individuals living by themselves with a low educational level are more vulnerable to COVID-19.


Introduction
COVID-19, from the term "coronavirus disease 2019", is an acute respiratory disease, caused by the novel coronavirus (SARS-CoV-2) (1) , which was declared Public Health Emergency of International Concern and characterized as a pandemic on March 11 th , 2020 (2) .

Its clinical management and appropriate treatment
have not yet been fully recognized (1) . It is known, however, that the virus is highly transmissible and mainly spreads from person to person (3) . Transmission occurs through respiratory droplets released through the nose or mouth when an infected person coughs or sneezes (1) . The presence of the virus on objects or surfaces is another form of contagion; hence, people are at risk of becoming infected if they touch their eyes, nose or mouth after touching contaminated objectives or surfaces (1) .
The clinical condition of COVID-19 in most cases is similar to other respiratory infections: fever (≥37.8ºC), running nose, dry cough, and fatigue (2) . Approximately 5% of the infected individuals develop the most severe form of the disease, with symptoms such as dyspnea and/or pulmonary bleeding, severe lymphopenia, and renal failure (4) .
Given the seriousness of the world situation and the need to decrease the spread of COVID-19 and flatten its epidemiological curve, preventive measures were adopted such as hand sanitation, respiratory etiquette, cleaning and disinfection of surfaces and objects, and social distancing (2) . Delay in adopting these measures resulted in an epidemiological curve with high mortality rates in Brazil, Italy, Spain, and the United States of America, even surpassing China (2) .
Due to the physiological changes inherent to the human aging process, which compromise the immunological system, and the greater number of complications accruing from chronic diseases at old age, the elderly are more susceptible to the more severe manifestations of COVID-19 and, consequently, death (5)(6) . Additionally, sociodemographic and economic characteristics, such as advanced age; low educational and income levels; and single-person households, favor the greater vulnerability of elderly individuals to COVID-19. These factors may interfere in the access to information and, consequently, knowledge and implementation of measures to prevent infection by the novel coronavirus (7)(8)(9)(10) .
Coupled with these, there has been an increase in the number of elderly individuals living by themselves (11) .
In Brazil, 15.7% of individuals aged 60 years old or older live alone (12) ; with the South (15.9%) and Southeast (15.7%) presenting the highest percentages (11) . Singleperson households may be seen as an accomplishment considering that older people can enjoy greater privacy and independence as they age (11) , however, elderly individuals living by themselves may become more vulnerable and deprived of social support when facing health problems (11,13) . Additionally, access to information depends on the context in which individuals live (7)(8) and knowledge regarding preventive measures is one of the crucial factors to prevent the contagion and spread of the novel coronavirus (1) .
In this context, the identification of factors related in long-term residential facilities for the elderly (14)(15) ; the knowledge held by adult and elderly individuals living in the community and their behavior in the face of COVID-19 (7)(8) ; the beliefs regarding the COVID-19 pandemic held by the population in a Brazilian state (16) ; the consequences of social isolation in the lives of elderly individuals (13,17) ; and the clinical characteristics and prognosis factors among COVID-19 patients aged 60 years old or older (5)(6) . Therefore, the objective was to describe the occurrence of COVID- 19 (Table 3). The following variables met the criterion (p≤0. 10) in the bivariate analysis and were included in the multiple linear regression final model: sex, age range, schooling, monthly individual income, and number of morbidities (Table 4). Being a man, 80 years old or older, and having a lower level of education were associated with poor knowledge of COVID-19 preventive measures (Table 5).

Discussion
The higher percentage of women found in this study is in line with the reports of Brazilian studies (11) .
One study conducted in a city in Minas Gerais verified that most elderly individuals in the group who lived by themselves were women (19) . The predominance of women among elderly individuals may be explained by the higher life expectancy among women in comparison to men, which is currently 80.25 years old in Brazil (20) .
The larger percentage of widows may be related to the predominance of women and their life expectancy, though women are also more likely to live by themselves than remarrying or being the head of the family (21) .
Regarding age, similar results were found in a Brazilian study, in which a larger number of individuals aged 75 years old or older lived alone compared to younger individuals (p<0.001) (11) . A Brazilian regional study, however, verified that most elderly individuals living by themselves were 60 to 69 years old (19) .
Individuals in advanced age living by themselves may face problems to use health services and perform daily tasks, which may become more difficult in the absence of family members (19) .
Similar to these findings, a study verified that most elderly individuals living by themselves had from one to four years of schooling (19) . Divergent data were found in a Brazilian survey in which the percentage of elderly individuals in single-person households (16.9%) had from eight to ten years of schooling (11) . A low educational level negatively affects self-care behavior (9) due to difficulties to access and assimilate information (10) .
Concerning monthly individual income, most of the participants living by themselves in a city in the interior of Minas Gerais received from one to three times the minimum wage (19) , a piece of information that is in line with this study's findings. and in the face of comorbidities, favoring the more severe forms of the COVID-19 (5)(6) .
International studies report that the main signs and symptoms presented by individuals diagnosed with COVID-19 include fever, cough, fatigue, and body ache (5,(22)(23) , the same symptoms presented by this study's participants. Note that a few participants for hours to days (27) when expelled through cough or sneeze (27)(28) , and the need to avoid handshaking and touching contaminated surfaces (27) , considering that a single droplet may contain an infectious dose (27) .
An international study reports that 71.7% of elderly individuals had knowledge of three symptoms of COVID-19 (7) , which is in line with the mean identified in this study. The infectious condition with the onset of fever is the clinical symptoms more commonly identified in COVID-19 (29)(30) , considered essential to screening the disease (25) , which is corroborated by the elderly individuals' reports. The period in which fever manifests, however, is unknown (30) . Elderly individuals may present Additionally, people may complain of body ache, fatigue, and malaise (5,29) . One scoping review and metaanalysis identified that 36% of the patients reported body ache, 12% reported headache, and 10% sore throat (30) . When the percentages are totaled, the results are similar to those found in this study, in which 52.8% of the elderly participants living by themselves reported being aware of these COVID-19 symptoms.  (1) .
The use of face masks is a measure adopted worldwide to prevent and control COVID-19, which has been widely reported by scientific studies (27,(31)(32) and is is spread is from person to person through droplets, followed by aerosols (25) , and hands are the main route of cross-contamination (27) . The virus may remain on surfaces and in the environment for different periods, ranging from hours to days (34) . For this reason, besides being a low-cost practice, hand sanitation is highly effective and is considered one of the most relevant measures to prevent COVID-19 (27) . Nonetheless, for microorganisms to be inactivated and levels of infection and transmission to decrease, the alcohol needs to present a concentration between 62% and 71% (36) . Its use is necessary in environments outside the home where water and soap are not readily available, whenever one has physical or close contact with people, objects, or surfaces that may be contaminated.
Note that social distancing was not a preventive measure most frequently reported by the elderly individuals, which is opposed to the expressive dissemination in the media and scientific studies of its needs and positive effects in the control of the transmission of COVID-19 (32,37) .
One study conducted in the state of Ceará, Brazil reports that elderly people partially adhered to social distancing and received visits (62.5%) (16) .
The same was found in this study, in which most elderly individuals left their homes during the time social distancing was recommended. Even though the Brazilian authorities emphasize social distancing, specifically for the groups most susceptible to develop the severe form of the disease (1-2,26,32,37) , one needs to consider and understand the reasons that lead these individuals to leave their homes.

Individuals living by themselves and without
social support need to run errands to meet their needs, such as: go to the grocery store and pay bills, among others, while the information they received may not have been sufficient to convince them of the need to adhere to social distancing. Emotional aspects such as loneliness also need to be considered in addition to beliefs and values. One Brazilian study reports that elderly individuals believed that the pandemic would be less severe in Brazil than in other countries (16) . Note that the way individuals respond to situations, such as a pandemic, vary according to their engagement in preventive care, and how they address problems and search for solutions (9) . soap and water, were the ones most frequently adopted, followed by avoiding crowded places.
The use of masks was also verified in a systematic review with meta-analysis, which reports an association between its use and the protection of healthy individuals at home and whenever social interaction is necessary (38) .
Its use involves a series of measures though, necessary to keep it viable, without becoming an object of new contaminations. For this reason, for a mask to function as a mechanical barrier against the novel coronavirus (35) , one should follow recommendations on how to put and remove it, how to sanitize it, and regarding the period it remains viable, up to its discard (35) .
The use of masks is coupled with hand sanitation, the second preventive measure the elderly individuals reported, which is consistent with the literature (27,33,35) .
Even though these measures are recommended (33)(34)(35) to ensure greater protection against transmission, one has to implement various measures together (27,(31)(32) , such as those necessary to implement when returning home, which few participants reported.
Considering that behavioral change depends on the context one is inserted in, and is characterized by the unpredictability of different sociodemographic and economic characteristics (39) , these findings reinforce the need for nurses to implement educational actions together with elderly individuals by using effective communication.
The association identified in this study between women and adult individuals (p<0.001) (7)(8) .
The little knowledge of COVID-19 preventive measures among the elderly men may be related to the fact that they do not value self-care; are little concerned with their health, and have difficulties sharing their feelings and verbalizing their needs (40) . This context may also affect the mortality rates caused by COVID-19, which are higher among male elderly individuals (41)(42)(43) . In Italy, 83.0% of the deaths occurred among 60-year-old or older individuals; 80% of whom were men (42) . The last Epidemiological Bulletin published on May 23 rd , 2020 reports that 69.4% of the deaths caused by COVID-19 in Brazil were among 60-year-old or older individuals, while 60.2% of them were men (43) . According to the Epidemiological Report of the COVID-19 pandemic, published on June 6 th , 2020, 72.7% of the deaths in Minas Gerais were among the elderly, 53.0% of whom were men (24) .
In this context, educational actions in the nursing field should be planned to reach elderly men living by themselves. In addition to educational practices within the healthcare network (44) , nurses' competencies such as preventive actions and the early detection of infections by the novel coronavirus should be implemented during gerontological nursing consultations.
In line with this study, one international study addressing adult and elderly individuals in the community reports that individuals of advanced age and those living by themselves presented a lower level of knowledge of COVID-19 (p<0.001) (7) , showing that older individuals are more vulnerable to the infection caused by the novel coronavirus (6) . These circumstances reinforce the need for actions and specific interventions for 80 years-old or older individuals living by themselves, as they may need more complex care with greater investment in health, like in the case of the infection caused by the novel coronavirus (7) .
The bond established between long-lived individuals and health workers was associated with preventive measures to combat COVID-19 (p=0.008) in a study conducted in the state of Ceará, Brazil (16) . This bond contributes to elderly individuals being more pro-active in the health-disease continuum and also promote the delivery of comprehensive health care (45) . The primary health care policy provides for the establishment of bonding and co-accountability between health teams and the population, ensuring the continuity of actions as well as establishing the service as a reference for these individuals (46) . From this perspective, bonding emerges as a fundamental element to favor the adherence of elderly individuals who live by themselves to the COVID-19 preventive measures.
One study conducted in the United States also found that elderly individuals (p<0.001), as well as those living alone (p<0.001), and with a low educational level (p<0.001), presented the worst level of knowledge concerning COVID-19 (7) . The low educational level of the elderly individuals may be considered a risk factor for the dissemination of viral infections and death (7,16) , considering that it may negatively influence the way elderly individuals understand and perform self-care (47) . Additionally, a low educational level may be associated with an individual's social status, suggesting that lifestyle, living conditions, and knowledge concerning COVID-19 influence its prognosis (7,16) . Therefore, less educated elderly individuals would be more prone to the infection caused by the novel coronavirus because they use crowded public transportation and have poor access to medical resources (16) .
This context represents a challenge for health workers, especially nurses providing care to elderly individuals living by themselves with a low educational level. For this reason, strategies that favor the knowledge and adherence to measures that prevent the spread and transmission of COVID-19 are needed (16) . Nurses should attempt to use efficient communication with these individuals, using clear and objective language when addressing the care necessary to prevent this disease.
Communication in the nursing scope is an essential strategy in the care provided to elderly individuals because it encourages individuals to trust health workers and expose their needs, promoting positive interaction between care recipients and nurses (48) .
One of this study's limitations refers to its cross-sectional design, which does not allow for the establishment of causal effects, and its sample, which strategies that are specific to elderly men, aged 80 years old or older, with a low educational level.
Additionally, the results can also direct the practice of nurses working in the primary health care network and having greater contact with these individuals, to perform nursing actions intended to prevent the infection by the novel coronavirus.