INTRODUCTION

By early 2022, the World Health Organization (WHO) reported approximately 300 million cases of COVID-19, more than five million deaths, and nine billion vaccines administered ¹. COVID-19 has disproportionately affected older adults, highlighting their vulnerability as well as the frailty of health systems. Older adults are more likely to develop severe forms of the disease due to immune system changes and chronic diseases, which generate high rates of hospitalization and mortality ². In 2021, Peru reported the highest per capita mortality rate for COVID-19 worldwide, attributed to the fragmentation of the health system and the scarcity of hospital resources ^{3 , 4}. In Peru, older adults represent 13% of the national population ⁵ and 70% of deaths due to COVID-19 ⁶.

Vaccination is the most appropriate measure to control infection in the absence of effective therapeutic interventions. The vaccination process against COVID-19 in Peru began in February 2021, and by May 28, 2022, more than 70 million doses had been administered ⁷. During 2021, older adults were immunized with the Pfizer vaccine and in some regions with AstraZeneca. Delayed vaccination could spread variants that overcome the immunity conferred by previous vaccines or by the disease ⁸. Nevertheless, the low acceptance of vaccines is a problem that prevents the mitigation of the disease. According to surveys conducted in Peru, the acceptance of the COVID-19 vaccine reached 49-60% between January and March 2021 ⁹.

The level of knowledge about COVID-19 has an impact on taking preventive measures, so it is necessary to develop educational interventions for vulnerable populations ¹⁰. Worldwide, studies have been conducted to measure knowledge, attitudes and practices in various diseases through the KAP (Knowledge, Attitude and Practices) format; however, few studies have been conducted in older adults ^{11 , 12}. Given the lack of evidence in Peru and considering the vulnerability of older adults during the current pandemic, the aim of this study was to describe the perception about vaccines and the level of knowledge, attitudes and practices related to COVID-19 in older adults from a general hospital in Lima, Peru.

THE STUDY

FINDINGS

A total of 320 older adults were contacted by telephone, of whom 220 did not answer the call, resulting in 100 who agreed to participate in the study. Of these, 17 were excluded because they did not meet the inclusion criteria. The final sample included 83 participants, 62.7% of whom were women. The mean age was 74.0 (SD: 7.7) years, and the most frequent marital status was married (46.9%). Of the participants, 25.3% reported having had COVID-19 during the pandemic (Table 1).

Regarding the perception about vaccines, 91.5% of the participants received at least one dose; 95% reported that the vaccines protect against severe forms of disease, 9.9% indicated that they are not safe (Table 2). Regarding knowledge, 98.8% have heard about the disease, 92.7% knew that it was contagious and 73.4% knew its viral etiology. The incubation period was unknown to 92.7% and 50.6% believed that it can be transmitted by dairy products or contaminated meat; 43.3% reported that there is no specific treatment or that it is only paracetamol, and 22.8% indicated that it is ivermectin (Table 3). Regarding attitudes, 96.3% considered it to be a serious disease and 65.4% reported that the level of social awareness of the disease was insufficient (Table 4). As for practices, 88.8% avoided leaving home to prevent infection, 93.8% avoided physical contact, 100% pay more attention to their hygiene and 61.7% used traditional medicine to prevent the disease (Tables 5).

DISCUSSION

In our study, most of the older adults recognized vaccines as a preventive measure, and also showed an adequate level of knowledge, attitudes and practices towards COVID-19. However, we also found erroneous beliefs that could influence their preventive behaviors in the face of the pandemic.

Regarding the perception about COVID-19 vaccines, most participants reported having been vaccinated and receiving two doses, which is similar to the local epidemiological situation during the study period (96.6% of older adults vaccinated with a second dose in northern Lima and 90% at the national level) ⁷. These findings suggest that vaccine acceptance in this age group is high. This contrasts with a study conducted at the beginning of vaccination in Peru, where the intention to vaccinate in older adults was 64.4% ¹⁵. The difference could be explained by to the massive vaccination campaigns carried out at the national level; however, vaccination could also have been influenced by the decision of the older adult’s family members.

Regarding knowledge, almost all participants are aware of the viral etiology and symptoms. This could be attributed to the fact that the Ministry of Health promoted the dissemination of information through the media since the beginning of the pandemic. These findings differ from international studies in which the level of knowledge is inversely related to age ^{12 , 16}. On the other hand, participants reported erroneous beliefs about the natural history of the disease, such as the possibility of foodborne transmission. In addition, most were unaware of the incubation period, suggesting that they may have been unaware of the isolation time required after exposure to a contact or a person diagnosed with COVID-19. Regarding treatment, responses were not uniform, which could be explained by the changing measures adopted to deal with the pandemic in Peru. For example, the Peruvian government promoted the use of ivermectin, hydroxychloroquine and azithromycin at the beginning of the pandemic, which could explain the heterogeneity of the responses.

Another relevant finding was that almost half of the participants considered the disease to be more dangerous in adults older than 50 years; a similar proportion stated that it affects all ages equally. This shows that a significant proportion underestimates the risk of older adults to have severe forms of COVID-19. However, it is important to consider that during the study period there was an increase in cases in young adults in our country, which could have influenced the participants’ perspective. Several international studies have shown that older adults’ risk perception about COVID-19 is underestimated, which is attributed to a phenomenon of paradoxical illusory optimism ¹⁷.

Regarding attitudes, most older adults recognized that COVID-19 is a serious disease, and that health education and quarantine can prevent its transmission. A notable finding in this domain was that more than half of the participants felt that society does not have sufficient awareness of the impact of COVID-19. In terms of practices against this disease, most adopted biosecurity measures to avoid contagion, as described in other studies ^{12 , 17}. In addition, more than half used herbal products and traditional medicine to prevent infection. Similarly, a study in an HIV-infected Peruvian population found that almost half of the participants (46.8%) believed that gargling with salt and water prevents COVID-19 ¹⁸. Another study in Cusco showed that 80.2% used medicinal plants for prevention, while 71% used them to treat COVID-19 ¹⁹.

A strength of our study is that it is one of the first to explore the perception of older adults about COVID-19 vaccines and the pandemic in Peru. The main limitations were the small sample size due to the limited use of cell phones among older adults. In this study, only 10% of respondents had their own cell phone, which may be due to low economic resources. In addition, the constant change of cell phone numbers in the family may have limited contact with the older adult, which would explain the poor response rate in the study.

On the other hand, during the study period, the number of COVID-19 cases was decreasing due to vaccination, which is evident from the heterogeneity of the participants’ responses. For example, in mid-April 2021, there were about 1600 cases per day, whereas in September 2021, there were about 1000 cases per day ²⁰. In addition, the use of the telephone was not appropriate for data collection, given the length of the survey. Also, participants’ responses may have been influenced by family members who were present during the call. Because the participants were all from the city of Lima, the results cannot be extrapolated to other regions of Peru. Also, the cultural validation of the instrument cannot be applied to populations with mother tongues other than Spanish.

In conclusion, most of the older adults surveyed had a positive perception of the COVID-19 vaccine and an acceptable level of knowledge, attitudes and practices towards this disease. However, they also presented numerous erroneous beliefs that could have an impact on preventive practices. Further studies in older adults are needed to obtain evidence on their perceptions and thus implement health and educational strategies in the face of possible future pandemics.