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Abstract

This study analyzes the self-perception of mental health of socially vulnerable elderly people during the COVID-19 crisis in Brazil. Conducted across all state capitals from February 2021 to October 2023, it included 366 participants living in various conditions such as camps, street situations, slums, and communities. The average age was 66.7 years, with a majority being male (59.0%), of Black or Brown race/color (62.3%), and earning below one minimum wage (36.6%). Findings revealed that older adults in street situations, experiencing psychological manifestations like sleep disturbances due to the pandemic, tended to assess their mental health more negatively. In contrast, older men of white race/color without such manifestations, and those practicing strategies like physical activity or relaxation, were less likely to perceive their mental health as poor. Addressing housing, implementing health strategies, and recognizing sample and regional complexities are crucial interventions for older adults in street situations.

Keywords

COVID-19 mental health social vulnerability aging

Introduction

According to the World Health Organization (WHO, 2017), globally, more than 20% of the population aged 60 and over has some clinical condition involving psychiatric disorders and neurological diseases, with dementia, major depressive disorder, and anxiety being the most prevalent (WHO, 2017). In addition to the changes inherent in the aging process, this population may face a lack of awareness and cognitive impairment associated with stress, environmental impoverishment, and the absence of social stimuli (Mehra et al., 2020).

Mental health, defined as the effective realization of individual mental capacities, reflects a state of well-being in which each person achieves their potential, copes effectively with daily challenges, contributes to their community, and maintains satisfactory productivity (WHO, 2003). This concept encompasses emotional, psychological, and social aspects, emphasizing that the mere absence of mental disorders does not guarantee full mental health (Artiga & Hinton, 2018). There is an increasing recognition that social and economic factors, as well as natural and human-caused events, influence mental health resilience. Social determinants, which include conditions at birth, life, work, age, ethnic status, among others, incorporate socioeconomic, educational, environmental, occupational variables, social support networks, and access to healthcare (Artiga & Hinton, 2018). These determinants, in turn, are shaped by macroeconomic, environmental, and political forces (Allen et al., 2014).

The occurrence of COVID-19 and other infectious diseases is strongly associated with symptoms of psychological distress, mental illness, and physical pain. Other pandemic experiences show that the number of people affected mentally exceeds the number of individuals physically infected by the disease, highlighting the significant influence of mental health in these historical periods (Lee et al., 2020). Specifically, the stress experienced during COVID-19 compared to other stressors was 1.5 times higher than the stress generated by the Middle East Respiratory Syndrome and 1.4 times higher than the psychological consequences caused by local earthquakes. Therefore, the detrimental impacts of COVID-19 on mental health can be acknowledged as more extensive and intense than those of previous pandemics, emphasizing the critical importance of this topic for studies, discussions, and health strategies (Lee et al., 2020).

The detrimental effects on mental health resulting from prolonged exposure to pandemic-induced stress are not evenly distributed in society, manifesting differently among various population groups. Vulnerable populations include the older adults, particularly those institutionalized, recent unemployed individuals, children, and adolescents (Codagnone et al., 2020; D’cruz & Banerjee, 2020; Imran et al., 2020; Team & Manderson, 2020). Groups that are more susceptible to the social, economic, and physical impacts of COVID-19, such as racialized individuals, immigrants and refugees, indigenous communities, and low-wage workers, are likely to be more vulnerable to mental health effects as well (Killerby et al., 2020; Millett et al., 2020). Groups facing increased vulnerability to the social, economic, and physical impacts of COVID-19, such as racialized individuals, immigrants and refugees, indigenous communities, and low-wage workers, likely exhibit a higher susceptibility to adverse mental health effects (Windsor-Shellard & Kaur, 2020).

Among the most vulnerable segments are the older adults, especially those residing in long-term care institutions, recently unemployed individuals, as well as children and adolescents (Webb Hooper et al., 2020). This complexity in the interactions between socioeconomic and health factors underscores the need for differentiated and context-sensitive approaches in addressing the psychosocial challenges associated with the pandemic (Windsor-Shellard & Kaur, 2020).

Older adults are highly vulnerable to the effects of loneliness due to the natural decline in their social circles as they age. COVID-19 social isolation restrictions have exacerbated this situation, limiting their participation in community and religious activities. This scenario contributes to increased social disconnection, anxiety, and depression among the older adults, who also face elevated risks of neurocognitive decline, autoimmune diseases, and cardiovascular conditions (Chen et al., 2021).

Furthermore, considering previous studies (Gerst-Emerson & Jayawardhana, 2015) that identified social isolation among the older adults as a “serious public health problem,” increasing the risk of cardiovascular, autoimmune, neurological, and psychiatric conditions, it becomes imperative that the ramifications of COVID-19 on the mental health of the older adults be thoroughly examined and addressed with due consideration, shaping a public health crisis.

The scientific literature review underscored the importance of this study, as no observational studies addressing the mental health of elderly individuals in situations of social vulnerability at a national level in Brazil were identified. While studies in specific cities within the country exist regarding mental health during the COVID-19 pandemic (Bohn et al., 2023; De Maio Nascimento et al., 2023; De Oliveira Andrade et al., 2022; Osei-Owusu et al., 2024; Schütz et al., 2024; Szlejf et al., 2023; Vidal Bravalhieri et al., 2022), none exclusively focus on the elderly in such contexts of social vulnerability, thereby highlighting a gap that this study uniquely and indispensably addresses.

Objective

Analyze the self-perception of mental health of socially vulnerable elderly people during the COVID-19 crisis in Brazil.

Methods

Study Design

A cross-sectional, descriptive-analytical study conducted through field interviews from February 2021 to October 2023 in all the capitals of the 26 Brazilian states and the Federal District. These interviews are derived from a matrix project entitled “Social Thermometer—COVID-19 in Brazil.”

Population and Sample

The study included participants in situations of social vulnerability (residents in camps/settlements/occupations/rural areas; homeless situation; slums/community; international border/refugees/international shelter/migrants; others: riverside dwellers/quilombola), all native or naturalized Brazilians who spoke and understood Portuguese, with at least 6 months in these conditions and aged 60 years or older. Those who did not respond to relevant questionnaire variables during the interview.

For the sample calculation, simple random sampling calculation for finite populations was employed, following classical references in opinion surveys, epidemiology, and surveys (Naderifar et al., 2017):

Finite population : n' = \frac{n}{1 + \frac{z^{2} \times \overset{\land}{p} (1 - \overset{\land}{p})}{ε^{2} N}}

Where: “z” is the z-score; “ε” is the margin of error; “n” is the population size; “pˆ ” is the population proportion. Through the calculation for finite populations, a minimum sample of 350 individuals was adopted, taking into account a random margin of error of 5%, a confidence level of 95%, a test power of 80%, and a variance of 50% (Bolfarine & De Oliveira Bussab, 2005). It is worth noting that the population size used in the calculation considered the survey conducted by Instituto Brasileiro de Geografia e Estatística (IBGE), which reported that in 2022, 14.8% of the population aged 60 or older were in a situation of poverty, and 2.3% in extreme poverty, totaling 5,752,796 older adults in these situations (IBGE Statistics, 2022).

Questionnaire and Data Collection

The questionnaire used for this research, titled “Social Thermometer COVID-19: Social Opinion,” was adapted and validated for the Brazilian context through the Delphi technique. Originally developed and validated by researchers from the National School of Public Health at the Nova University of Lisbon (ENSP/UNL) in Portugal, this questionnaire has been used in previously published studies. To ensure data integrity, the instrument was hosted on the REDCap platform at the University of São Paulo (USP) campus in Ribeirão Preto. It is relevant to note that REDCap is a browser-based electronic data capture software with a workflow methodology, designed for creating databases for clinical and observational research.

The instrument employed in this research comprises 141 items, encompassing questions in the form of checklists, multiple-choice, and Likert scale. For data collection, a network of contacts was established to recruit participants through professionals affiliated with research institutions, universities, and members of civil society. The mobilization strategy involved Social Movements, recognized for their connection to territories and populations in situations of social vulnerability.

This stems from the interaction established through various key strategies in these locations and for these populations. The instrument was administered by field interviewers designated for the research, using mobile devices such as phones and tablets. These interviewers underwent training to ensure consistency in instrument administration and to avoid any measurement bias. They were instructed to consider the pandemic period from March 11, 2020, when the WHO declared the COVID-19 pandemic, until the time of the interview. The average questionnaire application time was 20 to 30 min.

Considering the peculiarities of the sample, participation in the study occurred through sequential sampling, where participants were included as they were encountered, whether in public places, shelters, hostels, pensions, or slums/communities, as long as they demonstrated readiness to participate.

Before commencing the questionnaire administration, research participants were introduced to the Informed Consent Form (ICF). Only after agreement and the signing of the ICF was the interview initiated. The ICF was organized into two copies, read in its entirety, and initialed on each page by both the participant and the responsible interviewer. Consequently, the instrument was administered only once to each individual. In the case of illiterate participants, fingerprint impressions were collected, with each party keeping a copy, and was informed of the importance of the participant keeping the document. It is noteworthy that participation in the research was entirely voluntary.

Study Variables

Dependent Variables

Table 1 shows the dependent variables in our study, as derived from the questionnaire, along with the corresponding response patterns. It also shows the version used in the binary logistic regression analysis, which was dichotomized into values of 0 and 1.

Table 1.

Operationalization of the Dependent Variable Under Study.

Dependent variable	Original response options from questionnaire	Dichotomized into
In general, how do you consider your state of mental health?	1. Well; 2. Very well;.	0 = They considered his mental health to be well, very well and reasonable.
	3. Reasonable;4. Poorly;5. Very poorly;6. I prefer not to answer	1 = They considered his mental health to be poorly and very poorly.

Individuals who did not answer the dependent variable were excluded from the binary logistic regression model.

Independent Variables

The independent variables considered were:

Gender (Male; Female), Race/Ethnicity (White; Black/Brown; Yellow), Marital Status (Married; Divorced, separated, or single/Widowed/Separated), Territories (Camp/Settlement/Occupation/Rural area; Street situation; Slum/Community; International border/Refugees/International shelter/Migrants; Other: Riverside/Quilombola), Perception of the risk of developing a severe illness or complications if infected with COVID-19 (No risk; With risk), Have support from family, acquaintances, or the community to buy food, medicine, among other things (Yes; No), Comparing with the period before COVID-19, how have you mostly felt (I am more agitated, anxious, or tense; I am more irritable; I am sadder, more discouraged, or cry more easily; I am lonelier; I am always thinking about COVID-19; I am more overwhelmed; I can’t do everything I have to do; I have more trouble sleeping; I don’t feel anything mentioned), In the last few days, what have you been doing in your daily life to deal with the current situation (I keep in touch with family and friends, even from a distance; I try to establish routines for my days; I limit the amount of information I see about COVID-19; I eat more sweets, fats, or calorie-rich foods; I smoke more; I consume more alcoholic beverages; I engage in physical activity or relaxation techniques; I take advantage of the time at home to do things I like), Due to COVID-19, have you started or increased the use of tranquilizers or antidepressants (Yes; I continue to use tranquilizers or antidepressants as I did before; I do not take tranquilizers or antidepressants; No), Have you used medication because of COVID-19 (Yes; No), Have you needed health care during the pandemic for health problems not related to COVID-19 (Dental consultation; Ambulatory care; Emergency care; Specialty care; I didn’t need any care), and Have you been hospitalized due to COVID-19 infection (Yes; No).

Statistical Analyses

Following database consistency and standardization analysis, descriptive analyses were conducted to characterize study participants through calculations of measures of central tendency (mean), dispersion (standard deviation), absolute frequency (n), and relative frequency (%). The data were tabulated in Microsoft Office Excel 2010 spreadsheets and imported for analysis into R software version 4.1.1.

A binary logistic regression was conducted with the dependent variable being “In general, how do you consider your state of mental health?” The selection of independent variables for the final model occurred in two stages. In the first stage, the presence of multicollinearity was assessed to avoid introducing variables that are correlated. The Variance Inflation Factor (VIF) test was conducted for this purpose, and variables with a value equal to or greater than 10 were excluded from the model. The best model was selected based on the criterion of the lowest Akaike Information Criterion (AIC) value. For the final model, Odds Ratios (OR) with their respective 95% Confidence Intervals (CI) were calculated. After choosing the final model based on the lowest AIC value, likelihood ratio tests, Cox-Snell, Nagelkerke, and McFadden tests were conducted for model validation. Additionally, the predictive capacity and accuracy of the models were verified based on the area under the Receiver Operating Characteristic (ROC) curve with their respective IC95% values. The logistic regression analyses and validation tests were performed using RStudio software, version 4.1.1.

Ethical Aspects

The research received approval from the Research Ethics Committee (CEP), and the entire conduct of the investigation complied with Resolution No. 466, dated December 12, 2012, from the National Health Council and Declaration of Helsinki, adhering to relevant ethical and scientific principles.

Results

A total of 366 individuals aged 60 years or older in situations of social vulnerability were included in the study, with an average age of 66.7 ± 5.76 years. The majority of the older adults participants were men (n: 216; 59.0%), of black and/or brown race/color (n: 228; 62.3%), married (n: 145; 39.6%), retired (n: 138; 37.7%), with incomplete elementary education (n: 172; 47.0%), receive less than 1 minimum wage (n: 134; 36.6%), and residents in slums/communities (n: 176; 48.1%). Concerning their access to healthcare, the majority did not have any health insurance or plan (n: 334; 91.3%), relied on the public Unified Health System (SUS) (n: 350; 95.6%), received visits from Community Health Agents (ACS) (n: 183; 50.0%), and had a health post in their community or neighborhood (n: 294; 80.3%) (Table 2).

Table 2.

Socioeconomic and Healthcare Accessibility Characteristics of Older Adults in Situations of Social Vulnerability, Brazil, 2022 to 2023.

Socioeconomic and health accessibility variables	n (%)
Gender/sex
Female	149 (40.7)
Male	216 (59.0)
Other (transgender, fluid, homosexual, non-binary)	1 (0.3)
Race/ethnicity
White	117 (32.0)
Black and/or brown	228 (62.3)
Asian	8 (2.2)
Indigenous	8 (2.2)
Not declared	5 (1.4)
Marital status
Single	94 (25.7)
Married	145 (39.6)
Divorced or separated	59 (16.1)
Widowed	68 (18.6)
Occupation
Formal employment	33 (9.0)
Informal employment	91 (24.9)
Retired	138 (37.7)
Unemployed	88 (24.0)
Student	1 (0.3)
Education
Incomplete elementary school	172 (47.0)
Complete elementary school	49 (13.4)
Incomplete high school	28 (7.7)
Complete high school	67 (18.3)
Incomplete college	2 (0.5)
Complete college	12 (3.3)
Postgraduate	2 (0.5)
No education	34 (9.3)
Income
Less than 1 minimum wage	134 (36.6)
1 to 2 minimum wages	119 (32.5)
2 to 3 minimum wages	23 (6.3)
3 to 5 minimum wages	11 (3.0)
From 5 to 10 minimum wages	2 (0.5)
Above 10 minimum wages	0 (0.0)
No income	62 (16.9)
Not applicable
Territories
Camp/settlement/occupation/rural area	67 (18.3)
Street situation	110 (30.1)
Slum/community	176 (48.1)
International border/refugees/international shelter/migrants	7 (1.9)
Other (Riparian/Quilombola)	3 (0.8)
Has any health insurance or plan
Yes	30 (8.2)
No	334 (91.3)
Not applicable	2 (0.5)
Uses the SUS
Yes	350 (95.6)
No	15 (4.1)
Not applicable	1 (0.3)
Receives visits from ACS
Yes	183 (50.0)
No	182 (49.7)
Not applicable	1 (0.3)
Has a health post in their community or neighborhood
Yes	294 (80.3)
No	45 (12.3)
Does not know	27 (7.4)

Note. NR = no response; SUS = unified health system (Sistema Único de Saúde in Portuguese); ACS = community health agent (Agente Comunitário de Saúde in Portuguese).

With regard to self-perceived mental health, 62.8% (n: 230) of the older adults self-reported good/very good mental health, 35.8% (n: 131) fair/poor/very poor and 1.4% (n: 5) did not answer. Table 3 shows the results of the binary logistic regression analysis, where it was possible to observe that older adults in situations of social vulnerability who were homeless (OR: 1.79; 95% CI [1.00, 3.23]; p = .049), who presented psychological manifestations compared to the period before COVID-19, such as not being able to do everything they had to do (OR: 2.96; 95% CI [1.15, 7.99]; p = .027) and more difficulty sleeping (OR: 2.73; 95% CI [1.38, 5.53]; p = .004), have a higher probability of poor self-perception of their mental health status during the COVID-19 pandemic.

Table 3.

Factors Associated with Poor Self-Perceived Mental Health Among Socially Vulnerable Older Adults. Brazil, 2022 to 2023.

Model	OR (IC 95%)	p-Value
Gender: male	0.48 [0.28, 0.84]	0.009
Race/color: white	0.46 [0.26, 0.79]	0.006
Marital status: widowed	1.49 [0.78, 2.84]	0.219
Homeless	1.79 [1.00, 3.23]	0.049
Psychological manifestations felt compared to the period before COVID-19: Was more overwhelmed	1.26 [0.55, 2.89]	0.579
Psychological manifestations felt in comparison to the period before COVID-19: Couldn’t do everything they had to do	2.96 [1.15, 7.99]	0.027
Psychological manifestations felt compared to the period before COVID-19: Had more difficulty sleeping	2.73 [1.38, 5.53]	0.004
Did not have any psychological manifestations that were mentioned in the questionnaire (felt more agitated, anxious or tense; felt more irritable; felt sadder, discouraged or cried more easily; felt lonelier; was always thinking about COVID-19; felt more overwhelmed; couldn’t do everything they had to do and had more difficulty sleeping)	0.32 [0.18, 0.56]	<0.001
Strategies for coping with the current situation of the COVID-19 pandemic: You have tried to establish routines for your days	0.56 [0.26, 1.15]	0.126
Strategies for coping with the current situation of the COVID-19 pandemic: Practiced physical activity or relaxation techniques	0.31 [0.12, 0.73]	0.009
Strategies for coping with the current situation of the COVID-19 pandemic: Taking advantage of time at home to do things you enjoy	0.43 [0.21, 0.87]	0.022
Not taking tranquilizers or antidepressants due to COVID-19	0.88 [0.51, 1.53]	0.648

On the other hand, socially vulnerable older adults men (OR: 0.48; 95% CI [0.28, 0.84]; p = .009), white race/color (OR: 0.46; 95% CI [0.26, 0.79]; p = .006), who did not have any psychological manifestations that were mentioned in the questionnaire (felt more agitated, anxious or tense; felt more irritable; felt sadder, more discouraged or cried more easily; felt lonelier; thought about COVID-19 all the time; felt more overwhelmed; couldn’t do everything they had to do and had more difficulty sleeping) (OR: 0. 32; 95% CI [0.18, 0.56]; p < .001), who used physical activity or relaxation techniques as strategies to deal with the current situation of the COVID-19 pandemic (OR: 0.31; 95% CI [0.12, 0.73]; p = . 009) and used the time at home to do something they enjoyed (OR: 0.43; 95% CI [0.21, 0.87]; p = .022), were less likely to have a poor self-perception of their mental health status during the COVID-19 pandemic.

To assess the accuracy of the model outlined in Table 2, validation was carried out by analyzing the area under the ROC curve, which revealed a coefficient of .78. In addition, the Likelihood Ratio test was carried out (p < .001), as well as evaluations of the Cox-Snell (0.21), Nagelkerke (0.29) and McFadden (0.18) indices.

Discussion

This study aimed to reveal the impact on the self-perception of mental health of older adults in situations of social vulnerability during the COVID-19 crisis in Brazil. From this, we developed a comprehensive analysis of the conditions of social vulnerability among the older adults during the COVID-19 pandemic, exploring not only demographic and socioeconomic factors, but also the influence of these variables on the self-perception of mental health status. The results highlight distinct patterns that should be considered in order to guide specific interventions and policies aimed at this vulnerable population group.

The predominance of men, individuals of black and/or brown race/color, married, retired, with low schooling and an income of less than 1 minimum wage reflects the complex intersection of factors that contribute to social vulnerability among the older adults studied. These demographic features underline the imperative of adopting approaches that are sensitive to the nuances of gender and ethnicity when designing interventions and public policies aimed at this specific and vulnerable group (Fineman, 2023).

The average age of 66.7 years reveals a sample characterized by an advanced age group, emphasizing the need for careful consideration of the complexities associated with the aging process in contexts of social vulnerability (Pinho de Almeida, 2021). There is a projection that by 2025 Brazil will rank sixth among nations with the largest older adults population in the world (Escorsim, 2021). According to IBGE projections, by 2060 the older adults is expected to make up approximately a third of Brazilians (32.2% of the population) (Oliveira et al., 2014). In addition, the National Household Sample Survey (PNAD) carried out by the IBGE in 2012 identified a phenomenon of “feminization of ageing.” This trend is due to the fact that women live, on average, 7 years longer than men (Escorsim, 2021).

However, in our study it was not possible to observe this phenomenon of feminization due to increased life expectancy. Studies have shown that reduced social involvement, lack of support networks and low socioeconomic status can anticipate functional and cognitive decline, leading to a greater occurrence of chronic and infectious diseases. In other words, social determinants have a negative impact on an individual’s functional capacity, in addition to biological influences, reducing life expectancy (Barbosa et al., 2019).

According to Brazil’s National Policy for the Elderly (PNI), an individual aged 60 or over is considered older adults, but this is a specific age cut-off (chronological age) for naming who the older adults are in society. However, taking biological age into account, it is greatly influenced by social factors, economic consequences and personal and social resources that can lead to involution, resulting in exposure to stressful events that can predispose the individual to present alterations present in aging before reaching chronological age (Cardoso et al., 2021). Because of this, in this study it was not possible to observe a large number of older adults of advanced age or even the advancement of age specifically in women.

As for accessibility to healthcare, the high dependence on the SUS among the older adults in social vulnerability highlights the critical importance of this system in meeting the needs of a population that often faces financial barriers in accessing private healthcare services, especially during the COVID-19 pandemic. During the COVID-19 pandemic, access to SUS for the older adults has become a crucial concern, given the vulnerability of this group to complications from the virus (Hammerschmidt & Santana, 2020). In addition, mobility restrictions impacted attendance at medical appointments, and fear of exposure to the virus led many to postpone care. Health services, including SUS, adapted quickly, implementing specific screening and adopting strict protocols (De Souza et al., 2021). Awareness-raising campaigns were essential, highlighting the importance of continued medical care and prioritizing vaccination to protect the older adults. The complexity of access to the SUS highlights the need for public policies that improve access and reduce barriers in different regions of the country, and there is still a need to consider the multiple dimensions of social vulnerability, which is imperative to promote an inclusive and effective approach to tackling the challenges faced by these older people.

Self-perception of mental health status during the pandemic reveals a significant duality, with the majority reporting mental well-being but a sizable portion facing psychological challenges. The results of the binary logistic regression analysis offer valuable insights into the factors associated with negative self-perception of mental health. The finding that homeless older people, those who have experienced psychological manifestations during the pandemic and have faced difficulties sleeping are more likely to have poor self-perceptions highlights the importance of specific psychological support strategies and interventions targeted at vulnerable subgroups.

Lack of adequate housing, transportation, social disadvantages, climate change and adverse environment are risk factors that contribute to the increase in mental health problems, in addition, being at risk of homelessness or homelessness is closely associated with mental health problems (Team & Manderson, 2020). In this context, homeless people already present extreme social vulnerability before the COVID-19 pandemic period, living in environments conducive to a disease epidemic, mainly because they do not have regular access to basic hygiene supplies, adequate food and access to health, and with the increased risk of COVID-19 infection, they can generate high levels of stress, and thus exacerbate existing mental health conditions and induce new ones (Banerjee, 2020).

COVID-19 is considered “syndemic” because the consequences of the disease are aggravated by social and economic inequality, precarious housing, unstable working conditions, inequalities of class, race, gender and low income have a profound impact on mental health and well-being, our results corroborate and affirm this impact on mental health, and also in a population that is vulnerable in terms of age and socioeconomic status (Mezzina et al., 2022). In addition, it is worth noting that the link between poverty and mental health is bidirectional, that is, the increased risk of exposure to traumatic experiences and stress can increase vulnerability to mental health and mental health problems can induce people to poverty, mainly by reducing their ability to work (Mezzina et al., 2022).

According to the United Nations Human Rights Council (UNHRC) (Farha, 2020) it is estimated that 150 million people are homeless globally. We are looking at a significant portion of the population in extreme social vulnerability and who are in the process of ageing in a pandemic period. This extreme intersectionality is worrying and of great relevance when it comes to implementing public policies aimed at mental health in socially vulnerable populations.

The findings related to male gender, white race/color, absence of psychological manifestations and the adoption of healthy coping strategies, such as physical activity and relaxation techniques, indicate protective factors associated with a lower probability of negative self-perception of mental health. These results highlight the importance of promoting healthy and accessible coping strategies, suggesting that interventions focused on these activities can have a positive impact on the mental health of the older adults. As well as contributing to the prevention of chronic diseases and muscle strengthening, physical activity is a crucial ally for mental well-being, reducing stress, anxiety and depression, especially in times of social isolation. Regular exercise strengthens immunity and physical endurance, which are fundamental in a pandemic context. Even with social distancing, physical activity offers opportunities for virtual socialization, providing structure to everyday life and promoting a sense of normality (Possamai et al., 2020).

The findings of this study underscore the urgent need for robust public policies aimed at improving access and the quality of mental health care for older adults in socially vulnerable situations as a response to crises such as the COVID-19 pandemic. Such policies should take into account the social, economic, and cultural complexities that affect aging in Brazil, promoting equitable accessibility and incorporating strategies to strengthen community and family support. It is imperative to adapt mental health interventions to the specific needs of older adults across different regional and community contexts, emphasizing the importance of longitudinal studies to monitor the prolonged effects of the pandemic and guide the development of more effective interventions.

This study, however, has limitations, such as its cross-sectional nature, which limits the ability to establish causal relationships, and the potential introduction of bias due to reliance on participants’ self-perception to assess mental health. These limitations highlight the need for caution in interpreting the results and suggest the importance of future research to more deeply explore the diversity of experiences of older adults across Brazil, contributing to a more comprehensive understanding that can guide specific interventions and inclusive public policies.

The need for personalized interventions, taking into account the regional and individual diversity of Brazil, is clear. Future research and interventions must be culturally relevant, adapting to local needs and encouraging the active participation of older adults in the development of programs. Implementing community mental health programs, training community health workers, and promoting social and economic inclusion through policies such as income guarantee programs and adapted educational and leisure initiatives are essential to address the challenges posed by Brazil’s diversity and improve the mental health of older adults in vulnerable situations in the context of COVID-19.

Conclusions

In conclusion, this investigation has shed light on the intricate effects of the COVID-19 crisis on the self-perception of mental health among older adults in socially vulnerable conditions in Brazil, providing critical insights into how demographic and socioeconomic factors—such as gender, race, marital status, economic status, and educational background—interact to shape mental health outcomes. The reliance on the SUS by the majority of participants underscores the essential role of public healthcare services in supporting the mental well-being of this population, particularly during health crises when private healthcare options may be out of reach.

Despite a sense of well-being reported by many, the study identified a substantial segment of the older adults population grappling with psychological challenges, highlighting an urgent need for targeted mental health interventions and comprehensive public policies. These findings advocate for the adaptation of mental health services to the unique needs of older adults, emphasizing the importance of integrating social and economic support mechanisms to mitigate the adverse effects of the pandemic on this vulnerable population. In addition, future research similar to this study with a longitudinal approach and a more comprehensive sample size in order to identify changes in social determinants over a period of time and assess whether policies and interventions have had any positive impact on social security and well-being. Furthermore, investigating the impact of vaccination is crucial for developing interventions that address the myriad factors contributing to mental health vulnerabilities among elderly Brazilians during and post the COVID-19 pandemic.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was sponsored by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior—Brasil (CAPES)—Finance Code 001 Process: 88887.657730/2021-00—Programa Impactos CAPES and by São Paulo State Research Support Foundation (FAPESP) grant number 2021/08263-7. Post-doctoral fellowship (FAPESP process—2022/03964-0); CNPQ (Research Productivity Scholarship—Process Processo: 307014/2022-3).

Research Ethics and Research Participant Consent

The research was approved by the Research Ethics Committee (CEP) of the Ribeirão Preto School of Nursing at the University of São Paulo (CAAE 32210320.1.3001.5393), and the entire investigation was conducted in accordance with Resolution No. 466 of December 12, 2012, of the National Health Council and Declaration of Helsinki, complying with the relevant ethical and scientific principles.

Availability of Data and Materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

ORCID iD

Letícia Perticarrara Ferezin

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Self-Perception of Mental Health and Exacerbated Social Inequalities Among Vulnerable Older Adults During the COVID-19 Pandemic in Brazil (2021–2023)

Abstract

Keywords

Introduction

Objective

Methods

Study Design

Population and Sample

Questionnaire and Data Collection

Study Variables

Dependent Variables

Independent Variables

Statistical Analyses

Ethical Aspects

Results

Discussion

Conclusions

Footnotes

Declaration of Conflicting Interests

Funding

Research Ethics and Research Participant Consent

Availability of Data and Materials

ORCID iD

References