46 JNK JURNAL NERS DAN KEBIDANAN (JOURNAL OF NERS AND MIDWIFERY) http://jnk.phb.ac.id/index.php/jnk Positif Correlation of Anxiety and the Interest of Elderly in Visiting Health Facilities During the COVID-19 Pandemic Pria Wahyu Romadhon Girianto1, Dwi Setyorini2, Sri Untaminingtyas3 1,2,3Nursing Department, STIKes Karya Husada Kediri, Indonesia Article Information Abstract Anxiety about dealing with the infectious nature of COVID-19 could influence the elderly to avoid visiting health facilities due to concerns about the rapid transmission of the disease. The impact of decreasing interest in visiting the elderly with comorbidities to health facilities causes repeated recurrences, and they do not get treatment to improve their health. This research aimed to determine the correlation between anxiety and interest in visiting health facilities for the elderly with comorbid diseases during the COVID-19 pandemic. The variables in this research were anxiety and interest in visiting health facilities. A questionnaire was used for data collection. The design of this research was a correlation with a cross-sectional approach, a sample of 32 respondents, and a purposive sampling technique. The result showed that most of the respondents (53.1%), 17 respondents, experienced moderate anxiety. Most of the respondents (62.5%), 20 respondents, had sufficient interest in visiting. Based on the Spearman's rank test, a p-value of 0.032 (α = 0,05) was obtained, meaning that there was a correlation between anxiety in comorbid elderly people and interest in visiting health facilities during the COVID-19 pandemic with a weak correlation category (r = 0.380). The elderly's anxiety about visiting health facilities during the pandemic could be because the elderly are getting tired of the comorbid disease process they experience; the elderly also feel vulnerable to infection due to information related to COVID-19 transmission; the elderly were afraid to die when confirmed with COVID-19; the elderly worried about the health of their families and the elderly as well. Worried that they have contracted the COVID-19 virus. It recommended for respondents not be afraid or anxious about coming to health facilities during the COVID-19 pandemic. The elderly could visit health facilities during the COVID-19 pandemic safely by always complying with health protocols. History Article: Received, 16/04/2022 Accepted, 04/04/2023 Published, 25/04/2023 Keywords: anxiety, elderly, health facilities, covid-19 © 2023 Journal of Ners and Midwifery Correspondence Address: STIKes Karya Husada Kediri – East Java, Indonesia P-ISSN : 2355-052X Email : priawahyu88@gmail.com E-ISSN : 2548-3811 DOI: https://doi.org/10.26699/jnk.v10i1.ART.p046-052 This is an Open Access article under the CC BY-SA license (http://creativecommons.org/licenses/by-sa/4.0/) http://jnk.phb.ac.id/index.php/jnk mailto:priawahyu88@gmail.com https://doi.org/10.26699/jnk.v10i1.ART.p046-052 Girianto, Setyorini, Untaminingtyas, Positif Correlation of Anxiety and the Interest of Elderly in Visiting … 47 INTRODUCTION COVID-19 was an infectious disease caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARSCoV-2) (WHO, 2020). SARS-CoV-2 had become a global pandemic that poses a serious global health threat. There were at least two types of coronavirus that were known to cause diseases that could cause severe symptoms, such as Middle East Respiratory Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS) (WHO, 2021). Patients who were positive for the coronavirus can also have severe and aggravating symptoms if they have a comorbid disease. Comorbidities such as heart disease, hypertension, and diabetes mellitus could increase the risk of death for COVID-19 patients. The most common risk factors for comorbidities or comorbidities were cases of upper respiratory tract infection (ARI) or pneumonia at 18.2%, followed by DM (16.9%) and hypertension (16.2%), (Senewe, 2020). This certainly presents worries and anxiety for the elderly with comorbidities. Comorbid patient illnesses such as diabetes, heart disease, chronic kidney disease, and obesity are strongly associated with hospitalization and the severity of COVID-19. Several studies have shown that older age, underlying disease (e.g. hypertension, diabetes, cardiovascular disease, chronic lung disease, chronic kidney disease, and cancer), and presenting symptoms (including fever, cough, diarrhea, and shortness of breath) may be a predictor of the severity of COVID-19 patients (Sanyaolu, et al., 2020). The mortality rate of COVID-19 patients aged 60 years and over is 15.93%. Jing Yang, et al. (2020) reported that research results found comorbid diseases, namely hypertension 21.1%, diabetes (9.7%), cardiovascular disease or stroke 8.4%, and respiratory disorders 1.5%. If the severity of this COVID-19 case with comorbidities is found to be associated with 95% hypertension, 95% respiratory disease, and 95% stroke (Yang et.al., 2020). Xun Li et al., 2020, found in COVID-19 patients that age and underlying disease (hypertension, diabetes, heart disease) were the most important risk factors for COVID-19 death. Older people with underlying medical problems such as cardiovascular disease, diabetes, chronic respiratory disease, and cancer are more at risk of developing serious illnesses and requiring referral for intensive care because of their low immune status (Clark et al., 2021). The lowest number of visits reported by RL (report recapitulation) to the Ministry of Health occurred during July-August 2021 for non-Covid patients. The number of visits to health facilities, especially in the Non-Covid ER, decreased by 42%, from an average of 2,099,734 per week during May 2021, to an average of 1,220,211 per week during the second period of the pandemic in July-August 2021. Visits decreased for each age group, with the largest proportionate declines in visits by children aged 10 years (72%) and 50–60 years (71%) (JPW, 2020). According to the deputy minister of health, Dante Harbuwono, there was a significant decrease in ER visits nationally, noting that there was a decrease in the number of people visiting the ER at puskesmas and hospitals by 83% in July 2021 in East Java, which shows that the pandemic has changed the use of the ER by the community (Bajgain et al., 2021). In addition, visits to the emergency room at the Sutojayan Health Center, Blitar Regency, as a non-referral Covid-19 health center, experienced a decrease in visits in July- September by 65%, which occurred in the elderly with comorbid diseases. The rate of decline is due to public anxiety, especially in comorbid patients. An increased level of anxiety is a mental health problem that often occurs during a pandemic, including the ongoing COVID-19 pandemic. A person who experiences changes in emotions, if left unchecked and develops, will be pathological. The decrease in patient visits to the hospital emergency room was also due to the fear of being treated in isolation rooms, being afraid of being screened for COVID-19, and not understanding the education and motivation given by emergency room staff (Ejaz, 2020). Based on the results of a preliminary study conducted by researchers on September 15, 2021, in Sukorejo Village, Sutojayan District, Blitar Regency on 12 comorbid patients, it was found that 10 comorbid patients did not visit health facilities, especially in the emergency room during the COVID-19 pandemic, for reasons of fear of being in the hospital. Covid-19 was diagnosed by health workers while 2 patients with comorbid diseases were still visiting health facilities such as general practitioners. Fear of contracting COVID-19 in healthcare settings has caused many people, including comorbid patients, to neglect emergency care. Anxiety in the face of the infectious nature of COVID-19 may influence patients to avoid visiting 48 Journal of Ners and Midwifery, Volume 10, Issue 1, April 2023, page 46-52 health facilities due to concerns surrounding the rapid transmission of the disease. This pandemic further prevents patients from seeking medical care, which can reduce the utilization of ER services (Hutajalu et al., 2021). The impact of decreasing interest in visiting comorbid patients to health facilities causes repeated recurrences in the patient's comorbid disease, and, of course, the patient does not get the treatment he should get to improve his health status (Sugeng, 2020). Management and prevention of Covid-19 in patients with comorbidities One of them are to often monitor body condition with regular control to a doctor or to a hospital that is not a referral for COVID-19 patients when checking in a hospital, always comply with the health protocols that have been submitted by the Government. such as wearing a mask, keeping a distance, washing hands, and maintaining a clean environment. Then, controlling comorbid well to prevent complications by maintaining a healthy lifestyle and adjusting diet according to comorbid conditions. The purpose of this study was to determine the correlation between anxiety and interest in visiting health services during the covid-19 pandemic. METHOD The research design used a correlational design with the cross-sectional approach. The research was done at Sukorejo village, Sutojayan District, Blitar Regency. The sampling technique was used "purposive sampling" or saturated sampling, as 32 respondents were adjusted to the research objectives and selected based on inclusion criteria, elderly who were willing to be respondents in the study, elderly who had comorbid diseases, namely diabetes mellitus, hypertension, and cardiovascular disease, and elderly aged 60 years and over. Before treatment, the researcher introduced themselves to the respondent to build trust and created a therapeutic environment. The Geriatric Anxiety Scale (GAS) was distributed to respondents to measure anxiety levels, and interest in visiting health facilities questionnaire. Rank Spearman statistical test (α = 0.05) was used to analyze the correlation between the level of anxiety in the elderly, and interest in visiting health facilities. RESULT The presentation of respondent characteristic data includes age, gender, education, means of transportation, income, occupation, illness, duration of illness, a therapy used, type of therapy, implementation of COVID-19 vaccination, information about COVID-19, and information media about COVID-19. Table 1: Frequency Distribution of Respondents' General Data Characteristics. No Respondents Characteristics f % 1. Age 60 to 65 years old 66 to 70 years old 71 to 75 years old 14 13 5 43.8 40.6 15.6 2. Gender Male Female 14 18 43.8 56.2 3. Education Uneducated Junior High School Senior High School College 3 11 16 2 9.4 34.4 50 6.2 3. Transportation Motor Cycle Car 27 5 84.4 15.6 4. Income (Rp) More than 1.000.000 to 2.000.000 More than 2.000.000 to 3.000.000 More than 3.000.000 16 11 5 50 34.4 15.6 Girianto, Setyorini, Untaminingtyas, Positif Correlation of Anxiety and the Interest of Elderly in Visiting … 49 5. Profession Farmer Private PNS/TNI/POLRI Tradesman 7 14 6 5 21.9 43.8 18.8 15.6 6. Illness DM Hypertension Cardiovascular 14 11 7 43.8 34.4 21.9 7. Duration of Illness 6 to 10 years old 11 to 15 years old More than 15 years old 24 7 1 75 21.9 3.1 8. Routine Treatment Yes 32 100 9. Therapy Pharmacology Traditional treatment 25 7 78.1 21.9 10. Covid-19 Vaccine Not yet 1st Vaccine 2nd Vaccine No Vaccine 3 14 9 6 9.4 43.8 28.1 18.8 11. Covid-19 Information Ever Never 29 3 90.6 9.4 12. Covid-19 Information Media Electronic Media Health Provider Citizen 18 10 4 56.2 31.2 12.5 Total 32 100 Based on the result of table 1, showed that almost half of the respondents (43.8%), namely 14 respondents, have age 60 to 65 years old. Most of the respondents (56.2%), namely 18 respondents, were female. Half of the respondents (50%) are 16 respondents with the latest high school education. Almost all respondents (84.4%), namely 27 respondents, use motorcycle transportation. Half of the respondents (50%) are 16 respondents with an income of more than 1,000,000 to 2,000,000. Almost half of the respondents (43.8%), i.e., 14 respondents, worked as entrepreneurs. Almost half of the respondents (43.8%), namely 14 respondents, had DM. Most of the respondents (75%), namely 24 respondents, experienced a long illness of 6 to 10 years. Overall respondents (100%) are 32 respondents using therapy. Almost all respondents (78.1%), namely 25 respondents, used pharmacological therapy. Almost half of the respondents (43.8%), namely 14 respondents, carried out the 1st dose of the vaccine. Almost all of the respondents (90.6%), namely 29 respondents, had received information about COVID-19. Most of the respondents (56.2%), namely 18 respondents, received information about COVID-19 through electronic media. Table 2: Correlation Analysis of Anxiety and Interest in visiting health facilities. Anxiety Interest in visiting health facilities High Moderate Low F % F % f % Light 2 6,2 3 9,4 0 0 Moderate 8 25 8 25 1 3,1 Severe 0 0 9 28,1 1 3,1 Total 10 31,2 20 62,5 2 6,2 Spearman’s rank test P value = 0,032 < α = 0.05 r = 0,380 50 Journal of Ners and Midwifery, Volume 10, Issue 1, April 2023, page 46-52 Based on table 2, was known that most of the respondents (53.1%), experienced moderate anxiety. Most of the respondents (62.5%), had sufficient interest in visiting. The result of the Spearman's rank test obtained a p - value of 0.032 (α = 0.05), meaning that there was a correlation between anxiety in the elderly with comorbid diseases and interest in visiting health facilities during the COVID-19 pandemic in Sukorejo Village, Sutojayan District, Blitar Regency in 2022. The close correlation in this study was 0.380, which means that there was a weak correlation. DISCUSSION Based on the result of the study, it was known that the Spearman's rank test obtained a p-value of 0.032 (α = 0.05), meaning that there was a correlation between anxiety in the elderly with comorbid diseases and interest in visiting health facilities during the COVID-19 pandemic in Sukorejo Village, Sutojayan District, Blitar Regency in 2022. The close correlation in this study was 0.380, which means that there was a weak correlation. Policy easing of activities during this pandemic (New Normal), activities in health facilities such as the elderly posyandu at Puskesmas in several areas have started to be active again, but while still implementing health protocols and posyandu services issued by the government. However, the result of the study showed that all respondents were worried about contracting COVID-19 when visiting health services. This needs socialization and education from the village government and local health services. In examination services at health services, the public was aware of the dangers of COVID-19 transmission by complying with health protocols by applying a minimum of 3 M (Ministry of Health RI, 2020). During the COVID-19 pandemic, the elderly was one of the groups vulnerable to COVID-19 transmission. One of the contributing factors was decreased immunity with age. The anxiety felt by respondents at health facilities during this pandemic if they catch COVID-19 from health workers or other visitors. The Alvara survey (2020), concluded that during this pandemic the public will experience high panic and anxiety, with anxiety, will affect public behavior, especially health-related behavior. Several health behaviors have increased, such as wearing masks, washing hands, and exercising. However, there were also some declining health behaviors, such as being afraid to go to health services, being afraid to seek treatment, or being afraid to leave the house doing the posyandu because they feel anxious if they get infected with COVID-19 from health workers or other health service visitors. Prolonged anxiety will cause stress so that it interferes with daily activities and causes instability in situations and conditions, one of which was that the elderly are afraid to go to health services (Mubin, 2020). Based on research conducted by Sari & Utami (2020) on the Study of Anxiety Level Analysis with Compliance with Posyandu Visits During the COVID-19 Pandemic, it was found that almost half of the respondents were not anxious and obedient in visiting posyandu during the pandemic. Almost half of the respondents also experienced mild anxiety. and a small number of respondents experienced severe anxiety. The elderly who are not actively visiting the elderly posyandu will have an impact on their health conditions. They cannot be monitored properly so if they experience a risk of disease due to a decrease in body condition and the aging process, it was feared that it could be fatal (Firda & Lilisa, 2021). Research by Livana et al. (2020) showed that the spread of COVID-19 was taking place rapidly in Indonesia and causing concern, causing feelings of anxiety and fear, which were common responses from humans to the affected environment. The result of the study found that almost the entire community felt anxious to come to health services and almost half of the respondents did not check themselves during the COVID-19 pandemic. Currently, hospitals were also restricting inpatient and outpatient visits to reduce the transmission of COVID-19 infection (Adiputra, 2020; Chen et al., 2016; Irawan & Sudarsa, 2020). Based on research conducted by Santana et al. (2020), there had been a significant decline in the number of hospital services used since the beginning of the COVID-19 pandemic, especially outpatient services. Outpatient services were one type of health service in hospitals that have an important role in providing health services because they were the gateway to inpatient services and other health services (Sinaga, 2018). Outpatient services were the main concern of hospitals due to the tendency of the community (elderly) to seek treatment services Girianto, Setyorini, Untaminingtyas, Positif Correlation of Anxiety and the Interest of Elderly in Visiting … 51 that were practical once they come and on the same day receive complete services (one-day care). However, when the COVID-19 pandemic broke out, elderly outpatient visits decreased (Gugun et al., 2022). Therefore, the number of visits to health facilities for the elderly with comorbid diseases tends to decrease during the COVID-19 pandemic. The participation of the elderly in PTM posbindu activities during the pandemic has decreased due to excessive perceptions of COVID-19 (Nova et al., 2021). CONCLUSION Anxiety in the elderly with comorbid diseases was related to an interest in visiting health facilities during the COVID-19 pandemic with a weak correlation. This means that the more anxious the elderly are, the lower their interest in visiting health facilities, but other factors influence the interest in visiting health facilities for the comorbid elderly, including economic factors, the knowledge factor of the elderly, family support, and the distance between home and health facilities for the elderly. SUGGESTION The next researcher could improve and anticipate all the weaknesses that exist in this study on the dependent variable so that the instrument for the frequency of visits at health facilities uses the document observation method during the COVID- 19 pandemic. The variable of interest in visiting health facilities was influenced by several factors, one of which was the awareness of the elderly about their health. ACKNOWLEDGEMENT Pria W.R. Girianto, Dwi Setyorini, and Sri Untaminingtyas of the Bachelor Nursing Study Program, Karya Husada Kediri Institute of Health Science, prepared this journal article based on the report Elderly Interest in Visits to Health Facilities During the COVID-19 Pandemic Was Related to Anxiety. This work has been supported by the Bachelor Nursing Study Program at the Karya Husada Kediri Institute of Health Science. FUNDING This work has been funded by Bachelor Nursing Study Program under the programme of Research, and Community Service Grants 2021. The opinions expressed here in are those of the authors and do not necessarily reflect the views of funding agency. 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