The coronavirus disease (COVID-19) originated in Wuhan, China, towards the end of 2019, and by swiftly spreading across the world, in March 2020, it was declared a pandemic by the World Health Organization [1]. COVID-19 has impacted not only people’s physical health but also their mental health [2-4]. In this respect, it has been indicated that COVID-19 has had a detrimental impact on the mental health of people worldwide [5]. Another unfortunate consequence of the pandemic is that it has prevented the provision of adequate mental health services, particularly in developing countries [6] where access to mental health resources is already limited [7].

A recurrent emotional response, due to COVID-19, among people worldwide is fear of becoming infected or infecting others with the virus, fear of a loved one getting it and fear of death from this [8-12]. For instance, a survey of 439 participants from different countries (mostly from Europe and North America) has shown that the risk of loved ones becoming infected is a good predictor of fear of the virus [13]. When fear becomes irrational and excessive, it can be a crucial factor in the development of different mental health disorders [9, 13-15]. Among psychiatric disorders, the most prevalent ones are anxiety disorders [16]. During the COVID-19 era, many studies have indicated increased rates of anxiety, depression, and suicidal behaviors [17-21].

People living in poverty in developing countries are more vulnerable to mental health disorders [22]. In megacities of the developing world, many of the poor live in shantytowns located at the cities’ peripheries and, in many cases, have restricted access to public utilities. Also, residents of these deprived areas often lack proper education and have scarce employment opportunities. During the COVID-19 pandemic, literature is becoming available on the effects of the virus on the mental health of dwellers from these marginalized communities. A study carried out in two shantytowns in São Paolo, Brazil, has revealed that their residents with lower monthly income and moderate or severe food insecurity are more likely to show COVID-19 related psychological distress [23]. In Guatemala, research conducted in vulnerable communities has indicated that parents are at higher risk of showing greater levels of stress than non-parents [24]. The authors of the foregoing study have highlighted the need to implement prompt interventions considering the close relationship between parental stress and domestic violence and child abuse. Between June and July 2020, a study carried out in nine slums in Bangkok, Thailand, showed that the COVID-19-related stress of their residents was associated with their loss of income and self-quarantines [25]. In addition, some participants revealed fears of becoming infected with the virus and of being unable to maintain their already precarious livelihoods. Analysis of data from slum dwellers in Dhaka, Bangladesh, has revealed higher rates of anxiety and insomnia than pre-COVID-19 ones [26]. The Bangladeshi study has also shown that the fear of the participants of becoming infected with the virus is a strong predictor of anxiety and insomnia.

In this study, we aimed to further our understanding of the detrimental impact that COVID-19 is having on the mental health of the poor. Hence, a survey was administered to residents of households in four shantytowns in Lima, the Peruvian capital, to assess COVID-19-related anxiety and fear and their associated predictors.

The participants of the study were aged between 18 and 79 years, with an average age of 38.9 ± 13.9 years. A bit more than half of the sample comprised women (53.4%) while approximately half of the respondents indicated that they were living together with a partner (48.4%). The participants' highest educational achievement level was secondary school education, with 58.1% having completed this. When asked if they had a relative at home that was infected with COVID-19 before the fieldworkers’ visit or a relative at home who died of this, 40.6% and 36.4% of them responded positively, respectively. All sociodemographic characteristics of the sample can be seen in Table 1.

The independent variables that showed significant differences in anxiety were gender, marital status, educational level, occupation, whether a relative was infected with COVID-19 before the fieldworker’s visit and if a relative had died of the virus (Table 2). The overall mean anxiety score was of 7.3 ± 4.7 and a total of 367 (44.9%) participants showed anxiety levels beyond normal ones (≥ 9). In comparison to men, females experienced more anxiety, with a mean score of 9.1 ± 4.3. Those participants who were either married, illiterate or unemployed also had to endure more anxiety, with mean scores of 9.3 ± 5.2, 9.6 ± 3.1 and 9.0 ± 4.5, respectively. The two groups that affirmatively indicated whether a relative was infected with COVID-19 before the fieldworker’s visit and if a relative at home has died of the virus had the two highest mean anxiety scores, 10.1 ± 3.7 and 11.2 ± 3.5, respectively. The overall mean fear score was 19.8 ± 6.6, which was taken as the cutoff. A total of 308 (37.7%) reported high levels of fear. Table 2 also indicates that ages of the participants between 51 and 79 years, female gender, married, primary school education, unemployed, having a relative at home who was infected with COVID-19 before the fieldworker’s visit and having a relative at home who died of the virus had mean fear scores that were statistically significantly higher.

By using multiple logistic regression, the associated factors of anxiety and fear of COVID-19 are presented in Table 3. The first multivariate model showed that female gender (OR: 5.04, p < 0.001), single status (OR: 3.22, p < 0.001), being illiterate (OR: 18.86, p = 0.011), being a stable worker (OR: 8.77, p = 0.005) and occasional worker (OR: 32.58, p < 0.001), being unemployed (OR: 14.11, p < 0.001), having a relative infected with COVID-19 (OR: 98.14, p < 0.001) and having a relative at home that died of the virus (OR: 7.17, p < 0.001) were significantly associated with anxiety of COVID-19. The second multivariate model revealed that those aged between 31 and 50 years (OR: 4.10, p < 0.001) and between 51 and 79 years (OR: 4.43, p < 0.001), female gender (OR: 1.85, p = 0.01), being single (OR: 2.06, p = 0.005), being a student (OR: 3.80, p = 0.007), being unemployed (OR: 1.92, p = 0.01), having a relative infected with COVID-19 before the fieldworker’s visit (OR: 49.64, p < 0.001) and having a relative at home who died of the virus (OR: 1.83, p < 0.001) were significantly associated with fear of COVID-19.

People living in marginalized communities in developing countries are at greater risk of suffering from mental health issues [33, 34]. Stressors such as low levels of education, low income and high crime rates in these poverty-stricken places have been exacerbated due to COVID-19; hence, imposing a heavy burden on the mental health of their residents. In this study, we have investigated the anxiety and fear of COVID-19 among dwellers of four Peruvian shantytowns. In our sample, we have estimated that the prevalence rates of anxiety and fear of COVID-19 were 44.9% and 37.7%, respectively. The measured prevalence rate of anxiety was considerably high when considering those observed during previous virus epidemics such as MERS-CoV and H1N1 [35]. In this regard, recent studies have also pointed out that prevalence rates of anxiety and depression have increased from before to during the COVID-19 pandemic [36-39].

Our findings showed that older adults (≥ 51 years) had higher levels of fear than their younger counterparts. Older adults are the most vulnerable group to COVID-19 [40], particularly those with comorbidities [41, 42]. Since the outset of the pandemic, this information has been constantly conveyed to the general population by the media; thus, making older adults more fearful of the virus. A Bangladeshi study has pointed out that older adults who are unemployed, retired, or facing financial difficulties present more fear of the virus [43]. Moreover, it has been reported that many people in developed countries have not been able to get access to medicine or care [44], a situation which is aggravated among residents living in disadvantaged communities. Hence, it is likely that an aggregate of these factors, added to feelings of loneliness and isolation, due to the social distancing and intermittent lockdowns are causing the higher levels of fear observed among older adults.

Many studies have revealed that women are at higher odds of showing high levels of COVID-19-related fear [45-47] and anxiety [48-50]. Our work also agrees with the female gender being significantly positively associated with COVID-19-related anxiety and fear. Women are more distressed by adverse events [51], a situation which is further exacerbated among women living in slums and shantytowns. A recent study in northern India has shown that women from marginalized groups have stressed their fears of not having enough food to bring to their tables because of the reduction of their already meager incomes or total loss of these [52]. Among women, a risk factor for anxiety is the experience of traumatic events such as physical, psychological and sexual violence [51]. In the slums of Kampala, Uganda, reports of domestic violence have increased during the COVID-19 pandemic [53]. A female participant from the foregoing study revealed that her partner beat her up because she did not have money, and thus had nothing to eat at home. Water insecurity, which is a constant occurrence among disadvantaged communities in developing countries, is known to cause domestic violence as well [54]. To avoid this, women prioritize their partners’ water needs above theirs. In Peru, a national survey carried out between January and December 2020 reported that 54.8% of women aged between 15 and 49 had suffered from domestic violence [55].

The shantytown dwellers with single status in our sample were more likely to show fear and anxiety about COVID-19. Single individuals are more prone to use social media, where unfortunately, too much COVID-19-related misinformation is widespread. Misinformation added to sensationalism can trigger anxiety and fear [9]. Furthermore, among these individuals, a sense of loneliness is easier to arise, and it has been indicated that loneliness is a familiar risk factor for mental health issues such as anxiety and depression [56].

The COVID-19 pandemic has taken a heavy toll on day laborers in developing economies. For instance, millions of Bangladeshis working in the informal sector as construction workers, street vendors, transport workers or rickshaw pullers have lost their jobs due to COVID-19 [57]. In Chile, the unemployment rate among informal settlement residents has considerably increased from before to during the COVID-19 pandemic [58]. In relation to mental health issues, a Brazilian study carried out during the COVID-19 pandemic has shown that unemployed shantytown residents are at higher risk of phycological distress [23]. In our study, the unemployed shantytown dwellers were at higher odds of presenting more fear and anxiety about the virus. This is quite likely due to insecurity of being unable to find a new job, not providing enough food to their families and for themselves, and overall, of an uncertain future. It is important to consider that when not properly attended, anxiety can exacerbate suicidality in vulnerable individuals [59]. For example, a Bangladeshi auto-rickshaw driver in his 30s committed suicide because he could not make a living anymore due to a COVID-19 lockdown [60].

In the case of stable and occasional workers, our results have shown that they were more likely to present COVID-19-related anxiety. For them, there is not only a risk of infection at work but also on the way to and from work. A study in Japan revealed that commuting time, commuting distance and public transportation were positively associated with anxiety about becoming infected with COVID-19 [61]. Likewise, another study has shown that pregnant women in Israel who take public transportation presented high levels of COVID-19 related anxiety [62]. Big buses, medium-sized buses and vans (known in Peru as “combis”) make up a main part of Lima's public transportation system and are usually very crowded, even during the COVID-19 era. Added to this, some people that take public transportation do not follow the protective measures imposed by the Peruvian government (e.g., some do not adequately wear face masks or do not wear them at all). Therefore, it is no surprise that those shantytown dwellers who go to work daily or occasionally use public transportation are at higher odds of showing more anxiety about the virus.

Living with a relative that was infected, prior to the fieldworker’s visit, with COVID-19 was shown to be a good predictor of COVID-19-related anxiety and fear. The majority of Peruvian shantytowns lack access to proper water and sanitation services. Under these circumstances, having a family member at home suffering from moderate or severe COVID-19 symptoms such as fever and shortness of breath can be a very daunting experience. For instance, if an individual has a respiratory infection, it is suggested that they stay hydrated; in places where water accessibility is problematic, this recommendation is very difficult to meet [63]. Moreover, to care for patients with COVID-19 at home, it has been recommended to wash their bed linens, towels and dishes at least once a day [64]; once again, in marginalized communities where water is scarce, this is quite a difficult challenge. Hence, it is understandable that shantytown dwellers within our sample with a relative infected with COVID-19 are more likely to show fear of the virus. This agrees, for example, with a study in Turkey where it has been indicated that those individuals who had a relative infected with the virus were more fearful and anxious about it [65]. On the other hand, anxiety can be further intensified if a relative at home died of the virus; in this regard, families who have suffered the loss of a relative also experience great mental distress [9]. The latter agrees with our results that indicated that those individuals who had a relative at home who had died of the virus were at higher odds of showing more COVID-19-related fear and anxiety.

Recently, it has been reported that in Lima, only 12% of people with psychiatric disorders access mental health services [66]. Out of this percentage, how much represents those living in shantytowns and slums is, to the best of our knowledge, unknown; however, we suggest that it is quite low. Hence, strategies are urgently needed to address mental health issues among individuals living in these marginalized communities. A Peruvian study has indicated strategies such as telemedicine (e.g., online counseling meetings) and avoiding misinformation by following only official channels (e.g., Ministry of Health and local authorities) [67]. Another very important strategy is cash transfer programs, which have proven to be beneficial for the mental health of individuals living in marginalized communities in developing countries [68]. Economic support to address food security problems is an urgent need among shantytown dwellers, particularly considering that increased food insecurity may amplify psychosocial conditions that underlie anxiety [69]. Another recommendation is to stay connected with friends and family while maintaining a healthy relationship [48].

This study had three main limitations. One of them was its cross-sectional nature, which prevented us from establishing cause-and-effect relationships. Another one was that this study was carried out during the weekends. Finally, households with at least one member infected with COVID-19 during the period when the study was conducted were not considered due to safety measures.

Our study has revealed the associated predictors of anxiety and fear of COVID-19 among shantytown dwellers in Lima city. Those who were single, female, unemployed, with a relative at home who was infected with COVID-19 before the fieldworker’s visit and who had a relative who died of the virus were more likely to show COVID-19 related anxiety and fear. Also, stable and occasional workers are at higher odds of presenting anxiety about the virus. Severe consequences such as domestic violence and suicidality may arise within these vulnerable groups. Hence, there is an urgent need to provide targeted strategies to address mental health issues among them.