Introduction
The coronavirus disease 2019 (COVID-19) has infected more than 250 million people worldwide and caused more than 5 million deaths [2]. Older adults are at higher risk of contracting this disease and its complications compared to other age groups [4]. One of the psychological aspects of the COVID-19 pandemic is fear [4]. Many elderly people are known to be more vulnerable to COVID-19 due to underlying diseases. This can cause fear and panic for them [9]. One of the variables affecting the level of fear in the elderly is spiritual well-being [16]. The present study aims to assess the protective role of spiritual well-being on the fear of COVID-19 in the elderly in Qazvin, Iran.
Methods
This descriptive cross-sectional study was conducted on 400 older adults aged ≥60 years living in Qazvin, Iran. The participants were selected by a cluster sampling method. First, Qazvin was divided into three urban areas (clusters). From each cluster, about 130-135 eligible elderly people were recruited from public areas such as mosques, parks, and day care centers. In each cluster, two parks and four mosques were randomly selected. The members of two elderly day care centers were also participated in the study. Inclusion criteria were willingness to participate in the study, age 60 years and above, and the ability to communicate. To collect data, a demographic questionnaire, the fear of COVID-19 scale, and Paloutzian and Ellison’s spiritual well-being scale were used. Data analysis was done in SPSS software, version 24. The obtained data were described by descriptive statistics. To determine the predictors of the fear of COVID-19, first a univariate regression analysis was used. Then, the variables that had a significant relationship with the fear of COVID-19 were entered into multivariable regression model. A significance level of P≤0.05 was considered.
Results
The mean age of the elderly was 69.70 ± 6.99 years. Most of them were married (53.5%), living with their spouses and children (52%) and had a moderate economic status (62.8%). The most common physical diseases in the elderly were vision problems (28%), hypertension (27.5%), heart disease (21.8%) and diabetes (20.5%). According to the results, the mean score of fear of COVID-19 was 22‌±‌8.82, which was relatively high. In addition, most of the elderly (69%) had moderate spiritual well-being. According to the results in Table 1, sex (β=0.186), history of hypertension (β=0.130), history of diabetes (β=0.097), history of stroke (β=0.091), education level (β=-0.142), economic status (β=0.145) and spiritual well-being (β=-0.117) were predictors of fear of COVID-19 in the elderly.


Older women reported higher fear than older men. Also, illiterate elderly compared to those with high school education and above, those with moderate economic status compared to those with high economic status, and those with high blood pressure, diabetes and stroke, had higher fear of COVID-19. Furthermore, the elderly with high spiritual well-being reported lower fear.
Discussion
The results of the present study, in line with the results of Gokseven et al. [6] and Mistry et al. [7], showed that the fear of COVID-19 in the elderly in Qazvin city was relatively high. Probably, the increase in the number of deaths caused by this disease and the spread of its news in the social media, and on the other hand, the lack of definitive treatment for COVID-19, were effective in increasing the fear in the elderly. The results of the present study, in line with the results of Durmuş et al. [16] and Kasapoğlu [29], showed a significant negative relationship between spiritual well-being and fear of COVID-19. Spiritual well-being can provide social support for people, which can also reduce fear and anxiety and create peace [34]. By identifying the spiritual needs of elderly patients, especially the elderly with chronic diseases, health workers and caregivers can provide suitable situations to improve their spiritual well-being and reduce their fear and anxiety during the pandemic.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by Ethics Committee of Qazvin University of Medical Sciences (Code: IR.QUMS.REC.1399.286). After explaining the study objectives to the participants and assuring them of the confidentiality of their information, informed consent was obtained from them.

Funding
This study was funded by Qazvin University of Medical Sciences.

Authors' contributions
Conceptualization, methodology, investigation, initial draft preparation, editing & review, resources: All authors; data analysis and project administration: Seyedeh Ameneh Motalebi; 

Conflicts of interest
The authors declare no conflict of interest.

Acknowledgements
The authors would like to thank the Vice-Chancellor for Research of Qazvin University of Medical Sciences and all seniors participated in this study for their support and cooperation.


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