Health literacy on COVID-19 and COVID-19 vaccinations in Indonesia

Introduction

Since the COVID-19 pandemic, the spread of vast information on this topic has increased, including vaccines and vaccinations.^1,2 One must filter this information wisely to avoid fake news that might compromise the acceptance towards the COVID-19 vaccines and vaccinations.³ On the other hand, literacy levels on these subjects will also affect the opinion and personal beliefs when facing the issue.⁴ In the ongoing development of COVID-19 vaccinations and vaccines, evidence-based data released in a real-time fashion may lead to conflict when comprehended with no further authorized confirmation. In the study by Harisanty et al. (2021), it was reported that the digital literacy level of COVID-19 amongst 500 respondents in east Java, Indonesia was 3.69 and represented a good average level.^5–7 These data are valuable to the decision-makers party to understand public sentiment and thus act accordingly to contain the pandemic.⁶ The current study aimed to determine and compare public opinion and sentiments on COVID-19, COVID-19 vaccines, and vaccinations before and after the national vaccinations program was held in Indonesia (in January 2021). These data represent the health literacy on the subjects implicating people’s skills and knowledge to gain and to use this information accordingly, which is critically valuable amidst a pandemic.^7,8

The primary aim of this cross-sectional study was to elucidate the levels of public health literacy on COVID-19, COVID-19 vaccines and vaccinations in all regions of Indonesian (West, Central and East regions, respectively), which have yet to be analyzed largely based on specific age and sex groups. Here we assessed the respondents’ functional, and critical/interactive-literacy, the individual perceptions and acceptance toward COVID-19 vaccines and vaccinations, individual perception and acceptance towards other vaccinations, individual’s belief towards health protocols and COVID-19 vaccinations safety and effectiveness, and the accessibility and usage of internet and social media to gain information related to COVID-19; to determine whether there have been gaps in the health literacy levels between groups and significant relations with the sociodemographic characteristics.

Methods

This study was conducted in compliance with the Declaration of Helsinki (revised 2013 edition), the CHERRIES (Checklist for Reporting Results of Internet E-Survey), and STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines.^9–11 The principal objective of this cross-sectional study was to determine the levels of health literacy about COVID-19 vaccines and vaccinations (Vaccines and Vaccinations literacy-VL) in the Indonesian adult general population via a rapid survey distributed via the internet. Another objective was to assess the perceptions of the respondents about current adult immunization and beliefs about vaccinations in general, whilst analyzing their ability to seek and use information from the internet and social media; also to study any correlations of these variables with VL levels.

Results

A total of 1153 respondents gave responses, however, 10 of them declined to finish the survey due to technical matters, hence the number of total respondents included in our analysis was 1143. The responses were collected during the 12 weeks, starting September 2, 2021, mainly via social media and email. Most of the participants (n=512; 44.79%) answered during the second week. From Table 1, it was shown that the Q12, Q14, Q15 (questions to identify functional VL) had a strong effect on principal component 2; whilst Q16-Q21 (questions to identify interactive' critical-VL) showed a moderate to strong effect on the principal component 1. Responses to functional- and interactive/critical-VL questions exhibited good/acceptable internal consistency (Cronbach’s alpha=0.817 and 0.699, respectively), lowest values observed were 0.806 for functional scale and 0.640 for the interactive-critical scale. PCA analysis demonstrated two components accounting for 52.45% of the total variability. A varimax rotation was applied to determine relationship between items and showed that all functional VL questions were affluent on one component, whereas all interactive-critical questions were sided on the other component. The two distinguished factors loaded on the questions in each component could be discerned as predicted, i.e., close relation was observed between the questions inside each of the functional scale and of the interactive-critical one (Figure 1, Table 1).

Figure 1. Principal Component Analysis (PCA): circle correlation between questions and components after Varimax rotation.

Projection of functional VL questions (Q12, Q14, Q15) and interactive-critical VL questions (Q16-Q21) on two components (Factor 1 and Factor 2). Variables that are close to each other are significantly positively correlated.

Approximately 60% of respondents were females (n=686) and the rests were males (n=457). Most respondents were 18-30 years (57%, n=652), 36.2% were 31-50 years (n=414), 4.5% were 51-59 years (n=51) and only 2.3% were above 59 years (n=26). The education levels were mostly at the secondary stage (52.6%, n=601), 34.4% were at the primary level (n=393), 10.6% (n=121) were at the tertiary level, and the rests were either at the lesser degree or others. The university students were the predominant respondents (40.2%, n=460), followed by employees of the private sectors (23.9%, n=273), the civil servants (13.6%, n=155), entrepreneurs (6.6%, n=75) and others (15.7%, n=180). Respondents were mostly from Western-Indonesia (89%, n=1017), whilst only 8.6% (n=98) and 2.4% (n=28) were from the Central and Eastern-Indonesia. Most of respondents had a middle average of family income (34.7%, n=397 and 30.5%, n=349), 9.7 % (n=225) and 12.5% (n=143) had lower income, and 2.5% had a high income (n=29). About 57% (n=652) of all respondents had financial difficulty during the pandemic and 43% had no financial problem (n=491). There were 65.9% (n=753) respondents claimed that they or their household members had not been contracted COVID-19, whilst 34.1% (n=390) had been positively confirmed (Table 2).

Most of respondents claimed that they had no comorbidities (81.7%, n=934), 9.9% (n=113) stated that they do not know if they had comorbidities; the rests stated they had one or more comorbidity i.e. respiratory-related diseases (3.4%, n=39), controlled-hypertension (3.1%, n=36), 1.6% stated to have uncontrolled-hypertension (n=18), controlled-T2DM (1.3%, n=15), uncontrolled-T2DM (0.7%, n=8), autoimmune diseases (3.4%, n=39), under-treatment-cancer (0.6%, n=7), untreated cancer (0.4%, n=5), neurological diseases (1%, n=12), 0.3% with mental illness (n=3), 0.3% (n=4) with congenital diseases and the rests claimed to have hypercholesterolemia, hyper-uremia, heart diseases, etc. (3.7%, n=43) (Table 3).

There were 63.8% of respondents often use internet to search for information on COVID-19 and/or COVID-19 vaccinations (n=729), 33.2% were sometimes (n=380) and 3% never used it (n=34). Approximately 62.4% of respondents have social media account and had been using it often to engage to these topics (n=713), 33.2% (n=379) only sometimes, whilst 4.5% (n=51) never. About 74.4% (n=850) respondents sometimes believed these information, 19.1% (n=218) often, and 6.6% (n=75) had never been (Table 4).

Correlation of VL with other variables

The correlations between functional-VL with either education level or the age group were negative, with significance showed with the latter (r=-0.022, p=0.448 and r=-0.68, p=0.022). The interactive/critical-VL had significant correlations with both education level and the age group (r=0.109, p≤0.001 and r=-0.062, p=0.037). Significant correlations were found between the functional-VL and the interactive/critical-VL (r=0. 084, p=0.005) (Figures 2-3).

Figure 2. Observed functional Vaccines Literacy (VL) scores, visualized as mean and 95% CI (error bars), according to age groups.

Figure 3. Observed interactive-critical Vaccines Literacy (VL) scores, visualized as mean and 95% CI (error bars), according to age groups.

Discussion

Coronavirus disease 2019 (COVID-19) has become a worldwide challenge that has affected the health systems of many countries, including Indonesia.^15,17 SARS-CoV-2 mutated virus produces variants with dynamic responses to available vaccines.¹⁸ Although research is still emerging, the reported data show that people with chronic and comorbid illnesses are highly susceptible to COVID-19,^19,20 and experience higher levels of disease severity when they get infected.^21–23 Antiviral treatments and vaccines that are proven to be fully effective against viral mutations are under ongoing development.^24,25 Various scientific studies continue to grow every day; however, the research results are still mixed and often raise questions in the community.^26,27 The need to master the skill to understand, access, and act accordingly based on valid health information (health literacy) is emerging to be a vital psychosocial factor of health outcomes, determined by sociodemographic characteristics i.e., age, ethnicity, and economic levels.^7,28 The proposed effective way to contain this problem is to build good health literacy about COVID-19 and COVID-19 vaccinations, including via this online survey, as the public can contribute to the preventive and promotive measurement by protecting themselves while protecting others, to halt the spread of COVID-19.^27,29 As a result, health literacy is crucial because it becomes the centre value in filtering information about COVID-19 and COVID-19 vaccinations. Access to this information also plays a vital role in the level of health literacy,^30–32 although hoaxes can produce misunderstandings.^33,34

As an archipelago, Indonesia has a geographical disparity with cultural diversity that influences values and behaviour in facing external challenges i.e., COVID-19.^15,35 In addition, socioeconomic and educational levels determine literacy.³⁶ Individual compliance to health protocols, including physical distancing, voluntary screening tests, self-isolation if infected, face mask use in public places, and hand sanitation are various.^16,37 Together with the national vaccinations program, the infection rate has decreased by more than 90% since July 2021 when the Delta variant began to strike.³⁸ Restriction measures are applied by requiring returning travellers to do a quarantine, restricting public recreational places, non-essential sectors, offices, and schools to implement emergency micro-based social activity restrictions (PPKM) since 2020.³⁹ However, the disparity of engagement levels in these efforts might produce hotspots with additional waves of mutated-virus infection, certain clusters might be suffering more severely affected by COVID-19.^40,41

This rapid-on-line survey was responded predominantly by female participants and the age group between 18-50 years. They mostly graduated from the primary and secondary education levels, and this was presented in the predominant occupation of the respondents were university students, while private and public employees came next. The lack of direct promotion and distribution of the online survey during the pandemic might be the reason of the predominant respondents were from Java, Sumatra, and Kalimantan than from other regions i.e. Sulawesi, Maluku, Bali, Nusa Tenggara, and Papua.⁴² However, this could serve the purpose of this study to capture the data from where the highest incidence of COVID-19 was reported from that was in Western Indonesia. The monthly family income was mostly at between 2-24 million (IDR), which is classified as a middle-class economy, this could be affected by the pandemic as stated by more than half of respondents who also claimed that this pandemic had struck at least one of their household family members.

Approximately more than 80% of all respondents stated that they were free from any comorbidity i.e., respiratory-related diseases (asthma, COPD), hypertension, cancer, T2DM, psycho-neurology disorders, congenital abnormality, metabolic syndrome, and other pathological conditions, although about 10% was aware of these comorbidities. During the pandemic, an increasing number of people relied on the internet and social media to obtain information about COVID-19. In our study, we found that all respondents used the internet to seek information regarding COVID-19 and COVID-19 vaccinations, amongst these, they used at least one social media actively, with a high percentage of respondents sometimes believing the validity of this information (74.4%).^43,44

From the maximum number of the Likert scale of the vaccines literacy (VL), we observed high scores in both functional- and interactive/critical-VL where these were quite in a balance between sexes in the prior VL and higher in females for the latter. Perception and acceptance toward COVID-19 vaccines and vaccinations were generally positive shown from the predominant good responses on the safety and effectiveness of the vaccines and from the willingness to be vaccinated. However, when asked to pay for the vaccinations, almost half of the respondents disagreed (47.8%), 20.4% were still in doubt, whilst the other 39.7% agreed. More than 80% of respondents agreed that school-aged children must be vaccinated against COVID-19; 45% agreed that certain vaccine brands have more safety and effectiveness than the others (mostly due to the RNA-based vs. weakened- and/or killed virus-based vaccines) whilst about 47% respondents felt more self-assurance after they read the information on certain vaccines via internet. The acceptance on the information regarding these topics was higher when coming from the authority than the internet (65.4% vs. 47%); acceptance toward COVID-19 vaccinations was significantly correlated with both functional- and interactive/critical-VL but not significantly related to either education level or the age group. These data showed us that even though lots of people seek information using the internet, whilst might decrease their anxiety about the unknown part of COVID-19 vaccines and vaccinations, the validity of the information is questionable and they preferred the information from the authority.^45,46 Here, perception and acceptance of COVID-19 vaccines and vaccinations of Indonesian people were shown to have more strong correlation with the interactive/critical-VL rather than the functional-VL or other socio-demography characteristics i.e., sex and age group.³⁸

The disagreement of getting COVID-19 vaccinations due to its safety and/or effectiveness also due to the belief in natural immunity was quite low, whilst most respondents agreed at the value of conducting health protocols regardless of the vaccination states. The first two statements' perception and belief were significantly correlated with the functional VL and the interactive/critical VL, while the last statement was only significantly correlated with the functional VL. Arguably, the values play a vital role in facing the pandemic and speeding up the national vaccinations coverage that has started since the beginning of 2021 in Indonesia.^47,48 More respondents had been vaccinated against various infectious diseases, although only about 17.3% had been vaccinated for the influenza. Only about 10-18% of respondents claimed their intention to have these vaccinations again in the next season; these were significantly correlated with the interactive/ critical-VL and sex. These data might show us that most healthy persons had relatively low literacy on this topic; these vaccinations have more frequently done amongst school-age children than adults in Indonesia. Previous study on the consumption of supplements during the COVID-19 pandemic in Indonesia found that these behaviours was influenced by education, age, family income, and family expense.⁴⁹ We observed that both VL were significantly correlated with the age group, the highest was found in the 18-50 years age groups; whilst the interactive/critical-VL had a parallel and significant correlation with the education level.

To the best of our knowledge, this study is the first to analyze health literacy on COVID-19 and COVID-19 vaccines and vaccinations. The current study was carried out in a period between the first and the second dose of the COVID-19 vaccinations program was running. The results would be valuable for implementing boosters involving large populations where further studies are called. The VL has been used to show health literacy on various studies. Here it represented people's acceptance, perception and attitude towards COVID-19 and its vaccinations. The hesitance to the vaccinations was shown due to i.e., personal belief and knowledge, willingness-to-pay, accessibility, and the influence from the community and the authority. A vast amount of information on COVID-19 potentially confused people to the extent of believing or rejecting all news related to the disease.⁵⁰ Health literacy can assist people in filtering and finding correct information and then using these accordingly; including logically reason the vaccinations and health protocols.^12,51,52 Health education must be adjusted according to local wisdom and condition to meet the needs of diverse clusters hence could bridge the gap in the community with various health literacy.^6,50

This study adapted the convenience sampling in which university students were the predominant respondents. This was due to the practical reasons that these respondents are the most likely ones who regularly use the internet and social media and were familiar with the online survey. Another limitation is that the respondent’s demography was mostly from Java and least from the eastern part of Indonesia. Self-claimed responses might affect the generalization of study results. However, the PCA of both VL scales showed good internal consistency and component loading.

Furthermore, findings from the current study are valuable due to its topics and the relatively broad range of respondents in terms of education levels and family income can represent most part of the population; levels of VL and their associations to various independents variables were comparable to other similar studies, validated using direct interview methods. Uneven levels of health literacy are an adverse situation that might slow the successful rate against the pandemic. Further studies are needed especially on the comprehension of the importance of vaccinations and health protocols that can help people to adapt to the new normal era.

Conclusions

A self-stated online survey conducted in the current study can provide reliable data on the level of health literacy of quite a large sample population distributed in different islands. The findings of this study could help community and decision-maker parties prepare communication and action strategies to cope with the pandemic. The VL levels of all respondents showed strong relationships with the individual perception, belief, and acceptance toward vaccinations and health protocols. Valid information regarding COVID-19 from authority are called for and could help the public to act accordingly.