Increase in public interest concerning alternative medicine during the COVID-19 pandemic in Indonesia: a Google Trends study

Background: The COVID-19 pandemic has triggered individuals to increase their healthy behaviour in order to prevent transmission, including improving their immunity potentially through the use of alternative medicines. This study aimed to examine public interest on alternative medicine during the COVID-19 pandemic using Google Trends in Indonesia. Methods: Employing a quantitative study, the Spearman rank test was used to analyze the correlation between Google Relative Search Volume (RSV) of various search terms, within the categories of alternative medicine, herbal medicine and practical activity, with COVID-19 cases. In addition, time lag correlation was also investigated. Results: Public interest toward alternative medicine during COVID-19 pandemic in Indonesia is dramatically escalating. All search term categories (alternative medicine, medical herbal, and alternative medicine activities) were positively associated with COVID-19 cases (p<0.05). The terms ‘ ginger’ (r=0.6376), ‘ curcumin’ (r=0.6550) and ‘ planting ginger’ (0.6713) had the strongest correlation. Furthermore, time lag correlation between COVID-19 and Google RSV was also positively significant (p<0.05). Conclusion: Public interest concerning alternative medicine related terms dramatically increased after the first COVID-19 confirmed case was reported in Indonesia. Time lag correlation showed good performance using weekly data. The Indonesian Government will play an important role to provide and monitor information related to alternative medicine in order for the population to receive the maximum benefit.


Amendments from Version 1 • Tables:
We add up asterisk signs on p values < 0.05, there are ***significant at p<0.001, and ****significant at p<0.0001. We add up the detailed p-value based on suggestion from the reviewer.
• Introduction: Based on recommendations from the reviewers, we add up several references about alternative medicine, and remove "Currently, no vaccine has been developed for COVID-19" in the introduction section. . The data of COVID-19 case in Indonesia is also found in https://covid19.go.id/peta-sebaran, in which the data is integrated with the Indonesian Ministry of Health (MoH). The website (https://covid19.go.id/peta-sebaran) itself is published by COVID-19 Response Acceleration Task Force of Indonesia (RATF) that is directly created by Indonesian President to combat COVID-19 in Indonesia. Therefore, in order to create accessible data source in this article, we consider to use the data from RATF which is the data is integrate with previous website from MoH.
• Discussion: Based on suggestions and recommendations from the reviewers, we add up several references to support our discussion, and explain how this finding could improve disease surveillance. We also describe the limitation research, and give recommendations for further study. Besides, we change the subheading from "Statistical analysis" to "Correlation analysis results".

Introduction
The COVID-19 pandemic is a massive health crisis worldwide. Within seven months, it has affected 216 countries, and more than 11 million population have been infected by the SARS-COV-2 virus, which causes COVID-19 1  Alternative medicine in Indonesia is called Jamu and is well-known. It is commonly composed by herbal medicines, such as ginger and curcumin, which are extracted and added to water to be drinkable. Both ingredients and other methods of Jamu are accessible and available to the general population of Indonesia. Jamu is commonly used to preserve immunity, and it has existed hereditary 6 . Aditama 7 noted that 30.4% of total household in Indonesia used alternative medicine, in which this condition should be notice by Indonesian government in order to prevent alternative medicine misuse and misinformation during pandemic. Therefore, this study aimed to examine public interest concerning alternative medicines in Indonesia during the COVID-19 pandemic. Time lag scenarios were also investigated.

Methods
This was a quantitative study using secondary data from Indonesia. The data was obtained from Google Trends using Google Relative Search Volume (RSV) and COVID-19 case data. Google RSV presents information on how many terms have been searched at a particular time using the Google search engine, i.e. the data provides information about public interest towards a particular term 8 . A high RSV (maximum 100 points) indicates high public interest; while the lowest (0 points) shows an absence of public interest 9 . In this study, COVID-19 cases were defined as laboratory-confirmed cases positive for SARS-COV-2 virus as reported by the Indonesian Government, in which the case number refers to total daily case of COVID-19. On June 16 th 2020, the RSV data were retrieved from January 1 st 2019 to June 6 th 2020 weekly (total of 74 weeks; 2019: weeks 1-52, 2020: weeks 53-74). The setting of Google Trend was Indonesia as country, and all categories.

Data analysis
This study followed the methodology of previous studies 7,13 . After checking and cleaning the data, there was no missing data noted. The data was stored in Microsoft Excel 2010, and then transferred to STATA v13 (College Station, TX, USA) for analysis. Google RSV data was available weekly, and therefore COVID-19 case data was also analyzed weekly.
The data was not normally distributed, so Spearman rank test was used to examine the correlation between Google RSV and COVID-19 cases. Time lag correlation between Google RSV and COVID-19 was also analyzed, where the procedure referred to Husnayain et al. 13 and Torres-Reyne 14 . The significance level was set at 0.05.

COVID-19 cases and Google RSV
The pattern of COVID-19 case and Google RSV in Indonesia is visualized in Figure 1. Since the first confirmed COVID-19 case was reported in Indonesia on March 2 nd 2020 (week 61 of this study), COVID-19 cases have been increasing in Indonesia. According to the MoH, 30,514 confirmed cases of COVID-19 were reported during 14 weeks (March 2 nd -June 6 th 2020); mean weekly cases were recorded as ~315 cases.
A similar trend is shown for alternative medicine activities search terms ( Figure 1C). Before the pandemic (week 1-60) these terms had an RSV of 0-36 points. In week 61, the RSV increases ~2 fold higher.

Discussion
Since the first COVID-19 confirmed case was reported on March 2 nd 2020 (week 61), there have been a dramatic increases in cases in Indonesia. The mean weekly cases of COVID-19 is ~315 case (Figure 1), and we noted the highest case load reported on week 74 (4741 cases). We also show in our data that COVID-19 cases in Indonesia have increased by ~305% within 14 weeks (30,514 cases; Figure 1). This indicates a super-spread of COVID-19 in Indonesia. The high population and population mobility may take an essential role in intense COVID-19 transmission 15,16 .
Alternative medicine is one option for individuals to maintain and increase their immunity during the COVID-19 pandemic.
In our study, we found that the search activity of alternative medicine-related terms, including herbal medicine and activities surrounding alternative medicine, was low and steady before the pandemic (weeks 1-60  before the increase of COVID-19 cases in Indonesia. However, a strong correlation is detected at the present time (lag 0) compare to time lag scenario, particularly for the herbal medicine category. This study found that correlation analysis using weekly data of Google RSV compared to COVID-19 new cases in Indonesia showed good performance, which is collaborated by previous studies 9,19-23 . In addition, the moderate correlation occurs due to several factors, particularly public interest on alternative medicine term is high by intense exposure from mass media.
The trend of Google RSV for all search terms was higher during the pandemic. This indicates increasing public interest toward alternative medicine during the pandemic in Indonesia. This finding collaborates to Mavragani and Ochoa 24 , where monitoring online queries can provide insight into human behavior. Wise et al. 25 noted that awareness of the public related to the COVID-19 pandemic is elevated due to the risk posed by the virus, and the large number of available information sources serves to reinforce their protective behavior. Galankis 26 also reported that the public tend to search for information related to health either short-or long-term during the pandemic. Besides, Yuan et al. 27 reported association of internet search-interest with COVID-19 daily incidence and death in USA.
As a telemedicine, smartphone technology has important role in the current COVID-19 pandemic 28 . It contains web search that is a valuable resource for individuals and communities seeking health information or disease outbreaks, in which the search question includes geographical and timely information 29 . Google, as one of the search engines, will construct digital traces.
Google Trends data are highly related to traditional surveillance data 30,31 . It provides valuable source of information to investigate changes in disease patterns and health dynamics within populations using digital traces 32 . Indonesia itself has 53.7% of global internet usage 33 , and Google utilized is reported to be considerable at 98.3% 34 . Therefore, Google Trend became great alternative surveillance in Indonesia.
The Indonesian Government plays an important role in the high public interest toward alternative medicine during the pandemic. Actions concerning monitoring and providing valid information regarding alternative medicine to the public are urgently needed. These actions should prevent misuse of medical herbal among the public. In addition, information could be used to empower communities to provide self-remedial source at a household level, such as planting herbal medicines.
There are limitations in this study, namely: 1) The data time range is weekly. This condition occurs due to default setting in Google Trend, where the author retrieved the RSV data from January 1 st 2019 to June 6 th 2020, and the RSV appears weekly.
2) The author analyzes the trend of public interest on alternative medicine term in the early pandemic (14 weeks), where this is the latest COVID-19 update case since this study was written. Therefore, the author recommend further study is needed to analyze the trend of public interest on alternative medicine term during pandemic by using daily data on the current situation in Indonesia, with time series analysis. In addition, study to examine the government action to prevent misinformation and misused on alternative medicine-used during pandemic is also needed.

References
An interesting study also found that the Google Trend study cannot provide sociodemographic feature of user who search in Google, in which this condition may become challenging to examine public interest on particular search term by stratification of the population condition 35,36 .

Conclusion
Public interest on alternative medicine related-terms has dramatically increased during the early COVID-19 pandemic in Indonesia. Search terms relating to alternative medicine, herbal medicines and activities surrounding alternative medicines correlate positively with an increase of COVID-19 cases in Indonesia. This study recommends that the Indonesian Government take an active role in informing the public about alternative medicines, and monitoring and providing valid information. This may empower households to produce medical herbs independently.

2.
In Methods: Google Trends search: The time period was mentioned; but please mention the other filters: country (Indonesia?), categories (All categories or Health?).

3.
r > 0.7 indicates strong correlation. Please mention this and revise thoroughly the manuscript particularly for the word 'strong correlation'.

4.
In the Results: Please change the name of subheading "Statistical analysis". It was generally used in the Methods section. You may change "Correlation analysis results", or something appropriate.

5.
For your further studies, I suggest to consider performing time series analysis. 6.
Please discuss limitations of the study. The authors may refer following papers for limitations 4 , 5 .

If applicable, is the statistical analysis and its interpretation appropriate? Yes
Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes you for your suggestion 2. In Methods: Please add when the Google Trends database searched: E.g. On 11 February 2021, Google Trends data were retrieved from...

Response:
Sure, we applied this recommendation.
3. In Methods: Google Trends search: The time period was mentioned; but please mention the other filters: country (Indonesia?), categories (All categories or Health?).

Response:
Sure, we applied this recommendation 4. r > 0.7 indicates strong correlation. Please mention this and revise thoroughly the manuscript particularly for the word 'strong correlation'. Response: Sure.
5. In the Results: Please change the name of subheading "Statistical analysis". It was generally used in the Methods section. You may change "Correlation analysis results", or something appropriate. Response: Sure.
6. For your further studies, I suggest to consider performing time series analysis. Response: Sure, it become our recommendation for further study. Thank you for your suggestion. 7. Please discuss limitations of the study. The authors may refer following papers for limitations 4 , 5 . Response: Thank you. We had added this literature as our reference in order to describe limitation on our study. 8. Conclusion: Please add "early": "during the early COVID-19 pandemic".
In the latest version of our manuscript is revised based on your recommendation. Thank you for your review.

If applicable, is the statistical analysis and its interpretation appropriate? Yes
Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes © 2020 Zhang L. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Lanjing Zhang
Department of Biological Sciences, Rutgers University, Newark, NJ, USA This is an interesting article focused on the links between google search trend and daily incidence of COVID-19 in Indonesia. The findings appear novel since my search of the literature shows no similar works in the Pubmed. However, I have the following concerns: Major: The correlation coefficients appeared moderate (about 0.5-0.6). This low degree of correlation should be addressed. One of the approaches is to correlate the keyword with the google trend. If such a correlation is moderate (in Indonesia), the correlation coefficient become acceptable. Of course, some discussions are needed even so.

1.
Literature review is less comprehensive. It could be improved by citing related articles 1 , 2 , 3 and others.
368-369 PubMed Abstract | Publisher Full Text 3. Iyengar K, Upadhyaya GK, Vaishya R, Jain V: COVID-19 and applications of smartphone technology in the current pandemic.Diabetes Metab Syndr. 14 (5): 733-737 PubMed Abstract | Publisher Full Text Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Yes

If applicable, is the statistical analysis and its interpretation appropriate? Partly
Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes