p-ISSN 1693-5683; e-ISSN 2527-7146 60 Vol. 20, No. 1, May 2023, pp. 60-69 Research Article E-Health Literacy and Adherence to Health Protocols Among Self- Quarantined Patients with COVID-19 in a Sub-district in West Java Hesty Utami Ramadaniati*, Sondang Khairani, Nurul Azizah Department of Clinical and Community Pharmacy, Faculty of Pharmacy, Pancasila University, Srengseng Sawah Jagakarsa, South Jakarta, Indonesia 12640 https://doi.org/10.24071/jpsc.004176 J. Pharm. Sci. Community, 2023, 20(1), 60-69 Article Info ABSTRACT Received: 14-01-2022 Revised: 07-09-2022 Accepted: 13-09-2022 *Corresponding author: Hesty Utami Ramadaniati email: hesty.utami@univpancasila.ac.id Keywords: COVID-19; electronic health literacy; health protocol; self-quarantine During the Coronavirus Disease-2019 (COVID-19) pandemic, valid information was crucial and electronic health literacy (EHL) plays a significant role in public adherence to health protocols. This study aimed to evaluate the pattern of COVID-19 information-seeking, and the association between EHL, COVID-19 knowledge, and health protocol adherence among patients with COVID-19 during self- quarantine. Data were collected through an online survey sent to self- quarantined COVID-19 patients during March – December 2020 in a sub-district in West Java. Spearman tests were used to evaluate the relationship between EHL with COVID-19 knowledge, and EHL with health protocol adherence. There were 56 respondents with more than half being female (58.9%), university graduates (64.3%) and having good health status level (57.1%). Social media were the commonest online sources. During self-isolation, the frequency of Internet use increased (i.e., every day) with information on vitamins and supplements as the most commonly searched. Respondents had high scores on EHL (mean= 20.0), knowledge (mean = 8.89/10, SD = 1.796), and adherence (mean = 26.98/30, SD = 3.066). This study found significant relationships between EHL and knowledge (p-value = 0.001, r = 0.436), and the adherence (p-value = 0.011, r = 0.339). In conclusion, EHL had a modest influence on COVID-19 knowledge and minor relationship with adherence to health protocols among self- quarantined patients with COVID-19. INTRODUCTION The Coronavirus Disease-2019 (COVID- 19) has spread rapidly worldwide since early 2020 leading to an unprecedented global public health disaster. In the Indonesian context, this infectious disease emerged in March 2020 and since then there was an increased trend in prevalence until July 2021 and again in mid- 2022. Since September 2021 for about 6 months, the number of active cases and the daily cases decreased considerably (World Health Organization Indonesia, 2021; The Indonesian COVID-19 Task Force, 2021). The emergence of this new disease has created massive information seeking to gather vast amounts of COVID-19 related information, e.g. nature of disease, preventive measures and treatment management (Dadaczynski et al., 2021). Internet-resourced information has been one of major references among the public to address emerging health issues including COVID-19. This fact is not surprising given the increased public concern to restrict mobility to prevent the transmission. High utilization of digital platforms to access COVID-19 information has also been documented in Indonesia (Nugroho et al., 2021). It is evident that Indonesia is one of the countries with the highest number of Internet active users. There were 202.6 million active users as of January 2021 which had increased by 16% compared to the previous year. Indonesians used approximately eight hours per day on the Internet and more than one-third of the screen http://issn.pdii.lipi.go.id/issn.cgi?daftar&1180428136&1&& http://issn.pdii.lipi.go.id/issn.cgi?daftar&1465346481&1&& https://e-journal.usd.ac.id/index.php/JFSK/index https://creativecommons.org/licenses/by/4.0/ Journal of Pharmaceutical Sciences and Community E-Health Literacy and Adherence ... Research Article 61 Ramadaniati et al. J. Pharm. Sci. Community, 2023, 20(1), 60-69 time was spent on social media (Nurhayati-Wolff, 2021). Nonetheless, quality of digital health information varied so it is necessary to engage and empower public to have accurate health literacy. Indeed, the provision of accurate and quality online information is not adequate if not complemented with the measures to improve public electronic health literacy (EHL) (Chong et al., 2020). EHL refers to the ability to search, critically appraise the online information and accordingly use the information in making sound health decisions (Norman et al., 2006) It is vital to note that the sheer volume of COVID-19 information may lead to an “infodemic”, a term used to signify rapid spread of misinformation through social media applications and other digital platforms. Massive distribution of information asymmetry may result in false beliefs of COVID-19 related information and inappropriate behaviors jeopardizing the government efforts to contain the outbreak (Centers for Disease Control and Prevention, 2021). The pace of the COVID-19 infodemic might spread faster than the disease itself, but the extent of public health literacy in responding to the pandemic remains inconclusive. During the COVID-19 pandemic, valid information is crucial and EHL might play a significant role to influence public knowledge and their adherence to health protocols. Some previous studies demonstrated that health literacy related to digital information might provide the skills to differentiate the accuracy of the information from varying digital platforms and more knowledge on health information in general with the similar context to COVID-19 (Norman et al., 2006; Zarocostas, 2020). A systematic review conducted by Jacobs and colleagues highlighted the positive role EHL in improving health knowledge (Jacobs et al., 2016). Further, EHL is expectedly to be correlated with the improved practice to implement health behaviors as an essential part of preventive measures (Squiers et al., 2012). Indonesian government has launched a campaign called “3M” since the beginning of the pandemic to control the disease across the country. 3M refers to the precautionary actions to prevent the COVID-19 transmission i.e., wearing mask, washing hand regularly with soap/hand sanitizer and maintaining physical distancing. In addition, the government has updated the campaign into “5M” by incorporating two other actions, namely restricting people’s mobility and avoiding crowded public places (Djalante et al., 2020, The Ministry of Health of Indonesia, 2020). Some studies indicated that EHL can motivate individuals to practice healthy behavior in general, not specifically relevant to COVID-19 management supporting behavior (Nugroho et al., 2021; Britt et al., 2017; Ajzen, 2011). Nevertheless, the relationship between EHL and COVID-19 specific knowledge, and the influence of EHL on behavior to implement COVID-19 health protocol were supported by little evidence. Thus, this study aimed to explore the pattern of COVID-19 information-seeking among self-quarantined patients with COVID-19 and their level of EHL. In addition, this study analyzed the association between EHL with COVID-19 knowledge, and between EHL with health protocol adherence. METHODS Study Design and Sample A cross-sectional study with purposive sampling was conducted in a sub-district in West Java during March – December 2020. The study site was considered as a COVID-19 red zone during the data collection. The inclusion criteria of the respondents were COVID-19 patients aged >18 years old who underwent self-quarantine during the study period and their data were registered in the sub-district primary health center (PHC). The respondents were excluded if they disagreed to participate in the study. Total sampling approach was used to determine the sample size. Based on the preliminary data from the study site, there were approximately 156 potential respondents. The study was granted permission from the District Health Office and approved by the appropriate Institutional Ethics Committee (No: 174/IV/2021/KEPK). Informed consent was obtained from the respondents and participation was completely voluntary. Data collection and analysis An online questionnaire was distributed to potential respondents. The database of patients meeting the inclusion criteria was obtained from the assigned PHC. The questionnaire was disseminated through the WhatsApp® application to collect data from respondents. A set of questionnaires was adopted from some studies (Norman et al., 2006; Saefi et al., 2020) to assess patients’ EHL, COVID-19 knowledge and adherence to health protocols. Validity and reliability of the questionnaire was assessed using 45 self-quarantined patients with COVID- 19 in other sub-districts. Validity of the questionnaire was determined valid (calculated r/correlation coefficient for each questionnaire item > r table) and reliability was considered Research Article Journal of Pharmaceutical Sciences and Community E-Health Literacy and Adherence ... 62 Ramadaniati et al. J. Pharm. Sci. Community, 2023, 20(1), 60-69 adequate (Cronbach’s alpha = 0.840). The questionnaire consisted of four sections. Section 1 collected information on patients’ socio- demographic characteristics and the pattern of COVID-19 information seeking. Section 2 comprised of 5 questions to rate patients’ EHL level using the electronic Health Literacy Scale (eHEALS) with five answer choices (‘strongly agree’, ‘agree’, slightly disagree’, ‘disagree’, ‘strongly disagree’). Answers from each EHL question were totaled and median value was calculated. EHL status was categorized into ‘good EHL’ (patients’ median EHL ≥ questionnaire median i.e., 15) and ‘poor EHL’ (median EHL < questionnaire median i.e., 15). Section 3 was comprised of 10 questions with ‘true’ and ‘false’ answer choices to assess patients’ knowledge on COVID-19. Knowledge level of patients were rated using scores ranging from 0-10 and patients were categorized into three ranks: good knowledge (score of 7.6-10), fair (5.6-7.5) and poor (<5.5). Section 4 contained 10 questions with a 3-point Likert scale: (‘always’, ‘sometimes’, and ‘never’) to rate patients’ adherence to health protocol before and during self-isolation. Answers from each question were summed up to get the total adherence score and mean value was calculated. Based on the score, adherence status was categorized into ‘good adherence’ (mean adherence score > median value i.e., 20) and ‘poor adherence’ (mean adherence score < median value). The questionnaire required approximately 10-15 minutes to complete. Descriptive analysis was conducted to determine patterns of online information- seeking for COVID-19, EHL score, COVID-19 knowledge, and health protocol adherence. Spearman test was used to evaluate the relationship between EHL and COVID-19 knowledge, and EHL and health protocol adherence. Statistical significance was established at p<0.05 for the test. RESULT AND DISCUSSION There were 56 respondents who participated in this study. The sociodemographic characteristics of the respondents are detailed in Table 1, which shows more than half of the respondents were female (N=33, 58.9%), graduated from university as the highest education level (N=36, 64.3%). Just over 60% of the respondents were employees and approximately half of them earned IDR 5-10 million per month. Interestingly, nearly all respondents perceived their health status as good and very good. Self-rated health status is commonly used to examine someone’s overall health at a given point in time underlining the broad picture of a person’s current health status (Wuorela et al., 2020). Table 1. Sociodemographic Characteristics of the Respondents (N=56) Characteristics No. (%) Gender Male Female 23 (41.1) 33 (58.9) Age (years) 18 - 25 26 - 33 34 - 41 42 - 49 ≥ 50 13 (23.2) 18 (32.1) 16 (28.6) 7 (12.5) 2 (3.6) Education level Elementary Secondary Tertiary 1 (1.7) 19 (33.9) 36 (64.3) Employment status Unemployed Self-employed Employee 13 (23.2) 9 (16.1) 34 (60.7) Monthly Income (IDR) < 5 million 5 – 10 million >10 million 23 (41.1) 29 (51.8) 4 (7.1) Self-assessed health status Very good Good Fair 23 (41.1) 32 (57.1) 1 (1.7) Journal of Pharmaceutical Sciences and Community E-Health Literacy and Adherence ... Research Article 63 Ramadaniati et al. J. Pharm. Sci. Community, 2023, 20(1), 60-69 Table 2. Type of COVID-19 Online Information Navigated by Respondents Prior to and During Self- Quarantine Type of COVID-19 Information Prior to Self-Quarantine No. (%) During Self-Quarantine No. (%) Symptoms of the disease 45 (80.4) 43 (76.8) Preventive measures 36 (64.3) 35 (62.5) Treatment 33 (58.9) 44 (78.6) Self-isolation procedures 24 (42.9) 38 (67.9) Laboratory testing 15 (26.8) 21 (37.5) Vitamin and Supplement 39 (69.6) 45 (80.4) Herbal medicine 16 (28.6) 25 (44.6) Long-term effect of the disease 1 (1.8) 1 (1.8) Table 3. eHealth literacy Scale (N=56) Questions Strongly agree N (%) Agree N (%) Slightly disagree N (%) Disagree N (%) Strongly disagree N (%) Q1. I know how to use the internet to answer my questions about health 15 (26.8) 40 (71.4) 0 1 (1.7) 0 Q2. I know where to find health resources on the internet 14 (25.0) 41 (73.2) 1 (1.7) 0 0 Q3. I know how to find helpful health resources on the internet 18 (32.1) 37 (66.1) 1 (1.7) 0 0 Q4. I know how to use the health information I find on the internet to help me 15 (26.8) 41 (73.2) 0 0 0 Q5. I feel confident in using information from the internet to make health decision 9 (16.1) 35 (62.5) 9 (16.1) 3 (5.4) 0 eHealth literacy Median 20 Figure 1. Frequency of Internet Use for COVID-19 Information-Seeking by Respondents Prior to Self- Isolation (A) and During Self-Quarantine (B) Regarding the source of general health information searched by the respondents, social media (e.g., WhatsApp®, Facebook®, Instagram®) accounted for the most common references used to navigate for health information with 53.6%. The other Internet- based information sources, namely search engines, appeared popular which nearly 40% of the respondents chose this mode during information seeking. Meanwhile, conventional sources i.e., television was preferred by only 7% and none of the study participants considered printed newspaper as their preference to find health information. Research Article Journal of Pharmaceutical Sciences and Community E-Health Literacy and Adherence ... 64 Ramadaniati et al. J. Pharm. Sci. Community, 2023, 20(1), 60-69 As depicted in Figure 1A, before self- quarantine, most respondents (N=20, 35.7%) spent several times a month to navigate COVID- 19 information using the Internet to search for COVID-19 information and around 30.0% reported daily searching. Meanwhile, during self- isolation (Figure 1B) there was a slight increase in the frequency of Internet use where nearly all respondents (N=52, 93.0%) browsed online COVID-19 information at least several times in a month. Table 4. Respondents’ Knowledge on COVID-19 Correct Wrong N (%) N (%) COVID-19 is not dangerous and like common cold 52 (92.9) 4 (7.1) Corona virus cannot be transmitted when an infected person talks 49 (87.5) 7 (12.5) Only those with COVID-19 symptoms can spread the virus 48 (85.7) 8 (14.3) Healthy people do not need to wear masks when they go outside 52 (92.9) 4 (7.1) There is no need for children and adolescents to practice preventive measures as they have strong immune 53 (94.6) 3 (5.4) Antibiotic is effective for COVID-19 treatment 41 (73.2) 15 (26.8) Corona virus can survive a few hours outside human body 48 (85.7) 8 (14.3) Elderly people are likely to develop more severe symptoms than younger adults 53 (94.6) 3 (5.4) Death risk in COVID-19 patients is higher than those with chronic disease like diabetes, cardiovascular diseases, and obesity 53 (94.6) 3 (5.4) Self-isolation for infected persons is no longer required for those developing no COVID-19 symptoms 50 (89.3) 6 (10.7) Knowledge score: *Mean (SD) 8.89 (1.796) *10 is set as maximum score Table 5. Compliance to Health Protocol During and After Self-Quarantine During Self-Quarantine Always N (%) Sometimes N (%) Never N (%) Did you consume vitamin or supplement to improve your immune system? 31 (55.4) 24 (42,9) 1 (1,7) Did you do exercise regularly? 17 (30.4) 35 (62,5) 4 (7,1) Did you practice cough etiquette? 49 (87.5) 6 (10,7) 1 (1,7) Did you have enough rest? 50 (89.3) 5 (8,9) 1 (1,7) Did you clean your home more often using disinfectant? 32 (57.1) 19 (33,9) 5 (8,9) After Self-Quarantine Always N (%) Sometimes N (%) Never N (%) Over the past few months, have you practiced physical distancing in a public place? 43 (76.8) 12 (19.6) 1 (1.7) Over the past few months, have you used hand sanitizer while being in a public place? 45 (80.4) 10 (17.9) 1 (1.7) Over the past few months, have you washed your hands when returning from a public place? 50 (89.3) 5 (8.9) 1 (1.7) Over the past few months, have you changed your clothes when returning home? 39 (69.6) 15 (26.8) 2 (3.4) Over the past few months, have you worn mask in a public place? 52 (92.9) 4 (7.1) 0 (0%) Journal of Pharmaceutical Sciences and Community E-Health Literacy and Adherence ... Research Article 65 Ramadaniati et al. J. Pharm. Sci. Community, 2023, 20(1), 60-69 Table 2 describes the type of COVID-19 information navigated during online search. Before contracting the disease, the respondents predominantly searched for the disease symptoms. Additionally, information on the use of vitamins and supplements, and preventive were accessed by at least three out of five respondents. The nature of information searched after being infected slightly differed. During self- quarantine period, the respondents revealed that the top three most frequent health information was related to the use of vitamins and supplements, COVID-19 treatment and its symptoms. In line with our study, Nugroho et al. also found that the commonest types of information searched in Indonesia were disease symptoms and healthy lifestyles to prevent the disease (Nugroho et al., 2021). Similarly, an Italian study found the most common searched information during the pandemic included the preventive-related information (i.e., using face mask, disinfectant), symptoms of coronavirus and treatment (Rovetta et al., 2020) The eHEALS was used in this study to rate respondents’ digital health literacy. The scale is able to measure individual’s perception of their knowledge and skills in using health information from electronic sources and to find out if the eHealth approach can be suited to the individual (Choi et al., 2021). Assessment of EHL (see Table 3) uncovers the fact that respondents had high scores on digital health literacy (median 20 out of 15). Most respondents were confident in using the Internet to navigate health information and make informed health decisions related to COVID-19. The high level of EHL may prompt people to triangulate information to verify its credibility by comparing it with other trusted digital sources. The next stage of information triangulation involves discussion of the information with others and making sense the massive flow of information (Sykes et al., 2021). Similar finding was reported in an Indonesian study where 9 in 10 people had good COVID-19 related knowledge (Sulistyawati et al., 2021). Meanwhile, a study in South Korea documented lower EHL with respondents having moderate EHL (Choi et al., 2021). By contrast, another Indonesian study involving a younger population found more than half of the respondents had low EHL despite their increased access to online information as opposed to older population (Nugroho et al., 2021). This evidence may signify the fact that the youths had greater access to online platforms and more familiarity with the digital environments, yet they lacked the ability to evaluate and apply the information (Li et al., 2021). It is noteworthy that respondents had a good level of COVID-19 knowledge (mean = 8.89/10, SD = 1.796). As illustrated in Table 4, the majority of the questions could be answered correctly by more than 80% of the respondents. Intriguingly, only one question, namely the effectiveness of antibiotics for treating COVID- 19, in which less than three-quarter of them could choose the right option. Corresponding to our study, Yanti and colleagues also identified good COVID-19 knowledge among the Indonesian community. That study signified good knowledge related to mitigation measures to prevent the pandemic (Yanti et al., 2020). Another Indonesian study generally identified good knowledge since more than 70% of the respondents were able to correctly answer the questions related to symptoms, transmission modes and preventive strategies (Sulistyawati et al., 2021). Considerable knowledge on COVID-19 was also mentioned in a study involving respondents from United States of America (USA) and United Kingdom (UK) (Geldsetzer, 2020). Likewise, modest level of COVID-19 knowledge was documented in a Chinese study with the questions relating to transmission route and clinical symptoms having the lowest correct responses (Yue et al., 2021). On the contrary, a systematic review involving people on the American Continent revealed that many Americans had poor knowledge toward COVID- 19 risks (Yohanna et al., 2021). Table 5 reveals that respondents had good adherence to health protocol (mean = 26.98/30, SD = 3.066) both during and after self- quarantine. During contracting the disease, more than 80% of the respondents always implemented cough etiquette to prevent transmission and had adequate amount of time to rest. In addition, 1 in 2 respondents always consumed vitamins and supplements to boost their immunity, and practiced hygiene by cleaning their home more regularly with disinfectant. It appears that the threat of imminent disease elicits fear leading people to improve health knowledge and apply their adaptive behaviors (Ling et al., 2019). In accordance with our study, an Indonesian study involving respondents from many provinces reported a promising result with the majority of the respondents implementing good practice to prevent the disease transmission (Yanti et al., 2020). High levels of preventive behavior practice against COVID-19 were also Research Article Journal of Pharmaceutical Sciences and Community E-Health Literacy and Adherence ... 66 Ramadaniati et al. J. Pharm. Sci. Community, 2023, 20(1), 60-69 documented in China where respondents cited the three most frequent implementation of preventive behaviors included wearing face masks in public places, avoiding mobility to areas with high prevalence and restricting interaction with those showing flu-like symptoms (Liu, 2020). In contrast, a study by Gharpure et al. showed that nearly one third of the respondents in USA have adapted some high-risk COVID-19 preventive misbehavior e.g., washing fruits and vegetables with bleach, and applying household cleaning products on hands (Gharpure et al., 2020). In addition, this study also examined the relationship between EHL and knowledge and EHL and health protocol. A modest correlation was found between EHL and knowledge (p-value = 0.001, r = 0.436), whilst a weak relationship was revealed between EHL and compliance to health protocol (p-value = 0.011, r = 0.339). Consistent with our study, some studies conducted in China (Li et al., 2021), Norway (Riiser et al., 2020), Denmark (Klinker et al., 2020), South Korea (Li et al., 2021) and the USA (Wolf et al., 2020) identified significant relationships between EHL and COVID-19 preventive behaviors. Li and colleagues revealed a positive association between EHL versus COVID-19 knowledge (R=0.220, p<0.001) and between EHL and COVID-19 specific precautionary behaviors e.g., hand hygiene habit, regular exercise and nutritious diet (R=0.476, p<0.001) (Li et al., 2021). Similarly, a Norway study conducted during the early phase of COVID-19 pandemic exhibited significant relationship between EHL and health protective measures (Riiser et al., 2020). It has been thought that the Internet-based pandemic information might exacerbate concerns among the population and trigger them to follow protective behaviors as a routine health protocol (Sun et al., 2020). When comparing with previous pandemics (e.g., SARS, H1N1), a similar finding was revealed that devoting considerable amount of time to search for specific information may affect adherence to preventive strategies (Bults et al., 2011; Leppin et al., 2009). By contrast, a study conducted in Yogyakarta, Indonesia found that EHL did not directly affect self-care behavior since individuals with low level of EHL were still able to implement healthy behavior (Nugroho et al., 2021). It appears that the influence of more senior family members of the youth respondents in that study are likely to affect the practice of health behavior despite insufficient comprehension of their health literacy. Additionally, EHL is not the only factor affecting health behavior because people with low EHL can still access health information from non- digital source (e.g., television) and adopt relevant health behaviors as the part of the COVID-19 preventive protocols (Li et al., 2021). The findings of this research contribute to the limited existing knowledge on understanding the nature of health information seeking among people before and during contracting COVID-19, and their health literacy in relation to digital information. Improved community engagement through empowering them with sufficient health literacy could be used as one mode to resolve COVID-19 information asymmetry (Chong et al., 2020). In this sense, government institutions and other reputable non-government organizations can collaborate with social media giants (e.g. Facebook®, YouTube®, Google®, Instagram®) in order to design and disseminate targeted learning programs to improve public health literacy. In addition to its influence on knowledge and adherence to health behavior, it is of special importance to evaluate the impact of EHL on other parameters as previous studies signified the association between poor health literacy with undesirable health outcomes, e.g., health-related quality of life (Castro-Sánchez et al., 2016; Lorini et al., 2018; Neter and Brainin, 2019). Several limitations need to be considered in interpreting the findings of this study. This study applied a cross-sectional approach using non-probability sampling in a sub-district resulting in modest sample size, which limits the generalizability of the findings. In addition, the study may reflect some reporting bias since the respondents self-completed the questionnaire and further explanations were given only if they required additional information from the researchers. Furthermore, this study employed an online format for the questionnaire for collating the information. It is likely that a certain segment of the population such as the elderly cannot be included as the study samples due to their barriers to access digital platforms. CONCLUSION EHL had modest influence on COVID-19 knowledge and insignificantly affected adherence to health protocol among self- isolating patients with COVID-19. It is of paramount importance that access to official social media providing reliable information on COVID-19 should be widely disseminated by the Indonesian Authorities. However, the provision of health information through electronic platforms will be more beneficial if supported by the measures to improve people’ EHL. This Journal of Pharmaceutical Sciences and Community E-Health Literacy and Adherence ... Research Article 67 Ramadaniati et al. J. Pharm. Sci. Community, 2023, 20(1), 60-69 approach to the diverse level of EHL may provide insights for authorities on formulating valid and understandable digital materials regarding COVID-19 to the targeted populations. ACKNOWLEDGEMENT The authors would like to thank the respondents who participated in this study and shared their invaluable experiences. REFERENCES Ajzen, I., 2011. The Theory of Planned Behaviour: Reactions and Reflections. Psychology and Health, 26(9): 1113-1127. Britt, R. K., Collins, W. B., Wilson, K., Linnemeier, G., Engleber, A. M., 2017. eHealth Literacy and Health Behaviors Affecting Modern College Students: A Pilot Study of Issues Identified by the American College Health Association. Journal of Medical Internet Research, 19(12): e392. Bults, M., Beaujean, D. J.,de Zwart, O., Kok, G., van Empelen, P., Van Steenbergen, J. E., Richardus, J. H., Voeten, H. A., 2011. Perceived Risk, Anxiety, and Behavioural Responses of the General Public During the Early Phase of the Influenza A (H1N1) Pandemic in the Netherlands: Results of Three Consecutive Online Surveys. BMC Public Health, 11(2): 1-13. Castro-Sanchez, E., Chang, P. W. S., Vila-Candel, R., Escobedo, A. A., Holmes, A. H., 2016. Health Literacy and Infectious Diseases: Why Does It Matter? International Journal of Infectious Disease, 43: 103-110. Centers for Disease Control and Prevention., 2021. Coronavirus Disease (COVID-19): Stigma and resilience [WWW Document]. URL https://www.cdc.gov/mentalhealth/stress -coping/reduce-stigma/index.html [accessed 10.11.21]. Choi, S., Bang, K. S., Shin, D. A., 2021. eHealth Literacy, Awareness of Pandemic Infectious Diseases, and Healthy Lifestyle in Middle School Students. Children (Basel), 8(8): 699- 709. Chong, Y. Y., Cheng, H. Y., Chan, H. Y. L., Chien, W. T., Wong, S. Y. S., 2020. COVID-19 Pandemic, Infodemic and the Role of eHealth iteracy. International Journal of Nursing Studies, 108: 103644. Dadaczynski, K., Okan, O., Messer, M., Leung, A. Y. M., Rosario, R., Darlington, E.. Rathmann, K., 2021. Digital Health Literacy and Web- Based Information-Seeking Behaviors of University Students in Germany During the COVID-19 Pandemic: Cross-sectional Survey Study. Journal of Medical Internet Research, 23(1): e24097. Djalante, R., Lassa, J., Setiamarga, D., Mahfud, C., Sudjatma, A., Indrawan, M., Haryanto, B., Sinapoy, M., et al., 2020. Review and Analysis of Current Responses to COVID-19 in Indonesia: Period of January to March 2020. Progress in Disaster Science, 6: 100091. Geldsetzer P., 2020. Use of Rapid Online Surveys to Assess People's Perceptions During Infectious Disease Outbreaks: A Cross- sectional Survey on COVID-19. Journal of Medical Internet Research, 22(4): e18790. Gharpure, R., Hunter, C. M., Schnall, A. H., Barrett, C. E., Kirby, A. E., Kunz, J., Berling, K., Mercante, et al., 2020. Knowledge and Practices Regarding Safe Household Cleaning and Disinfection for COVID-19 Prevention - United States, Morbidity and Mortalality Weekly Report, 69(23): 705-709. Jacobs, R.J., Lou, J.Q., Ownby, R.L., Caballero, J., 2016. A Systematic Review of eHealth Interventions to Improve Health Literacy. Health Informatics Journal, 22(2): 81-98. Klinker, C. D., Aaby, A., Ringgaard, L. W., Hjort, A. V., Hawkins, M., Maindal, H. T., 2020. Health Literacy is Associated with Health Behaviors in Students from Vocational Education and Training Schools: A Danish Population-Based Survey. International Journal of Environtal Research and Public Health, 17(2): 671. Leppin, A., Aro, A.R., 2009. Risk Perceptions Related to SARS and Avian Influenza: Theoretical Foundations of Current Empirical Research. International Journal of Behavioral Medicine, 16(1): 7-29. Li, S., Cui, G., Kaminga, A. C., Cheng, S., Xu, H., 2021. Associations Between Health Literacy, eHealth Literacy, and COVID-19-Related Health Behaviors Among Chinese College Students: Cross-sectional Online Study. Journal of Medical Internet Research, 23(5): e25600. Ling, M., Kothe, E. J., Mullan, B. A., 2019. Predicting Intention to Receive a Seasonal Influenza Vaccination Using Protection Motivation Theory. Social Science and Medicine, 233: 87-92. Liu, P. L., 2020. COVID-19 Information Seeking on Digital Media and Preventive Behaviors: The Mediation Role of Worry. Cyberpsychology, Behavior and Social Networking, 23(10): 677-682. Research Article Journal of Pharmaceutical Sciences and Community E-Health Literacy and Adherence ... 68 Ramadaniati et al. J. Pharm. Sci. Community, 2023, 20(1), 60-69 Lorini, C., Santomauro, F., Donzellini, M., Capecchi, L., Bechini, A., Boccalini, S., Bonanni, P., Bonaccorsi, G., 2018. Health Literacy and Vaccination: A Systematic Review. Human Vaccines and Immunotherapeutics, 14(2): 478-488. Neter, E., Brainin, E., 2019. Association Between Health Literacy, eHealth Literacy, and Health Outcomes Among Patients With Long-Term Conditions: A Systematic Review. European Psychologist, 24(1): 68- 81. Norman, C. D., Skinner, H. A., 2006. eHEALS: The eHealth Literacy Scale. Journal of Medical Internet Research, 8(4): e27. Nugroho, D.C.A., Sulistiawan, D., Arifa, R.F., Gayatri, M., Puspitasari, M.D., Prabowo, F. W., 2021. eHealth Literacy and Self-care Behavior During the Coronavirus Disease- 19 Pandemic Among Youths: A Path Analysis. Macedonian Journal of Medical Sciences, 9: 722-728. Nurhayati-Wolff, H., 2021. Penetraton Rate in Indonesia 2017-2026 [WWW Document]. URL https://www.statista.com/statistics/2544 60/internet-penetration-rate-in- indonesia/ (accessed 22.12. 21). Riiser, K., Helseth, S., Haraldstad, K., Torbjornsen, A., Richardsen, K. R., 2020. Adolescents' Health Literacy, Health Protective Measures and Health-related Quality of Life during the COVID-19 Pandemic. PLoS ONE, 15(8): e0238161. Rovetta, A., Bhagavathula, A.S., 2020. COVID-19- Related Web Search Behaviors and Infodemic Attitudes in Italy: Infodemiological Study. JMIR Public Health and Surveillance, 6(2): e19374. Sarria-Guzman, Y., Fusaro, C., Bernal, J.E., Mosso- Gonzzales, C., Gonzales-Jimenez, F.E., Serrano-Silva, N., 2021. Knowledge, Attitude and Practices (KAP) Towards COVID-19 Pandemic in America: A Preliminary Systematic Review. The Journal of Infection in Developing Countries, 15(1): 1-13. Saefi, M., Fauzi, A., Kristiana, E., Adi, W.C., Muchson, M., Setiawan, M. E., Islami, N.N., Ningrum, D.E.A.F., Ikhsan, M. A., Ramadhani, M., 2020. Validating of Knowledge, Attitudes, and Practices Questionnaire for Prevention of COVID-19 infections among Undergraduate Students: A RASCH and Factor Analysis. Eurasia Journal of Mathematics, Science and Technology Education, 16(12): em1926. Squiers, L., Perinado, S., Berkman, N., Boudewyns, V., McCormack, L., 2012. The Health Literacy Skills Framework. Journal of Health Communication, 17(suppl 3): 30-54. Sulistyawati, S., Rokhmayanti, R., Aji, B., Wijayanti, S.P.M., Hastuti, S. K.W., Sukesi, T.W., Mulasari, S.A., 2021. Knowledge, Attitudes, Practices and Information Needs During the COVID-19 Pandemic in Indonesia. Risk Management and Healthcare Policy, 14: 163-175. Sun, Z., Yang, B., Zhang, R., Cheng, X., 2020. Influencing Factors of Understanding COVID-19 Risks and Coping Behaviors among the Elderly Population. International Journal of Environmental Research and Public Health, 17(16): 5889. Sykes, S., Wills, J., Trasolini, A., Wood, K. & Frings, D., 2021. eHealth Literacy During the COVID-19 Pandemic: Seeking, Sharing, Suspicion Amongst Older and Younger UK Populations. Health Promotion International, 103: 1-10. The Indonesian COVID-19 Task Force, 2021. COVID-19 Distribution Map [WWW Document]. URL https://covid19.go.id/peta-sebaran- covid19 (accessed 16.10. 21). The Ministry of Health of Indonesia, 2020. Guideline of Prevention and Control of the Coronavirus Disease (COVID-19) [WWW Document]. URL https://covid19.go.id/storage/app/media/ Protokol/REV-05_Pedoman_P2_COVID- 19_13_Juli_2020.pdf. (accessed 27.03.21). Wolf, M. S., Serper, M., Opsasnick, L., O'Conor, R. M., Curtis, L., Benavente, J. Y., Wismer, G., Batio, S., Eifler, M., Zheng, P., Russell, A., et al,, 2020. Awareness, Attitudes, and Actions Related to COVID-19 Among Adults with Chronic Conditions at the Onset of the U.S. Outbreak: A Cross-sectional Survey. Annals of Internal Medicine, 173(2): 100-109. World Health Organization Indonesia., 2021. Update on Coronavirus Disease in Indonesia [WWW Document]. URL: https://www.who.int/indonesia/news/no vel-coronavirus. (accessed 25.10.21). Wuorela, M., Lavonius, S., Salminen, M., Vahlberg, T., Viitanen, M., Viikari, L., 2020. Self-rated Health and Objective Health Status as Predictors of All-cause Mortality Among Older People: A Prospective Study with a 5- , 10-, and 27-year Follow-up. BMC Geriatrics, 20: 120. Yanti, B., Mulyadi, E., Wahiduddin, W., Novika, R. G. H., Arina, Y. M. D., Martani, N. G., Nawan, Journal of Pharmaceutical Sciences and Community E-Health Literacy and Adherence ... Research Article 69 Ramadaniati et al. J. Pharm. Sci. Community, 2023, 20(1), 60-69 N., 2020. Community, Knowledge, Attitudes, and Behavior Towards Social Distancing policy as a Means of Preventing Transmission of COVID-19 in Indonesia. Indonesian Journal of Health Administration, 8(1): 4-14. Yue, S., Zhang, J., Cao, M., Chen, B., 2021. Knowledge, Attitudes and Practices of COVID-19 Among Urban and Rural Residents in China: A Cross-sectional Study. Journal of Community Health, 46(2): 286- 291. Zarocostas, J. 2020. How to Fight an Infodemic? Lancet, 395(10225): 676.