54  P-ISSN: 1858-3598  E-ISSN: 2502-5791  
 

© 2023 Jurnal Ners. This is an open-access article distributed under the terms of the Creative 

Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by/4.0/). 

 

 Volume 18, Issue 1, March 2023, p. 54-60 

http://dx.doi.org/10.20473/jn.v18i1.37721 

 

ORIGINAL ARTICLE OPEN ACCESS 

Health literacy and post-vaccination covid-19 

prevention behavior in the community: a cross-

sectional study in Indonesia 

 

Yofita Refvinda Desfiani
1

, Jon Hafan Sutawardana
1
* , and Nur Widayati

1
 

1 Faculty of Nursing, Universitas Jember, Jember, Indonesia 

*Correspondence: Jon Hafan Sutawardana. Address: Faculty of Nursing, Universitas Jember, Jember, Indonesia. Email: 

hafan@unej.ac.id 

Responsible Editor: Retnayu Pradanie  

Received: 22 July 2022 ○ Revised: 3 March 2023 ○ Accepted: 18 March 2023 

ABSTRACT 

Introduction: The government has made vaccination as the primary strategy to control the COVID-19 pandemic. 

However, the public still needs to implement COVID-19 prevention behavior even though they have been vaccinated. 

This study aimed to determine the correlation between health literacy and post-vaccination COVID-19 prevention 

behavior of the community in the work area of the Patrang Public Health Center, Jember Regency, Indonesia. 

Methods: A cross-sectional design was performed in the public health center in Jember Regency Indonesia, in May 

2022. The sample in this study was 435 people selected by purposive sampling with the inclusion criteria of those 

aged >17 years old and receiving a total primary vaccination dose. The data were collected using the Health Literacy 

Survey Coronavirus Disease Questionnaire 22 (HLS-COVID-Q22) and the COVID-19 prevention behavior questionnaire. 

The data were analyzed by using Spearman test with a significance level of α<0.05.  

Results: The results showed that the most of health literacies were inadequate (n=188, 43.2%), and the post-

vaccination COVID-19 prevention behavior was in the moderate category (n=186, 42.7%). There was a moderate 

correlation between health literacy and post-vaccination COVID-19 prevention behavior (p < 0.001; r = 0.513). 

Conclusions: The higher the health literacy, the better the post-vaccination COVID-19 prevention behavior. The 

nurse was important in providing health education about COVID-19 by paying attention to community health literacy 

ability. Improving health literacy is an important strategy to enhance COVID-19 prevention behavior and reduce 

coronavirus transmission. 

Keywords: COVID-19 prevention behavior; health literacy; post-vaccination 

Introduction 

Vaccines are the primary strategy for controlling the 

pandemic that is effective in overcoming infections of 

Severe Acute Respiratory Syndrome Coronavirus 2 

(SARS CoV-2) and cases of Coronavirus Disease 2019 

(COVID-19) (Haas et al., 2021; World Health 

Organization, 2021). However, COVID-19 prevention 

behavior, despite vaccination, still needs to be done 

because COVID-19 infection with symptoms or without 

symptoms can still occur (Bahl et al., 2021; Jain, Iyengar 

and Ish, 2021). People who have been fully vaccinated 

but are infected with SARS CoV-2 are called 

"breakthrough infections" (Centers for Disease Control 

and Prevention, 2021). Individuals loosen COVID-19 

preventive behavior after vaccination, it can be seen 

that fewer people are wearing masks in public area after 

vaccination. This behavior can increase the potential risk 

of infection in a new wave of virus variants and would 

possibly provide loopholes for causing virus 

transmission (Zhang et al., 2021; Satuan Tugas 

Penanganan COVID-19, 2022).  

Health promotion and preventive measures still 

need to be implemented to stop the pandemic (Yuan et 

al., 2021). However, there are still global gaps in the 

https://creativecommons.org/licenses/by/4.0/
mailto:hafan@unej.ac.id
https://orcid.org/0000-0001-8866-6242
https://orcid.org/0000-0002-5059-6821
https://orcid.org/0000-0003-2257-3128


Jurnal Ners 

  http://e-journal.unair.ac.id/JNERS  55 

availability and accessibility of various preventive and 

public health protection measures that can prevent the 

virus's spread and future global pandemics (Taggart et 

al., 2022). Sometimes information is subjected to   

contradictory opinions and experts’ views. Too much 

information made it hard to distinguish between correct 

and incorrect information, allowing for the introduction 

of misconceptions and wrong beliefs, often under cover 

of almost scientific language (Silva and Santos, 2021). 

Even if fully vaccinated, precautions such as keeping a 

distance of at least 1 meter from other people, wearing 

a mask, avoiding poorly ventilated places, washing 

hands frequently, staying home if unwell and testing for 

COVID-19, staying informed about COVID-19 must be 

still implemented (World Health Organization, 2020). 

But a loosening of the behavior of COVID-19 prevention 

has happened globally. Based on research in Israel, 

preventive behavior was reported to show a decrease in 

the rate of wearing masks (21.1%) and implementing 

social distancing (47.3%) in people who had been 

vaccinated (Rahamim-Cohen et al., 2021). Facts related 

to the application of preventive behavior in data as of 

January 30, 2022, in Indonesia show that 88.89% of 

people adhere to wearing masks and 85.61% adhere to 

keeping their distance. However, individuals actually 

weaken the behavior prevention of COVID-19 after 

vaccination (Zhang et al., 2021). 

One of the factors that can influence COVID-19 

prevention behavior is the level of health literacy 

(Sánchez-Arenas et al., 2021). Health literacy is defined 

as an ability that requires knowledge, motivation, and 

individual competence to seek or access information, 

understand its meaning, and assess health information 

to make decisions so that they can adequately apply 

information into actions in daily life. This health 

information relates to healthcare, disease prevention, 

and health promotion to maintain and improve a better 

quality of life (Okan et al., 2019). Good health literacy 

levels are associated with better attitudes as a key to 

prevention strategies against COVID-19 and its spread 

leading to better health outcomes (Silva and Santos, 

2021).  

Health literacy during the pandemic is essential to 

find or access information about COVID-19, 

transmission, preventive behavior that needs to be 

done, understand what it means, and assess the 

information so that decisions can be made to   apply 

knowledge to behavioral compliance (Sørensen et al., 

2012; Do et al., 2020; Hong et al., 2021). Good health 

literacy allows individuals to gain knowledge about 

COVID-19, seek relevant facts about infection 

transmission and prevention behavior, and find the 

necessary information and apply it in daily life (Do et al., 

2020). Increasing health literacy becomes very 

important at the individual and community level to deal 

with pandemic situations that require immediate and 

rapid action (Abdel-Latif, 2020). Accordingly, this study 

aimed to determine the relationship between health 

literacy and post-vaccination COVID-19 prevention 

behavior. 

Materials and Methods 

Research design 

This study used a descriptive correlation with a cross-

sectional approach to determine the correlation 

between health literacy and post-vaccination COVID-19 

prevention behavior. 

Respondents 

The sample was 435 people in the work area of the 

Patrang Public Health Center which covers a 

geographical area consisting of the sub-districts of 

Patrang, Gebang and Jember Lor in May 2022. The 

sample was collected by purposive sampling in order to 

get the complete address of the respondent, as there 

were no clear data about the address of the respondents 

from Public Health Center. Minimum total sample based 

on the Lemeshow formula n = [Z21−α × (p) × (1 − p)]/d2, 

assuming the proportion of the COVID-19 vaccination 

coverage rate as 50% with a precision level of 0.05 

(Nursalam, 2020). The inclusion criteria were aged >17 

years old and receiving 2 or 3 doses of COVID-19 vaccine. 

The exclusion criteria were healthcare workers, because 

the health workers are likely to have good health 

literacy, and people with mental and cognitive disorders 

validated by the Mini-Mental State Examination (MMSE) 

for the respondents >65 years old.  The MMSE is used in 

respondents >65 to determine the presence of 

dementia, and are suspected of experiencing cognitive 

problems related to aging beyond normal memory 

problems. Respondents with mental and cognitive 

disorders such as mental disorders, mental retardation 

were immediately excluded from the study. During the 

research the MMSE test was conducted on 37 

respondents with the interpretation that all 

respondents had normal cognitive status.  

Instruments 

This research used the self-report data collection 

techniques by filling out a questionnaire. The 

questionnaires used were the respondent's 

characteristics (age, gender, marital status, education 

level, occupation, income level, history of comorbidities, 

and sources of information about COVID-19), Health 



Desfiani, Sutawardana, and Widayati (2023) Supremo, Bacason, and Sañosa (2022) 

  56  P-ISSN: 1858-3598  E-ISSN: 2502-5791 

Literacy Survey Coronavirus Disease Questionnaire 22 

(HLS-COVID-Q22) and COVID-19 preventive behavior 

questionnaire. This questionnaire is specifically used to 

analyze health literacy during the COVID-19 Infodemic. 

Health literacy is measured by the HLS-COVID-22Q 

designed by Okan et al. (2020). This questionnaire has 

been translated into the Indonesian language by Utami 

et al. (2021) with the results of the validity test having a 

correlation coefficient of 0.412–0.690 (r > 0.300) and 

Cronbach's alpha reliability test showing α = 0.921. This 

questionnaire consists of 22 questions that are used to 

assess the difficulty or ease felt by respondents when 

accessing (6 questions), understanding (6 questions), 

considering (5 questions), and applying (5 questions) the 

health information about COVID-19. The assessment in 

this questionnaire uses a Likert scale of 1-4 with a score 

of 1 (very difficult) to 4 (very easy). This questionnaire 

used an interval scale with a minimum score of 22 and a 

maximum score of 88 which obtained by adding up the 

answer scores for each question item (Okan et al., 2020; 

Utami et al., 2021). According to Okan et al. (2020), the 

final assessment of this questionnaire can also be 

presented as an index or category of health literacy. The 

presentation of the data is by using the average cut-off 

values which the average value was 2.5 (inadequate 

health literacy), >2.5–<3 (problematic health literacy), 

and 3 (sufficient health literacy). 

Post-vaccination COVID-19 prevention behavior was 

measured by a questionnaire consisting of seven 

favorable and unfavorable questions based on the 

guidelines of the Ministry of Health of the Republic of 

Indonesia. The questionnaire includes wash hands with 

soap or use hand sanitizer after handling objects in 

public places, take a shower and change clothes after 

coming home from traveling, wear a mask in public 

places, keep a distance of at least 1 meter, keep distance 

from elderly, don’t attend large gatherings and don’t use 

public facilities or go to public places. This questionnaire 

has been tested for validity and reliability by Yanti et al. 

(2020); with the results of the validity test having a 

correlation coefficient 0.187-1 (r > 0.1409) and the 

Cronbach alpha reliability test α = 0.770. Assessment in 

this questionnaire used a Likert scale with 0-3 for 

favorable questions with the score of 0 (never), 1 

(rarely), 2 (almost always), and 3 (always) and vice versa 

for unfavorable questions. The calculation for the 

prevention behavior had a total score 0-7 (low protocol 

adherence), 8-14 (moderate protocol adherence), and 

15-21 (high protocol adherence). 

The data were collected using a door-to-door 

technique where more than one respondent can be 

taken from each house according to the inclusion and 

exclusion criteria. The data collection was assisted by 

two enumerators. Enumerators were selected from 

undergraduate students of Faculty of Nursing, 

Universitas Jember who were first given the training to 

equate perceptions and understanding about study, 

questionnaire and the data collection process used in 

this study. Search for the respondents’ addresses was 

assisted by the head of the community association in the 

research area. Respondents were recruited from 

accessible communities and according to established 

inclusion and exclusion criteria.  

 

 

Table 1 Demographic characteristics of respondents (N=104) 

Variable n % 

Age (years)  
 

18-25 57 13.1 

26-35 85 19.6 

36-45  110 25.3 

46-55 92 21.1 
56-65  54 12.4 
>65  37 8.5 

Gender  
 

Male 100 23 
Female 335 77 

Marital status  
 

Married 365 83.9 

Unmarried 45 10.3 
Widowed 25 5.8 

Educational level  
 

Elementary and lower 171 39.3 

Junior high school 56 12.9 
Senior high school 176 40.5 
Collage 32 7.3 

Occupation  
 

Unemployed 23 5.3 
Student 10 2.3 

Entrepreneur/trader 103 23.7 
Farmer 10 2.3 
Civil servant 7 1.6 

Retired 12 2.7 
Private employees 53 12.2 

Laborer/driver/housekeeper 24 5.5 

Housewife 193 44.4 

Income level  
 

<Rp2.400.000,- 371 85.3 

≥Rp2.400.000,- 64 14.7 

History of comorbidities  
 

Have comorbidities 60 13.8 
Hypertension 36 8.3 

Diabetes 6 1.4 
Asthma 13 3.0 
Tuberculosis 2 0.5 

Liver disease 1 0.2 
Heart disease 1 0.2 
Cancer 1 0.2 

Have no comorbidities 375 86.2 

Most used sources of information about COVID-19  

Television 163 37.5 

Internet (Website/Online Magazine/etc.) 53 12.2 
Newspaper/magazine 1 0.2 

Radio 1 0.2 

Social media 
(Instagram/Twitter/Facebook/etc.) 

82 18.9 

Message apps (WhatsApp/Line/Telegram/etc.) 11 2.5 

Health workers 32 7.4 
Family or friends  92 21.1 

 



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Data analysis 

Data analysis in this study used univariate and 

bivariate analysis using SPSS version 27. The results of 

the univariate analysis of health literacy and post-

vaccination COVID-19 prevention behavior will be 

presented in frequency and percentage, while the 

bivariate analysis was carried out using the Spearman 

non-parametric correlation to determine the correlation 

between health literacy and post-vaccination COVID-19 

prevention behavior. 

Ethical consideration 

This research was approved by the Health Research 

Ethics Committee of the Faculty of Nursing, Universitas 

Jember with a certificate No. 

063/UN25.1.14/KEPK/2022. During the research the 

respondents and researchers continued to use masks 

and wash their hands with the handrub/hand sanitizer 

provided by the researchers before data collection was 

carried out and have agreed to informed consent as 

evidence of involvement in this study. 

Results  

Characteristic of the respondents 

The results of the study which consisted of 435 

respondents showed that the most age of respondents 

was 36-45 years (n=110, 25.3%), the most gender was 

female (n=335, 77%), and the majority of respondents 

were married (n= 365, 83.9%). Based on education level, 

most of the respondents were senior high school 

students (n=176, 40.5%) and most of the respondents in 

this study were housewives (n=193, 44.4%). Based on 

the income level it was at most less than IDR 2,400,000 

(n = 371, 85.3%). Most of the respondents in this study 

did not have comorbidities (n = 375, 86.2%). The most 

frequently used source of information about COVID-19 

by respondents was television (n=163, 37.5%). The 

details are shown in Table 1.  

 

 

Health literacy 

Table 2 shows that the health literacy in 

respondents' results were 155 (35.6%) in the sufficient 

health literacy, 92 (21.2%) in the problematic health 

literacy, and 188 (43.2 %) in the inadequate health 

literacy. Based on this research, the highest result is 

shown in the inadequate health literacy. Based on the 

indicators of health literacy, the highest and the lowest 

are present in Table 3. The highest score of the average 

value per item of the indicators of health literacy ability 

is the ability to understand the health information 

(mean=2.67) and the lowest score is the ability to 

appraise the health information (mean=2.37).  

Post-vaccination COVID-19 prevention behavior 

Table 4 shows that the highest level of community 

adherence was moderate protocol adherence 186 

(42.7%) followed by high protocol adherence (41.4%) 

with a slight difference (1.3%). As seen in Table 5, the 

best post-vaccination COVID-19 prevention behavior is 

wearing masks when in public places (mean=2.37). In 

contrast, the worst post-vaccination COVID-19 

prevention behavior is shown in the behavior of keeping 

a distance from the elderly (mean=0.83). 

The correlation between health literacy and post-

vaccination COVID-19 prevention behavior 

This research shows a moderate positive correlation 

between health literacy and post-vaccination COVID-19 

Table 2 Health literacy in respondents (n=435) 

Health Literacy f % 

Inadequate health literacy 188 43.2 
Problematic health literacy 92 21.2 

Sufficient health literacy 155 35.6 

 

Table 3 Indicator of health literacy in respondents (n=435) 

Indicator Mean (SD) Median (Min-Max) 

Access  2.61 (±1.085) 3 (1-4) 
Understand  2.67 (±1.020) 3 (1-4) 

Appraise 2.37 (±0.999) 2 (1-4) 
Apply 2.40 (±1.010) 2 (1-4) 

 

Table 4 Post-vaccination COVID-19 prevention behavior in 

respondents (n=435) 

Post-Vaccination COVID-19 

Preventive Behavior 
f % 

Low protocol adherence 69 15.9 
Moderate protocol adherence 186 42.7 

High protocol adherence 180 41.4 

 

Table 4 Post-vaccination COVID-19 prevention behavior in 

respondents (n=435) 

Question 
Mean 
(SD) 

Median 
(Min-Max) 

I wash my hands with soap or use 
hand sanitizer after handling objects 

in public places 

2.2 
(0.976) 

3 (0-3) 

I take a shower and change clothes 
after coming home from traveling 

1.69 
(0.935) 

2 (0-3) 

I wear a mask in public places 
(markets, terminals, prayer places, 

etc.) 

2.37 
(0.831) 

3 (0-3) 

I keep a distance of at least 1 meter 
from other people when outside the 

house 

1.22 
(0.952) 

1 (0-3) 

I keep my distance from elderly  

0.83 
(0.872) 

1 (0-3) 

I attended an event that gathered 

many people  

2.16 

(0.831) 

2 (0-3) 

I use public facilities or go to public 
places (public transportation, malls, 
markets, tourist attractions) 

2.31 
(0.896) 

3 (0-3) 

 



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  58  P-ISSN: 1858-3598  E-ISSN: 2502-5791 

prevention behavior with a significance value <0.001 

and a coefficient correlation r=0.513. 

Discussions 

The pandemic has been going on since January 2020. 

Even though the majority of people have received the 

COVID-19 vaccine, confirmed cases of COVID-19 are still 

significant showing an increase in the third wave of the 

new variant of the coronavirus. This study revealed that 

there is a positive correlation with moderate of 

relationship between health literacy and post-

vaccination COVID-19 prevention behavior. This means 

that the higher the level of health literacy, the higher the 

community's adherence to prevention of COVID-19 

behavior. Study about health literacy and COVID-19 

prevention behavior found that health literacy was 

significantly related to COVID-19 awareness and COVID-

19 prevention behavior (Gautam et al., 2021).  

Health literacy during the pandemic is very necessary 

to find or access information about COVID-19, 

transmission, preventive behavior that needs to be 

done, understand what it means, appraise, or interpret 

the information correctly so that they can make 

decisions and apply information in the form of behavior 

adherence in everyday life (Sørensen et al., 2012; Okan 

et al., 2019; Do et al., 2020; Bin Naeem and Kamel 

Boulos, 2021; Hong et al., 2021). The better health 

literacy indicates the possibility for individuals to gain 

knowledge about COVID-19, seek relevant facts about 

infection transmission and prevention behavior using, 

and find the necessary information (Do et al., 2020). 

Therefore, better attitudes are expected as a key to 

prevention strategies against COVID-19 and its spread 

leading to better health outcomes (Silva and Santos, 

2021) 

Based on this study, most respondents had 

inadequate health literacy, but had already performed 

moderate to high protocol adherence of COVID-19 

prevention. The best prevention behavior shown in this 

study is wearing a mask when in a public place although 

the easing of the use of masks has been announced 

(mean=2.37). Wearing masks has been practiced for 

health and cultural reasons so that the use of masks on 

COVID-19 prevention behavior does not cause conflicts 

that arise if people are forced to change cultural norms. 

In addition, the majority of the community also has a 

habit of wearing masks to overcome air pollution 

(Nguyen et al., 2020).  

Health literacy so far remains a concept that is 

underestimated as a public health problem in the 

context of the COVID-19 pandemic, although health 

information about COVID-19 has dominated most of the 

sources of information and communication (Paakkari 

and Okan, 2020; Sentell, Vamos and Okan, 2020. The 

respondents in this study had received two or three 

doses of COVID-19 vaccine, but still had inadequate 

health literacy. The respondents’ ability to appraise the 

health information had the lowest average score (mean 

per item=2.37). Assessing and interpreting health 

information demands more excellent cognitive skills and 

resources. In addition, too much and complicated 

information in various media such as the internet or 

smartphone applications also increases the difficulty in 

processing those large amounts of information 

(Svendsen et al., 2020). 

Health literacy is an important competency that 

must be developed during the current pandemic 

(Luengo-Oroz et al., 2020). Too many sources of 

information and inaccurate information (hoax) related 

to COVID-19 caused the spread of fear and panic among 

the public much faster than the virus (Abdel-Latif, 2020). 

Health literacy is needed because it has the potential to 

make individuals understand the reasons for the 

recommendations and the impact or results of 

implementing COVID-19 preventive behavior. Improved 

health literacy will reduce health expenditure costs and 

ease the tremendous burden on the healthcare system 

(Shaukat, Asghar and Naveed, 2021). Health literacy 

limited to individuals, populations, and systems can 

cause adverse effects for some and even entire 

communities. When people are not competent to assess 

health information critically, health information 

providers cannot ensure the means to protect valid and 

useful information against the many sources that spread 

invalid information (hoax information). This can cause 

panic, and interfere with the effectiveness of 

information distribution and health interventions in the 

community (Okan et al., 2020). 

The results of this research have implications for the 

importance of providing health education or counseling, 

especially regarding COVID-19, by paying attention to 

the health literacy ability of the community. Nurses as 

educators can play a role in increasing health literacy, 

one of which is by providing health education or 

counseling, especially related to COVID-19 as a form of 

new normal for society to continue to carry out healthy 

living behaviors not only to prevent COVID-19 but other 

infectious diseases. In addition, a strategy that can be 

done is to improve the quality of health information and 

training to improve information search skills about 

COVID-19. 

 



Jurnal Ners 

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Limitation of the study 

The limitation in this study is that the sampling 

technique   used purposive sampling which can limit the 

generalization of the findings. Furthermore, self-

reported technique could be biased for filling the 

questionnaire 

Conclusions 

The majority of respondents to this study had 

inadequate health literacy. They already understand the 

information but have low ability to assess valid 

information. Post-vaccination COVID-19 prevention 

behavior in respondents showed moderate adherence 

to health protocols as indicated by adherence to 

wearing masks in public places. Thus, this study reveals 

that there is a moderate positive correlation between 

health literacy and post-vaccination COVID-19 

prevention behavior. This means that the higher the 

health literacy, the better the post-vaccination COVID-

19 prevention behavior. Based on the results of this 

study, it is necessary to improve community health 

literacy. Further research is expected to be able to 

develop a model of increasing community health literacy 

that can be applied effectively. 

Acknowledgment 

The authors would like to thank the respondents 

who have participated in this study. In addition, the 

author would also like to thank the community leaders 

who have helped researchers in finding research 

respondents. The same gratitude goes to the Faculty of 

Nursing, Universitas Jember for all the technical and 

bureaucratic assistance. 

Funding source 

No sponsors were involved in this study. Research 

funding used private funds. 

Conflict of interest 

There is no conflict of interest 

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How to cite this article:  Desfiani, Y. R., Sutawardana, J. H., and 

Widayati, N. (2023) ‘Health literacy and post-vaccination covid-19 

prevention behavior in the community: a cross-sectional study in 

Indonesia’, Jurnal Ners, 18(1), pp. 54-60. doi:  
http://dx.doi.org/10.20473/jn.v18i1.37721