The novel coronavirus, SARS-CoV-2, was identified as a cluster cause of atypical cases of pneumonia in Wuhan, China1. World Health Organization (WHO) has declared this coronavirus disease (COVID-19) a global health emergency due to many confirmed cases in more than 70 countries2. Indonesia, the world's fourth most populous country, was reported as having confirmed two cases of COVID-19 infection on March 2, 2020. The number of COVID-19 cases remains rapidly increasing in this country3. Over the study period, the latest data regarding COVID-19 reported an increase significantly with an average of over 1790 confirmed cases, with 113 new cases, 170 dead cases, and 112 recovered cases4.

The Indonesian government has issued several restrictive measures to curtail the spread of the virus across the nations. However, those policies affect an individual psychologically, which causes frustration, anxiety, and even the need to change their daily behavior5-8. A systematic review9 reported that this pandemic has led to high mental disorder rates among the general population. Separate inline, another study10 has also stated that quarantine measures could worsen a person's psychological condition, such as depression, anxiety, stress disorder, and health risk perception.

Illness risk perception and efficacy beliefs are reliable predictors of preventive health behavior11,12. Illness risk perception is a subjective assessment to respond to fearful communications about a health threat. It could relate to the efficacy beliefs as individual capabilities in taking protective action behavior towards a potential threat13. Health behavior theories suggest that perceptions of illness risks relate to perceptions of vulnerability, severity, and threat14. Individuals perceiving significant risks were more likely to implement protective behaviors. These behaviors are significantly influenced by how much danger they perceive the event to be, how likely it is to occur, how effective their current coping behaviors are, and what they believe they can do to solve the problem15. Therefore, monitoring risk perceptions and efficacy beliefs is integral to public health emergency management.

The COVID-19 risk perception is considered an essential aspect of health and risk communication as its goal is to understand what risks of COVID-19 to the public and how the public addresses them16. During the COVID-19 pandemic, the public will have different efficacy beliefs that will influence how people react to risk17. Our previous study18 found that the perceived risk of acquiring COVID-19 was low when there was no confirmed case among Indonesian. Meanwhile, the COVID-19 perceived threat was high at the beginning of outbreaks from March 3 to 27, 202019. People are more considered COVID-19 to be a life-threatening danger to them at that point. Therefore, our study investigated the individual characteristic factors influencing COVID-19 risk perception and efficacy beliefs in different outbreak stages when the number of cases increased significantly. Those factors include sex, gender, region, education level, occupation, marital status, monthly personal income, income condition, direct cash assistance, health status, quarantine conditions, chronic illness, smoking history, and supplement use. In collaborating with the private sector, the Indonesian government has pursued comprehensive policies such as large-scale social distancing, work-from-home, region quarantine, self-isolation, face mask use, and social distancing to prevent the transmission of COVID-1920. Hence, understanding risk perception and efficacy belief will give public health authorities a vital reference for protective behavior among Indonesian. Furthermore, these results will determine the willingness of the Indonesians efforts and contribution to handling COVID-19.

Materials

The instrument was designed based on previous SARS research21, translated and modified to Indonesian19. Quantitative data was generated from a questionnaire containing closed-ended questions. The online questionnaire was distributed via a link to Google Forms: http://bit.Ly/WHOQOLID.

Methods

Study design and data collection

The study has been reviewed for ethical considerations and obtained approval from Universitas 'Aisyiyah Yogyakarta Research Ethics Committee (No. 1305/KEP-UNISA/IV/2020). This cross-sectional online survey was conducted from April to July 2020. The target population was Indonesian active social media users who used specific platforms such as Facebook, Twitter, WhatsApp, and Instagram. The participants' eligibility criteria were Indonesian people aged 17 to 70 years old, active social media users who resided in Indonesia, and could give informed consent. We classified the participants into several age groups, such as adolescents (17 to 25 years old), adults (26 to 45 years old), elderly (46 to 65 years old), and geriatric (above 65 years old). Exclusion criteria were those non-Indonesian residents who did not complete responding to one or more online survey items. The minimum sample size of 220 participants was selected using the Survey System Sample Size Calculator (https://www.surveysystem.com/sscalc.htm), an online survey software package, with 95% confidence and a 5% significance level. This study was voluntary and anonymous. The individuals' consent was obtained before data collection.

Research instrument and study variable

Prior to the distribution of the questionnaires, reliability tests were carried out. The pilot test was conducted on a total of 30 study participants. The assessing instrument for risk perception and efficacy belief were reliable. The Cronbach's alpha and the validity test for risk perceptions were 0.806 and 0.782, while efficacy beliefs were 0.703 and 0.612.

The questionnaire comprised two sections: sociodemographic characteristics and risk perception with efficacy beliefs. The first section comprised questions on respondent sociodemographic characteristics: age, sex, region, education level, occupation, marital status, personal income, income condition, direct cash assistance, health status, quarantine conditions, history of chronic illness, smoking history, and the use of supplements. The second section consisted of a question about perceived risk and efficacy beliefs. Risk perception has three dimensions: perceived threat, vulnerability, and severity. In comparison, efficacy beliefs are associated with response efficacy and self-efficacy.

The measurement of risk perception is based on the construct of the protection motivation theory (PMT). The perceived severity assessed the severity of COVID-19 using a 10-point Likert scale, from 1 (not severe) to 10 (very severe). Meanwhile, the perceived vulnerability assessed the likelihood of acquiring this disease using a 5-point Likert scale, from 1 (very unlikely) to 5 (very likely). The questionnaire used in this study was adapted from a previous study, whereas each perceived dimension was rated on a different Likert scale. Furthermore, we calculated the perceived threat as the overall risk perception measure, which was determined by the formula as follows (the square root of the multiplication of severity/2 and vulnerability). In order to achieve a level of comparability between the scores, the severity score was initially divided by two. A square root transformation was performed to normalize the skewed distribution of the new variable, resulting in a scale ranging from 1 (low) to 5 (high) for measuring perceived threat 19. The perceived threat rating was on a scale from 1 to 5, with 1 being "low" and 5 being "high". The response efficacy was assessed by asking participants to respond to how confident they believe others around them would be in taking practical actions to prevent contracting COVID-19 using a 4-point Likert scale from 1 (not at all) to 4 (very much). Additionally, self-efficacy was determined by asking how confident people felt that they could prevent contracting the disease. The respondents were asked each question on a rating scale from 1 ("not confident") to 4 (very confident). Respondents completed a survey concerning these categories.

Data analysis

A descriptive statistical analysis was used to examine the frequency of data on socio-demographic characteristics, risk perception, and efficacy belief toward COVID-19. All the variables were tested for normality using the Kolmogorov-Smirnov test, and none were normally distributed. Therefore, the Kruskal-Wallis and Mann-Whitney tests were employed to determine significant differences in the categorical independent variable (socio-demographics) on the dependent variable of risk perception (perceived vulnerability, perceived severity, perceived severity) and efficacy beliefs (response efficacy, self-efficacy). We analyzed the data using SPSS version 21.0. Values of p less than 0.05 were considered statistically significant.

The study sampled 232 eligible subjects who filled out the questionnaire with a response rate of 94.8%. After excluding five participants with incomplete data, a final sample of 227 subjects were required in the current study. The majority of participants who dominated the survey were female (56.8%), adult (60.4%), living in the western region (74.4%), holding higher degrees in education (63.9%), and married (67.4%). Overall, 89% of the participants had good health, 59% used supplements, and 4.8% had a prior history of chronic illness. Regarding income conditions, they still work outside the home daily (36.1%), whereas 52.0% have decreased income during the pandemic. Only 6.2% of participants provided direct financial aid from the government. The sociodemographics of the participant are listed in Table I.

TableI. Demographic characteristics of respondents.

Table II revealed a statistically significant difference between the efficacy responses between men and women (p = 0.045). Men participants had a significantly higher mean of response efficacy than women. Therefore, they are more confident in being able to take action in trying to prevent COVID-19. Moreover, men are physically stronger and emotionally more stable than women. Thus, they are more willing to take precautions to reduce their risk of COVID-1922. It is also likely because men have a lower immune system, which can be attributed to their differences in innate and adaptive immune responses. Sex-specific responses result from X chromosome inheritance which contains genes associated with high immunity23. Therefore, men perceived a higher efficacy response to prevent them from contracting COVID-19 during a pandemic.

This study also showed a significant difference in perceived threat between regions (p = 0.027). Participants in the western region had a significantly lower mean of a perceived threat than those in the middle or eastern regions. People living in the western region perceive that they are less likely to be exposed to the COVID-19 threat. The highest number of cases in Indonesia is in the western regions. World Health Organization estimates that as of February 3, 2022, 65.8% of Indonesia's cumulative confirmed cases have been reported on Java Island. In contrast, Jakarta has the highest number of confirmed cases per one million, followed by East Kalimantan, North Kalimantan, the Special Region of Yogyakarta, and Central Java24. The low perception of threat among people in the Western Region could affect adherence to health protocols. These regions also have high mobility and population density, where many business industrial centers are still operating continuously. It will be a potential cause of the increasing number of confirmed cases in this area.

Occupation differences also have a statistically significant relationship with perceived severity (p = 0.036) and self-efficacy (p = 0.018). Those who work in government have a significantly higher perceived seriousness than those who work in the private sector or entrepreneurship. It means that if government workers suffer from COVID, it will severely threaten them. The potentially higher risk of severe outcomes for COVID-19 depends on the worker's characteristics in various occupations25. Previous research26 has also demonstrated that government employees have the highest risk of serious adverse outcomes due to COVID-19. Furthermore, our study found that those in the private sector have a greater sense of self-efficacy than others. Private companies have stringent rules in issuing their employees' policies regarding work regulations and health protection due to the COVID-19 pandemic27. Therefore, private sector employees have more ability to defend themselves from the pandemic.

Our findings also revealed that smoking history and use of supplements were significantly correlated with self-efficacy (p = 0.037; p = 0.029, respectively). Non-smokers have a stronger belief in their capability to counteract the pandemic threat. Smoking can increase the likelihood of hand-to-mouth transmission of COVID-19. It can pose a significant threat to the COVID-19 spread since contaminated fingers and cigarette sticks will contact the smoker's lips28,29. A clinical study suggested that ACE2 may be the receptor being used by SARS-CoV-2 to gain entry into cells30,31. Meanwhile, cigarette smoke could induce mucosa, the primary source of ACE2 in the lungs. Smoking also increases ACE2 in the lungs, thus enhancing the individual's susceptibility to COVID-1932. This statement aligns with a study about tobacco smokers at high risk of developing severe co-infections due to impaired lung function, cross-infection, and vulnerable hygiene habits29. Furthermore, the mortality rate among smokers with COVID-19 infection is higher at 38.5% than non-smokers33.

Our study stated that people who consume nutritional supplements have significantly greater self-efficacy than those who do not. It indicates that they have a lower sense of risk associated with the pandemic threat, as they take supplements regularly. Regular diet supplementation with vitamins and micronutrients can enhance the immune system. It is a different approach to preventing the transmission of COVID-1934,35. Sahebnasagh et al.36 demonstrated that specific vitamins are vital in innate and adaptive immune responses. Vitamins A, D, E, C, and B have antioxidant and immunomodulatory properties which benefit the immune system. A study has shown that taking probiotics, omega-3 fatty acids, multivitamins, or vitamin D supplements can reduce the risk of positive COVID-19 test results37.

According to our findings, participants' mean perceived threat and severity score was (3.28±0.86) and (8.50±2.05), respectively. Furthermore, we identified that most respondents had moderate to high levels of concern regarding the risks related to COVID-19. The majority of participants revealed that they were susceptible to COVID-19. As COVID-19 cases increase significantly in the field, public concern in Indonesia regarding the severity of the disease and population vulnerability is also growing38.

TableII. Illness risk perceptions and efficacy beliefs toward COVID-19.

Note: * Significantly different

Table II reported that respondents' mean score of perceived severity was male (8.38±2.04) and female (8.59±2.06). This high score indicated that the perceived severity of COVID-19 among males and females was severe and fatal. The general population's severity perception in Indonesia is higher than in the Myanmar-based study39. Similar results were found in a study in Hongkong40, in which all participants agreed that the COVID-19 disease was very severe. Regarding the pandemic, the internet and other information sources can better influence people's thinking in applying protective measures41. A study reported that respondents in Indonesia had taken more protective behavior. People who often get information related to COVID will have firmer self-efficacy beliefs42. Mya et al.39 have reported that individuals would engage in more protective behavior due to easy access to mass media and social media.

A person perceiving the high risk of COVID-19 is likely to feel stress, panic, depression, and try to adapt to others' behavior. It is because strong negative emotions could encourage one to think about protective behavior in the face of this pandemic43. Nevertheless, the higher threat perceived by vulnerable groups may increase their self-protective behavior, which is beneficial in pandemic control. However, those with a low-risk perception of COVID-19 are less likely to engage in protective behavior. Thus, public health education is targeted at this group44.

Understanding risk perception is a complex phenomenon created from various psychological, social, and cultural factors in different places and times. This phenomenon can be interpreted as a form of pandemic preparedness. Based on previous studies, risk perception can assess and evaluate an individual's response to a pandemic45. Though perceived risk acts as a trigger for preventive actions, it is also determined by a person's social networks, community beliefs, and the source of information about health behavior46. Social networks may amplify the spread of beneficial or dangerous behavior during this COVID-19 pandemic47. As a non-medical measure, personal protective practices are needed to control the COVID-19 pandemic by implementing health protocols, wearing masks, avoiding crowds, and maintaining social distancing. The community's willingness could play a vital role in successfully implementing government policies48.

We concluded a moderate to high level of risk perceptions associated with COVID-19 in Indonesia's general population. Additionally, they had a relatively good efficacy response in adopting self-protection measures during the COVID-19 pandemic. The public's risk perception of a pandemic contributes to increasing participation in preventing the COVID-19 pandemic. Furthermore, these findings will contribute to the health authorities regarding COVID-19 pandemic risk communication management.

We are grateful to all participants who gave their time to this research. The authors received no financial support for this study, authorship, or publication.

Lolita: study design, methodology, data collection, validation, and writing–original draft. Azis Ikhsanudin: data management, data collection, visualization, statistical analysis, and editing.

None.

The authors declare no conflict of interest.

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