'Believe it or not, it's Covid-19':
Family Perceptions of Covid-19 in Palembang, Indonesia
Najmah, Siti Khodijah, Najema Alkaff, Siti Fadhila Muharomah, Fenny Etrawati, Achmad Fickry Faisya,
Sharyn Graham Davies, Tom Graham Davies and Sari Andajani
In early 2020 the World Health Organization (WHO) officially declared Covid-19 a global health pandemic. Almost all countries have been broadly affected by this disease. These impacts go far beyond health, to include broader social and economic effects. In February 2021, Indonesia reported the highest numbers of Covid-19 cases in South East Asia, with 1.29 million cases and 34,691 deaths. It should be noted that these official figures should be treated with caution as there is limited Covid-19 testing in Indonesia, as well as significant health facility disparities across thirty-four provinces and over 514 cities/municipalities. Therefore, reported cases may well be underestimated. For example, at the time of writing this research, the coverage of Covid-19 tests was about 15,000 per 1 million or just over 0.01 per cent of the population. In addition, limited testing and health infrastructure disparities are also compounded by geography, as Indonesia has over 270 million people scattered over five main islands and over 17,000 smaller ones.
Indonesia has issued a policy to control and prevent the spread of Covid-19 in the Government Regulation of the Republic of Indonesia, number 21 of 2020, concerning large-scale social restrictions to accelerate the handling of the Corona virus. The implementation of this policy includes the area of Palembang, South Sumatra Province. Sadly, this policy has proven to be ineffective in slowing the growth of cases of Covid-19 infection. The resulting economic impact of social restrictions resulted in a slowing of Indonesia's growth rate, causing the government to relax the 'large-scale social restrictions'. As a result, the relaxation of policy may have influenced family perceptions of Covid-19. Just as many governments appear to have made decisions incorporating, or even favouring economic health, over reduced death rates, preventive health behaviours and health decisions at the individual level may also be strongly influenced by perceptions of the cost and benefits of specific choices for individual and family members.
Godfrey Hochbaum (1958) cited in Irwin Rosenstock, authored early studies regarding the role of perceptual factors as part of efforts to prevent and control illness conditions, within the Health Belief Model (HBM). The primary concept of the HBM includes perceptions of success, severity, benefits, barriers, cues to action and self-efficacy. Also, the belief that one is susceptible to a severe health problem or the sequelae of that illness or condition.
Cost refers to perceived barriers that must be overcome to follow the health recommendations and includes, but is not restricted to, financial outlays. Therefore, to optimise policies aimed at behavioural change to protect individuals and community from Covid-19, messages need to successfully challenge perceived barriers, highlight benefits to conducting Covid-19 prevention, as well as targeting individuals' belief in their capacity to undertake Covid-19 prevention, as well as garnering a realistic understanding of the threat posed by Covid-19.
Munir Ahmad, Khadeeja Iram and Gul Jabeen also highlight the role of perceptions of Covid-19 and how they might contribute to preventative behaviours, particularly at the family level. These authors note that, with complex intersected factors, family perceptions related to Covid-19 are varied. These factors include threat perception, trust, and compliance towards leadership, risk communication of Covid-19, and social norms and cultures. The perception of Covid 19 may also be related to health literacy regarding the risk of Covid-19 to the general population in relation to the proliferation of social media.
While social media offers many health experts the capability of conveying accurate and robust information about the hazards of Covid 19 quickly to a large-scale and dispersed audience, it also provides a platform, or even encourages others to counter expert knowledge with the spread of misinformation.
This research is divided into three main sections. Section One provides an overview of the Pangling Project in Palembang, South Sumatra and outlines our research methods, including our research framework, participant recruitment and data analysis. In Section Two, we provide a brief overview of Indonesia's response to Covid, followed by our results and discussions, by way of a thematic analysis, which unpacks some of the impacts of Covid and how they intersect with social media, religious views and economic pressures, within a uniquely Indonesian context.
Research methods: The Pangling Project, Palembang, South Sumatra
The Pangling or Penyuluhan Keliling Anak project was a mobile community awareness program to raise children's awareness of Covid-19 and its prevention. This project was conducted in two small clusters (kampung), kelurahan (sub-district) 13 Ulu and 14 Ulu in Palembang-city, South Sumatra. The Ministry of Administrative and Bureaucratic Reform awarded Pangling a national top 21 public service innovation award for mitigating Covid-19 in Indonesia and the project came in the top three at community level.
The Pangling Project was started in April 2020 with ten female volunteers being drawn from groups of mothers and wives (ibu rumah tangga), teachers in an Islamic school, a kindergarten, as well as students at university. The project educated over 250 children (aged five to twelve years) by targeting weekend recreational areas. The volunteers distributed over 1,000 masks and 300 sanitation packs that were funded by donations and an online media campaign. All the work with the children and the subsequent interviews were conducted in Indonesian. The interviews were then translated into English for this paper.
Research framework: Feminist-Participatory Action Research (PAR)
The Pangling Project employed a Feminist-Participatory-Action Research (PAR) framework to encourage volunteers to get involved in this project. Initially, Najmah was worried about going to the field in the early days of a pandemic in Indonesia. Yet, after discussion with some female volunteers, they said, 'We can go to the field as this is our own kampong [village]' (Field notes, April 2020). After four months, Najmah discussed with ten volunteers about whether it would be effective if the Pangling Project was conducted without them understanding the families' perceptions towards Covid-19, particularly after the government introduced the propaganda of New Normal in the middle of June 2020.
Najmah listened to learn and learned to listen from the voices of female volunteers. One volunteer said to her: 'Kids' parents cannot force kids to wear masks as their children cried when their mothers asked them to use the mask.' Another volunteer said, 'It might not be effective to distribute face masks to families. People in our kampung stopped believing that Corona is real. Kids in our kampong … stopped using masks. The kids played with other kids [with] no masks.'
Figure 1 summarises the research cycle of Feminist-PAR in this study by adopting some principles and dimensions of Feminist research by M. Brinton Lykes and Rachel Hershberg, and Colleen Reid and Wendy Frisby and Participatory Action based on research by Alice McIntyre and Hal Lawson and colleagues. Applying a Feminist-PAR, we highlight the centrality of a woman's position in decision-making and action. This PAR method is followed by co-constructing knowledge and engaging in the co-learning process through women's shared experiences, thoughts, and aspirations during the process. In Feminist-PAR, the researchers were encouraged to adopt four primary attitudes and actions:
- a critical mindset
- a 'Go-along' interview technique to engage a 'deep voice' from participants
- using observation, ethnography, diary notes, participant's response from a Covid-19 poster, reflection notes from weekly, online-discussion groups or face-to-face meetings, as a form of triangulation
- accounting for intersectionality to understand complex factors that contribute to individual perceptions of Covid-19.
Figure 1. Feminist-Participatory Action Research (PAR) cycle of enabling female volunteers' involvement in research
Source. Developed by Najmah. © Namjah 2021
There were thirty participants in this study aged from twenty-four to sixty years, consisting of twelve males and eighteen females. Participants were recruited using purposive sampling. The participants' inclusion criteria were:
- from low to middle income families
- living in Palembang, South Sumatra
- working in informal and formal sectors.
Out of the thirty participants, a third were university educated. All-female participants identified themselves as housewives (ibu rumah tangga), though most of them also worked to support their families. Among the twelve male participants, ten worked in informal sectors, and two of them were key leaders in the community (for more detail, see Appendix 1).
Richard Carpiano's (2009), notion of the go-along interview was used to gain meaningful insights into participants' strengths, capacities, and assets within their networks that allow for the process of empowerment to happen. This technique encouraged insights to develop, which might not be easily noticed during a more formal interview process with open-ended questions. We conducted go-along interviews with over thirty women, and men aged from twenty to sixty years from kampung 13 Ulu. They were our neighbours, friends, and other people we met in our daily activity. The first four authors produced observation and field notes. Interviews and observations were conducted in different settings, universities, schools, and neighbourhoods.
Najmah, Siti Khodijah, Najema Alkaff and Siti Fadhila conducted interviews, compiled field notes and and produced coding and themes, which were then discussed with Sari Andajani to discern the final themes to be included in this article. Field notes were used to complement the contextual understanding of the themes derived from the data. The field notes included a description of research activities, details of participants involved, observations of the research process and participants' evaluations of research activities. Researcher field notes were also analysed and included a focus on self-reflection as a critical research tool.
Results and discussion: At a glance: Indonesia's approach to mitigating Covid
In the early stages of the Covid epidemic, neighbouring countries, such as Singapore, Thailand and Malaysia, openly reported their first cases. In contrast, Indonesia failed to officially detect any cases at all. This is unsurprising as the Indonesian government's response to Covid tends to be one of Covid denial and playing down the danger posed by the disease. The World Health Organization (WHO) was concerned that Indonesia had not reported a single confirmed case in the nation of nearly 270 million people. Covid denial can be seen in the way the WHO was 'assured' by relevant authorities that laboratory testing in Indonesia was working well. In contrast to worldwide analysis of the danger posed by Covid, the Indonesia Ministry of Health concluded that the: 'Flu is more dangerous than coronavirus' (Flu lebih berbahaya daripada virus korona).
In March 2020 however, the first cases of Covid were officially announced. As the disease gained ground, shortages of personal protective equipment (PPE) for health workers became a worrying issue. Due to shortages, health workers were reduced to wearing raincoats as a substitute for hazmat suits to protect themselves. Wide-scale social restrictions were also put in place causing a widespread economic downturn and the Rupiah lost nearly a quarter of its value. Cognisant of the economic turmoil, the Indonesian government backtracked and Covid denial evolved into official policy in the form of a policy titled 'The New Normal'. The 'New Normal' represents a reversal of large-scale social restrictions or Pembatasan Sosial Berskala Besar (PSBB), and may be interpreted by most of Indonesia as 'back to normal'.
The New Normal was a form of Covid denial propaganda, which became the rational for the Indonesian government to focus on economic recovery, as well as playing down the potential impact by promoting trials of Covid-19 vaccines in 2020. As part of the lacklustre governmental response, parallels may be drawn to Sweden's policy of naturally developing herd immunity and the equally disastrous United States' response which saw over 500,000 deaths (January 2020–February 2021). Both of these examples prioritised economic development over protecting human life, to catastrophic effect.
A corollary of Covid denial was the Indonesian Government's public information campaign, which may charitably be described as unclear. An example, is the mixed message delivered by President Joko Widodo who appeared to be suggesting that it was possible to have both strict health protocols in place, and for people to go about their lives normally.
We must coexist with Covid-19 (hidup berdampingan dengan virus Korona). Most importantly, people must stay productive and be safe from the virus. Living in peace with it does not mean we are giving up, but we are adapting. We fight the virus by prioritizing and requiring strict health protocol.
Figure 2 summarises the messages and actions taken by the Indonesian Government.
Figure 2. Denial after denial of Covid-19 in Indonesia during 2020
Source. Developed by Najmah. © Najmah 2021.
The about-face of the official narrative related to Covid-19, may be evidenced through Presidential Decree Number 9. In 2020, the National Disaster Management Agency (BNPB – Badan Nasional Penanggulangan Bencana) was given primary responsibility for responding to Covid-19 in collaboration with other ministries, including the Ministry of Health, and the Ministry of State-Owned Corporation (BUMN – Badan Usaha Milik Negara), the Ministry of Defence, and the Indonesian Police. However, the Task Force for Covid-19 was later replaced by the Task Force for Covid-19 and Economic Recovery on 20 July 2020. The head of coordination is the Ministry of State-Owned Corporations,  clearly signalling the government's priorities in this area
Perceptions of Covid-19
A further corollary of covid denial may also be witnessed by the unclear information dissemination pertaining to the overall level of the risk of Covid-19. At the public level, the message of denial has, in turn, contributed to a lack of perceived susceptibility to the threat of Covid-19 in the wider population. During our interviews it quickly became apparent that these concerns were indeed correct, mirroring an ambivalent government position. The above concerns, we found, became apparent in the data collection and analysis phases of our research.
Analysis of the interview data produced three main themes related to common perceptions of Covid-19.
I believe in Corona as a motivation to adopt a particular health behaviour.
- I do not believe in Covid 19: self-perceived susceptibility.
- I hesitate, or I am not sure.
These themes are addressed individually in the following sections.
Corona culture: Motivation to adopt healthy behaviour
All participants had heard of Covid-19, and when we asked what Corona was, a common reply was: 'Corona is originally from China', and the 'Corona virus can attack the respiratory system', and 'Coronavirus is really dangerous and can result in death'. The participants were also aware of taking early precautions to protect themselves and their families from Covid-19, such as regular handwashing, physical distancing, and wearing masks outside or in a crowd.
Yet only a small proportion, five out of thirty subjects, believed that Covid-19 was a real phenomenon. Some went as far as claiming that Corona is 'only a hoax', 'not real', and it is only [a] way for the government to earn money for health programs'.
It was also interesting to note that all participants who thought that the threat of Covid 19 was real, were women. It was thought among the researchers that this was perhaps a result of selection bias, but it also might reflect a gender element where women are more likely to be carers for children and elderly and therefore may be more likely to experience the effects of Covid firsthand. The intersection between gender and a higher rate of belief in Covid may also be explained as women are more likely to be employed in the health and education sectors.
Drawing from her personal experience, one participant, a female teacher, explained her belief in the existence of Covid-19. She emphasised the importance of trusted information from one's family member who worked in a public health centre. Najema Alkaff asks, 'Do you think, is coronavirus real?' and 'Why do you believe in the existence of Corona?' The teacher responded:
Yes, the virus is hazardous. It can attack our respiratory system and result in death. There is a lot of evidence of many mortality cases related to Covid-19, not only in our country but also worldwide. It is impossible all the world was lied to; otherwise, we pretend not to know it. My sister worked in a community health centre (puskesmas), and she explained that there are many Covid-19 cases. Health workers know about it, so I always asked her. Our family was so cautious to prevent Covid-19. If my sister went home from puskesmas, my mother asked her to directly take a bath as we did not know who had interacted with her during her work in puskesmas. (Ani, female, 36 years old, teacher and housewife, bachelor's degree).
In contrast, the opposite position was held by male participants. They also relied on social networks or peer solidarity to form an opinion of their perceived level of threat. In an Islamic gathering (pengajian) or Friday prayer (Shalat Jum'at) in the kampung, if only a few people wore a mask within a crowd, others were likely to bully or tease them. As one participant put it: 'Uncle, there was no corona, only you wore a mask in this mosque; please look at us' (pointing at those not using masks) (Fieldnotes, Sept. 2020).
Sometimes, men would also make light of Covid 19, for instance, when one person sneezed, the male crowd said 'corona, corona' and laughed. Another man said, 'Whatever!' (matilah sana). Sadly, the man who sneezed did not cover his mouth with a hand or elbow to reduce the risk of transmission (Fieldnotes, Sept. 2020). It may be, we argue, that to be accepted within the community, men may decide not to obey health protocols to save face (jaga muka) rather than to protect themselves and their families from the risk of Covid-19.
Disbelieving Corona virus
At the time of this study, in September 2020 in Indonesia, there were approximately 4,000 new cases of Covid-19 and 50 to 100 deaths related to Covid-19 daily. Twenty-five participants shared their disbelief about Corona, with the following reasons given:
'The virus is human-made from China' or 'Indonesia is not the same as China, in climate, etc.'
- 'Corona has been blown out of proportion by the government.'
- 'Corona is just like a common cold, flu, and cough.'
In this study, most participants tended not to believe in Covid-19 or be hesitant about believing it is real as they never saw patients with Covid-19 within their neighbourhood. Participants also suggested that people who were diagnosed with Corona, were not real. These participants believed that people diagnosed with Covid-19 suffered from other diseases, like heart-attacks, or conditions relating to being old.
Personal experience of Covid may also lead to further ambiguity. Many participants argued that none of the people surrounding them were sick or had died from Covid-19. So, Corona is therefore a hoax! The participants discussed how they knew about Covid-19 patients only from watching TV. They had never seen people with Corona in their daily life.
We have never seen anyone or any patients of Covid-19. People only know if they feel sick and go to the hospitals, they will immediately be diagnosed with Corona. People will [only] believe it, [if] the family of a patient who has looked after him or her for a long time. (Siti, female, 26 years old, housewife and senior high school graduate)
I got the information about Corona from television; I never saw ... people with Corona directly. There was no proof; it is a hoax. People with heart diseases were diagnosed with Corona; people with epilepsy were diagnosed with Corona. (Eni, female, 40 years old, street food vendor, junior high school graduate)
In our area, I think no one believes in Corona. You can observe our site; everything seems safe; there have not been any cases of Corona. The government escalated the information and report[ing] of the numbers of corona cases. (Hasan, male, 49 years old, trader of fish cakes, senior high school graduate).
Institutional uncertainty and risk
In this thematic node, the intersection between religion, class and covid denial propaganda is apparent. Some participants in this study said, 'Percayo dak pecayo' (Believe it or not) suggesting that participants may know that the virus exists; therefore, they also engage in early prevention to protect themselves from Corona, such as cleaning their house, using masks, and maintaining physical distancing. However, to strengthen the individual's resilience in dealing with Covid-19, they may not have wanted to think about Covid-19 too much as they needed to earn money to support their livelihoods, and they believed the Covid-19 Pandemic was a trial (cobaan) from God.
I believe in, and I don't believe in [Covid], as far as we take care of ourselves. I was diligent in washing my hands, using masks when going outside, and soon I would have a wash or shower after going out. (Desi, female, 35 years old, street food vendor, senior high school graduate)
The trickling down of the Covid denial narrative also plays a role in how health professions within Indonesia are perceived. We recorded, that despite a generalised belief in Covid, it was believed by some individuals that false diagnoses occurred at many health centres (puskemas). This belief acted as a deterrent to stop people from visiting such centres in the belief that despite whatever issues or symptoms they might present with, they would be falsely diagnosed as having Covd-19.
I believe in Corona, so we need to be vigilant. However, if you were sick, please do not go to the hospital and community health centre. Health workers would ask you many questions, and then they would diagnose you as Covid-19. (Mat Gofar, male, 42 years old, street food vendor, senior high school graduate)
Factors influencing perceived risk
In this section, we analyse perceptions of risk within a context of the evolving political messages we outlined in Section Two. These messages shifted from outright denial through to acceptance and action and then finally to the self-contradictory policy of the New Normal.
Initially, actors within Indonesian society may demonstrate a belief in Covid-19 and the danger it poses. The participants in this study may have experienced these messages which reflect their beliefs in the media and governmental sources. In contrast to the Indonesian government's initial response of Covid-denial, as outlined in Figure 2, the intensive health education surrounding Covid-19 has clearly impacted on the view they now have of Covid-19. Public perception, however, has shifted in Indonesia, broadly following the announcement of the New Normal.
This study reveals some factors that may intersect with the New Normal perception of Covid-19. The elements include:
misleading information from the media and peer groups
economic pressures undermining Covid prevention
- the lack of understanding of Covid health promotion
- family's and neighbour's perception of Covid-19 and
5) the interpretation of religious teachings in dealing with the Pandemic. Many factors influenced notions of risk and threat as we now outline.
Misleading information from media and peer groups
One of the issues related to Covid-19 is the perception of the ways that hospitals and doctors are purported to diagnose every patient as Covid-19 positive when they accessed health services. A corollary of this perception was that medical professionals were profiting from the fear of the Covid virus by falsely diagnosing patients and requiring Covid tests. While we are unaware of any evidence to support these assertions, the question was raised in the media. One headline stated: 'Doctors reject the accusation that they are extracting economic benefits by asking every patient to get a Covid-19 test' or 'Health professional organisation denies taking profits amid the Covid-19 pagebluck.'
The perception of profiteering from testing practices may have arisen from the practice that every patient who was hospitalised had to be tested for Covid-19. In addition, the perception of profiteering was reinforced by the enactment of stricter Covid protocols in relation to how hospitals and health centres handled the cadavers of people who died in care. As result of this new regimen, patients who died in the hospital were more likely to be buried with Covid-19 protocols. Consequently, people were afraid of visiting public hospitals and chose instead to see private practice doctors when they felt sick. Many participants shared such views with us:
Initially, I believed in Corona, that it is real. I was so careful and took so many precautions when I went to brick-a-brack stalls. But now, I do not believe in Corona anymore. I felt I was being lied to by the media. I have watched the information on the private station, and there was a health expert, I forgot his name, and he said that health services took advantage of this pandemic. The news about Corona was overwhelming. From that moment, I started to not believe in Corona. There was something wrong. It was a challenging situation. Additionally, kids were studying at home. We felt sorry for our kids' parents. We, teachers, also felt the same. (Anti, female, 44 years old, teacher and housewife, bachelor's degree)
Another participant added:
I believe in Corona, so we need to be vigilant. However, if you [are] sick, please do not go to the hospital and community health centre. Health workers would ask you many questions, and then they would diagnose you as Covid-19. Yesterday, my wife was sick; I went to a doctor in his private practice. The doctor did not say anything about Corona. The doctor only asked about my wife's symptoms I said she had a headache. Then he checked my wife. The doctor used [a] face-shield and masks and prescribed medicines. (Mat Gofar, male, 42 years old, street food vendor, senior high school graduate)
The lack of explanation from the Ministry of Health and health services concerning health workers' incentives appeared to enhance the fears held by participants.
Economic pressures undermining Covid-19 prevention
Economic pressures clearly played a part in undermining belief on Covid-19, both at the central government level as well as individual and family levels. Families from low to middle income brackets may well have believed in Corona in the initial stages of the virus. However, economic pressures which were amplified by anti-Covid policies forced many into the unenviable position of having to choose between risking infection by leaving home to earn much needed money to feed their family, or, to stay at home with their family and endure conditions of deprivation or even in some cases, starvation. This dilemma was expressed by one participant:
I was accompanied by my best friend whose husband needed treatment from the hospital. Her husband was [Covid] positive and sought health care services in a private hospital. The doctor said that he [should] stay at home … rest and take some vitamins. However, he still needed to work despite his positive status. We know that if we talk about food needs, people may not think of Corona again. (Asti, female, 38 years old, soybean milk vendor, bachelor's degree)
Many of the women in this study earned income for their family from outside the home in the informal sector. As a result, policies aimed at supporting those affected by the economic downturn were difficult to implement as much economic activity, i.e., working, is not recorded through taxation or otherwise. Consequently, the government's economic support was scattered, and not all people got this support, particularly women who are over-represented in the informal sector. As a result, many may distrust the governments' seriousness in mitigating the economic effects of Covid-19.
One of my family members passed away and was diagnosed with Covid-19. We rejected the hospital's wish to bury our family member with Covid-19 procedures in a particular cemetery for Covid-19 patients. But the hospital threatened us if we rejected their procedures. They would test all family members for Covid-19. If the results showed positive, all family members would be isolated in a different building. (Kanya, female, 35 years old, housewife, senior high school graduate)
Corona will die in this hot pan. We just need to keep our distance, take care of our health. We have not sold fried rice during the fasting month. Now we need to work to fulfil our daily necessities. You know the government's support was scattered. ( Adi, male, 49 years old, street food vendor, senior high school graduate).
A further example of inconsistent government policy undermining public confidence may be seen in relation to how public gatherings were managed. Government policy cancelled school activities but left unrestricted access to public spaces, such as markets and shopping malls. As one participant observed:
Lack of understanding of Covid-19 health promotions
Here we asked questions about how the participants in this study avoided the spread of Covid-19, maintained social distancing (SD) and adhered to the New Normal:
Yes, we have to wash hands, clean our house and spray disinfectants on rubbish bins. (Eka, female, 37 years old, housewife, elementary school graduate)
These responses may reflect the actions of participants through what the central and local governments did in the early stages of the pandemic, such as the widespread use of disinfectant in public spaces. In our study, some participants understood the importance of washing hands to prevent the spread of Covid-19, yet they also think that cleaning the house and spraying disinfectant on their rubbish bins may protect them from Covid-19. Furthermore, there was confusion around understanding the government's messages aimed at stopping the spread of Covid-19, particularly in the social large-distancing policy in April 2020, and New Normal in May 2020, Adapting to new habits in July 2020 and a mini lock down in September 2020.
We need to wash our hands. I did not get used to wearing a mask as I cannot breathe properly. We need to sweep, to mop, so our house is clean (Yanti, 33 years old, housewife, elementary school)
Social Large-Scale Distancing is enemy soldiers (pasukan sekutu) (laugh); SD, I suggest when people need to keep distance … I don't know. New normal is back to normal; the condition is getting better. (Eni, female, 40 years old, street food vendor, junior high school graduate)
[SD] is [when] people need to keep distance, traders were not allowed to sell their stuff, so there would not be many crowds. New normal, I am not sure, but I think we may do our daily activities again. We are free. Corona has vanished. (Desi)
[SD] is one prevention approach to avoid crowds. If our activities were not necessary, we did not need to go outside. [With the] New normal, we aim to return to normal activities, but still need to maintain our health. That is what I understand. (Anti)
Health literacy and the family unit
Perceptions related to Covid-19 from family members and neighbours may also impact on individuals' health literacy. In this study, we found that if a person has one family member working in a health setting the family's belief in Corona may be affected. Health workers dealt directly with Covid-19 patients and based their experiences on the health setting. The lived experience of family members who interacted directly with Covid-19 patients necessarily impacted on their' health literacy. In Indonesian culture, a family has a basic need for affection with a strong bond and it is a source of advice. For instance, the children will follow their mother's advice to wear masks because they love and respect their mother. Najmah asked about what people think about the doctors and health settings.
Many people do not understand. For instance, if one of your family visited the hospital, and was confirmed Covid-19, they [the family member] would deny the result
: As far as we know, people with asymptomatic Covid-19 can endanger other people. In reality, many asymptomatic patients of Covid-19 thought they were healthy, but after getting tested for Covid-19, they were confirmed positive [for] Covid-19. Hospitals and health workers have fulfilled their work. My sister works in a community health centre, and she explained that there are many Covid-19 cases. Health workers know about it, so I always asked her. (Ani, female, 36, teacher and housewife, bachelor's degree)
Alternatively, individuals' perceptions about Corona may contribute to a lower level of perceived threat of Covid-19 due to what they see on a daily basis in the surrounding neighbourhood. A family afraid of Covid-19 enacted preventive protocols. The older generation (over 50 years old) may see what they observed in their neighbourhood. For instance: 'kids who play outside seem healthier than your kids who just stay home during the Pandemic and [are] sick' (Tomi, male, 45, religious leader and parent, senior high school graduate). Another instance was that the community gathered for their daily activity without using masks, such as daily praying in mosques. They believed that no one of them got infected with Covid-19 after three months of their gatherings for prayer.
In these three months, we always prayed in a small mosque (mushola), without using masks. Not one of us got infected with Covid-19. In television, there were many reported Covid-19 cases, yet we did not know who they were. So we did not believe in Corona; all news on television about reported cases of Covid-19 is fake. So we need to be aware of other diseases, not Covid-19. (Erwin, male, 60 years old, community leader, primary high school graduate)
Religious doctrine and Covid
The interpretation of religious teachings in dealing with pandemics is a key factor in understanding Indonesian responses to Covid. A common theme from the participants' responses relates to the religious notion of tawakal dengan Allah swt or God willing. This commonly held belief means essentially that what will happen in one's life or the future is God's intended destiny. This fatalistic understanding of religious doctrine, in our view, arguably undermined efforts to perform preventive measures in people's daily lives. If one accepts the view that lives are largely pre-destined to follow a pre-determined trajectory, it follows that personal decisions may make little or no difference in a person's life. Therefore there is little to be gained from attempting to take control of the events in one's life or taking responsibility for important decisions. In terms of responses to Covid, from this point of view, it also follows that if Covid is God's will, then actions to reduce its impact will also have little or no effect.
However, not all participants believed this to be the case and some religious leaders provided guidance on this issue by encouraging their followers to carry out early prevention by providing handwashing facilities and free masks in centres of Islamic gatherings. Indeed, ritualistic cleansing of the face and hands or wudu before prayer is one key aspect of Islam that synergizes well with Covid guidelines.
In this light, religiousness can be seen as a potential means of strengthening individual and community resilience in dealing with the Pandemic in Indonesia. One participant described her experience of how centres of faith can implement and potentially enhance Covid health guidelines.
We wore masks from home to Islamic gathering in [the] mosque. But we open our masks when we entered the mosque as the female Islamic teacher opened her cadar (burqa). The teacher explained to us we can shake… hand[s], but after we went home, please wash [them] as soon as possible. I suggest that the teacher thinks Corona still exists, but we did not need to worry too much as long as we … obey health protocol and depend on our life to God (tawakal). Therefore, being a Muslim, we need to deal with this calamity, and God will ease our ways for those who were patient and pray to God. (Ika, female, 55 years old, street food vendor, senior high school graduate)
As most Indonesians are practicing Muslims, the above statement highlights the potential of the Islamic faith, as a critical nexus of many of Indonesian's social networks, to act as a conduit for delivering consistent health messages. In addition, as shown above, the role of peer acceptance of attitudes towards Covid-19 guidelines can mean the difference between failure and general compliance.
Conclusion and recommendations
This article shows that there are a variety of understandings about Covid-19 within Indonesia, both at the central government and the individual level. We have shown that ithout clear and unified messaging from the government or national health bodies, people receive mixed messages about the impact of Covid-19 and what measures should be followed to slow infection. These competing narratives surrounding Covid-19 mean that people are unsure about where they can get reliable information about the disease and how to prevent further infection.
The lack of a unified message is compounded by a lack of understanding among families where education levels are low. Health messages are even further diluted, even amongst educated families, through the power of social media and its penchant for disseminating a variety of often contradictory 'truths'. Even where people understand the true dangers posed by Covid-19, without adequate resources, there is little they can do to protect themselves if economic necessity drives them out of the home because of the need to generate enough income for survival.
Given these factors, we have three recommendations for the government. First, the government and official health institutions should collectively develop a coherent and consistent message delivered across all sectors of Indonesian society, particularly those in more deprived areas. Second, the government must improve their data collection practices, better identifying those who work in the informal sector. More accurate knowledge of the informal work sector should lead to better targeting of the wage subsidy, particularly for women. Finally, improved resourcing and distribution of personal protection equipment for frontline health staff and centres. If the national government can prioritise these key areas, Indonesia will be better equipped to deal with the ongoing impacts of the Covid-19 pandemic.
Appendix 1. Participants' pseudonyms with characteristics
|Anti||female||44||teacher and housewife||bachelor's degree|
|Ani||female||36||teacher and housewife||bachelor's degree|
|Maya||female||39||teacher and housewife||bachelor's degree|
|Yanti||female||33||housewife||senior high school|
|Siti||female||26||housewife||senior high school|
|Yunita||female||38||teacher and housewife||bachelor's degree|
|Kanya||female||35||housewife||senior high school|
|Sarah||female||27||housemaid||elementary school |
|Desi||female||35||street food vendor||senior high school|
|Eni||female||40||street food vendor||junior high school|
|Asti||female||38||soybean milk vendor||bachelor's degree|
|Ika||female||55||street food vendor||senior high school|
|Mat Gofar||male||42||street food vendor||senior high school |
|Johan||male||36||private sector||bachelor's degree|
|Erwin||male||60||community leader||primary high school |
|Hasan ||male||49||trader of fish cakes||senior high school |
|Adi ||male||49||street food vendor||senior high school |
|Bay ||male||35||community leader ||diploma|
|Tomi ||male||45||religious leader||senior high school |
|Yayan ||male||37||religious leader||bachelor's degree|
|Jamal ||male||50||civil servant (PNS)||bachelor's degree|
|Yanto||male||40||driver||senior high school |
|Komar ||male||43||driver ||elementary school|
|Kamal||male||45||street food vendor||senior high school |
Unless otherwise stated, all URLs were working on 11 Mar. 2021.
 Figures obtained 23 Feb. 2021 from Google: Corona Virus Disease, Indonesia.
 President of Indonesia, Peraturan Pemerintah Nomor 21 Tahun 2020 tentang Pembatasan Sosial Berskala Besar Dalam Rangka Percepatan Penanganan Coronavirus Disease 2019/COVID-19 (Governmental regulation number 21 in 2020 about large-scale social restrictions in mitigating Covid19. Jakarta: Indonesia), 2020.
 Muhammad Irawan, Muhammad Rizki, Tri Joewono and Prawira Belgiawan, 'Exploring the intention of out-of-home activities participation during new normal conditions in Indonesian cities,' Transportation Research Interdisciplinary Perspective 8 (2020):1–6, doi: 10.1016/j.trip.2020.100237.
 Jay Bavel, Katherine Baicker and Robb Willer, 'Using social and behavioral science to support COVID-19 pandemic response,' Nature Human Behaviour 4 (2020): 460–71, doi: https://doi.org/10.1038/s41562-020-0884-z. See also Najmah and Sharyn Davies, 'Working together: Exploring grass-root initiatives to mitigate Covid-19 in Indonesia,' submitted to LSE Saw Swee Hock Southeast Asia Centre (SEAC).
 Irwin Rosenstock, 'Historical origins of the health belief model,' Health Education Monographs 2 (1974): 328–35, doi: 10.1177/109019817400200403.
 Bavel, Baicker and Willer, 'Using social and behavioral science to support COVID-19 pandemic response,' 461.
 Munir Ahmad, Khadeeja Iram and Gul Jabeen, 'Perception-based influence factors of intention to adopt COVID-19 epidemic prevention in China,' Environmental Research 190 (2020): 1–9, doi: 10.1016/j.envres.2020.109995.
 Yani Ding, Xueying Du, Qinmei Li, Miao Zhang, Qingjun Zhang, Xiaodong Tan and Qing Liu, 'Risk perception of coronavirus disease 2019 (COVID-19) and its related factors among college students in China during the quarantine,' PloS one 15(8) (2020): 1–13, doi: 10.1371/journal.pone.0237626.
 Kristen Malecki, Julie Keating and Nasia Safdar, 'Crisis communication and public perception of COVID-19 risk in the era of social media,' Clinical Infectious Diseases 72(4) (2020):697–702, doi: 10.1093/cid/ciaa758.
 Ministry of Administrative and Bureaucratic Reform. 'The Ministry announces the top 21 Innovations of public services in mitigating Covid-19,' 2020.
 Najmah Yeni and Sharyn Davies, 'Predictive modelling, empowering women, and Covid-19 in South Sumatra, Indonesia,' ASEAN Journal of Community Engagement 4(1) (2020): 103–13.
 M. Brinton Lykes and Rachel Hershberg, 'Participatory Action Research and Feminism: Social Inequalities and Transformative Praxis,' in Handbook of Feminist Research: Theory and Praxis, ed. Sharlene Nagy Hesse-Biber, 331–67, Thousand Oaks, CA: SAGE Publications, 2012; Colleen Reid and Wendy Frisby, 'Continuing the Journey: Articulating Dimensions of Feminist Participatory Action Research (FPAR),' in Sage Handbook of Action Research: Participative Inquiry and Practice, ed. Peter Reason and Hilary Bradbury, 93–105, London: SAGE Publications, 2008.
 Reid and Frisby, 'Continuing the Journey.'
 Alice McIntyre, Participatory Action Research, Qualitative Research Methods Series 52, Los Angeles, CA: SAGE Publications California, 2008; Yeni and Davies, 'Predictive modelling, empowering women, and Covid-19 in South Sumatra, Indonesia.'
 Hal Lawson, James Pyles, Janine Jurkowski and Christine Bozlak, Participatory Action Research, Pocket Guides to Social Work Research Methods, Oxford: Oxford University Press, 2012; Reid and Frisby, 'Continuing the Journey,' 97–101.
 Najmah, 'My baby deserves love, not HIV: Enabling HIV-positive to access prevention of mother-to child transmission of HIV services,' PhD thesis, Auckland University of Technology, 2019.
 The term ibu rumah tangga is generic and used to refer to married women who are either fully financially dependent on their husbands or who work to support their families.
 Richard Carpiano, 'Come take a walk with me: The "go-along" interview as a novel method for studying the implications of place for health and well-being,' Health and Place 15(1) (2020): 263–72, doi: 10.1016/j.healthplace.2008.05.003.
 Krishna Regmi and Jennie Naidoo, 'Understanding the processes of writing papers reflectively,' Nurse Researcher 20(6) (2013): 33–39, doi: 10.7748/nr2013.07.20.6.33.e320.
 James Massola, 'WHO concerned Indonesia appears to be Coronavirus free,' Sydney Morning Herald, 5 Feb. 2020.
 Dany Garjito and Aditya, Rifan, 'The way of communication of MoH-Terawan was criticized: Four statements of MoH about Corona became a spotlight,' Suara.com, 4 Mar. 2020.
 James Guild, 'The Economic Consequences of Coronavirus in Indonesia,' The Diplomat, 30 Mar. 2020.
 President Jokowidodo, statement, May 2020. The statement was quoted from Adjie, Fiqih Prawira. '"Let's coexist with Covid-19": Jokowi calls on residents to adapt to “new normal”,' Jakarta Post, 16 May 2020.
 Najmah, Sari Andajani and Sharyn Graham Davies, 'Health worker's vulnerability to Covid-19 in Indonesia: Chaos, loyalty, and broken trust,' in 1st International Conference on Social & Political Development Issues (ICONIDS), 25 Oct. 2020.
 Riyanti Djalante, Jonatan Lassa, David Setiamarga et al., 'Review and analysis of current responses to COVID-19 in Indonesia: Period of January to March 2020,' Progress in Disaster Science 6 (April 2020): 100091, doi: 10.1016/j.pdisas.2020.100091.
 Rizki Fachriansyah and Fathur Rahman, 'Erick Thohir set to oversee the newly formed Covid-19 mitigation/economic recovery team,' Jakarta Post, 20 Jul. 2020.
 All participants were given a pseudonym. Their details can be found in Appendix 1.
 Editorial team, 'Health Professional Organization denies taking profits amidst the Covid-19 pagebluk,' VOI, 10 June 2020; Sandy Lesmana, 'Doctors reject the accusation that they are extracting economic benefits by asking every patient to get a Covid-19 test,' Suara.com, 6 Jun. 2020.