PRELIMINARY

 
The World Health Organization (WHO) states that COVID-19 is an infectious disease that attacks human
breathing. A person infected with COVID-19 will experience fever, fatigue, dry cough, and show signs and
symptoms of pneumonia. The COVID-19 virus is thought to spread among people mainly through droplets that
come from coughing, sneezing, or other means when interacting with an infected person. As of March 11, 2020,
there were 64,835 cases and 33,106 deaths worldwide, so WHO announced COVID-19 as a pandemic (Kompas,
2020).

In Indonesia, the COVID-19 pandemic situation is still not under control and spreading to various locations. From
the map of the spread of COVID-19 in Indonesia until December 21, 2020, 671 thousand positive patients were
recorded for COVID-19 (Covid19.go.id). A total of 546 thousand patients were declared cured of COVID-19 and
20,085 died. This figure continues to increase from March 1, 2020, where on March 1, 2020, there were no patients
who were positive in Indonesia.

Due to the increasing number of COVID-19 patients, the Indonesian government has begun implementing the
preventive measures recommended by WHO. WHO (2020) has established recommended preventive measures,
including washing hands, covering mouth when coughing, maintaining a distance of about 1.5 meters from other
people, and monitoring and conducting self-isolation for at least two weeks. The wider community is also asked to
carry out self-quarantine and physical distancing in their respective homes and not outside the house if they do not
have urgent interests. Many shops and downtown were closed. The government has urged celebrations such as
wedding receptions and other celebratory events to be postponed. The government also closed schools and
implemented a Distance Learning (PJJ) policy and appealed to office workers to Work From Home (WFH). Apart
from that, the Government also took policies such as limiting travel and canceling large mass gatherings.

Pandemics are often associated with stressors due to health threats to oneself and loved ones, disruption of
routines, separation from family and friends, lack of food and medicine, loss of wages, social isolation due to
quarantine or other social distancing programs, and school closures ( Taylor, 20 19 ). Various studies on the
psychological condition of society, including a survey on psychological distress conducted on 52,730 Chinese
people, found that women are most vulnerable to stress and are most likely to have a post-traumatic disorder (Qiu
et al., 2020). A community study in China found that of the 2,446 participants, nearly 80% had high levels of
anxiety, with women and young individuals likely to have higher levels of anxiety (Lin et al., 2020).

From the results of research conducted on March 31, 2020, in people in China with a total of 263 participants, it is
known that the majority of participants (53.3% of participants) felt helpless due to the pandemic, and 52.1% of
participants felt afraid and worried due to the pandemic. the. The COVID-19 pandemic is associated with the
impact of light stress on the ongoing COVID-19 pandemic (Zhang, et. Al. 2020). From research on people in Iran, it
was found that the prevalence of stress was 29.6%, anxiety was 31.9%, and depression was 33.7% of the total 9,074
participants in Iran (Salari et al., 2020). The study also found that people who frequently follow COVID-19 news
experience more anxiety. From research on communities in Bangladesh, it was found that as many as 85.6% of the
340 participants reported that they experienced stress due to the COVID-19 pandemic (Islam et al., 2020). The
study found that the COVID-19 pandemic is creating fear in Bangladeshis. The results of this study also found that
the stress experienced by the participants inhibited their sleep adequacy, made them irritable and temperamental,
created chaos or commotion in the family because of the many conflicts in the family, and some participants even
reported suicidal thoughts.

Health workers also experience psychological problems, especially nurses. This can result from the anxiety of being
infected with a virus or illness, unpreparedness with new procedures and work environments, discomfort due to
wearing special medical clothing, witnessing illness or death from a patient, being separated from the family
resulting in bad emotional reactions, doubt, and helplessness (Zhang et al. al., 2004). A study found that 85% of
first-line nurses on COVID-19 experienced severe emotional reactions, including 2 nurses experiencing depression,
16 nurses experiencing anxiety, and 21 nurses having stress (Xu et al., 2020).

In Indonesia, one of the most recent studies on the description of mental health during the COVID-19 pandemic was
carried out by the Master of Professional Psychology Majoring Adult Clinical Psychology Class of 2019
Universitas Padjadjaran about a description of the mental health conditions of the Indonesian people during the
COVID-19 pandemic and Physical Distancing in July 2020. Based on The results of research on the description of
mental health in Indonesia found that from 73 participants, it was found that the criteria for mental health were
predominantly healthy, as many as 47 participants (63.5%), 15 participants (20.3%) for mild disorders, 7
participants for moderate disorders. (9.5%), the criteria for severe disorders were 3 participants (4.1%), and the
criteria for very severe disorders were 1 participant (1.4%) (Master of Professional Psychology, Padjadjaran
University, 2020).

The various research results above illustrate the psychological conditions experienced by people during a
pandemic, including stress, depression, and anxiety. How stress, depression, and anxiety in individuals will affect
individual compliance can be explained by how the individual perceives events that individuals experience during
the COVID-19 pandemic. An individual's perception of an event experienced or a person's negative appraisal
largely determines whether the event he experiences can have positive or negative consequences (Lazarus &
Folkman, 1984). In the context of reacting to stressful situations, appraisal ( appraisal ) will generate emotions and
immediately provide emotional reactions in various forms. Referring to Lazarus and Folkman, stress is a
consequence of an individual's assessment of the events he experiences, primary appraisal occurs when someone
tries to understand the events that occur and tries to interpret those events. Events can be assessed in the form of
danger (harm ), threat ( threat ), or challenge ( challenge ). Assessing the situation as a danger or threat ( harm or
threat ) will usually be associated with negative emotions, such as boredom, anger, and assess the situation full of
threats, which will make the individuals experiencing stress.

Apart from the primary appraisal, there is also a secondary appraisal, which is how individuals assess whether
their resources are sufficient to meet the demands of the environment (Lazarus & Folkman, 1984). According to
Taylor (2015) when a person's resources are more than sufficient to deal with a difficult situation, he may feel a
little stressed and instead make the situation a challenge. Meanwhile, when the person feels that there may be
enough resources to handle the event but with just a lot of effort, he or she may feel a moderate amount of stress.
When a person feels that his resources may not be sufficient to deal with a stressor, he may experience intense
stress.

Experience of having a disease, medical treatment, diagnosis of illness, and anxiety about the development of any
disease can trigger stress reactions. How individuals experience coping with stress and how they perceive the
disease itself will also affect whether and how individuals seek medical care and social support, as well as how well
individuals comply with health professional advice (Glanz, Rimer, & Viswanath, 2018). Reactions to stressors can
promote or inhibit healthy behavior, and influence motivation to adhere to health-enhancing habits (Glanz, Rimer,
& Viswanath, 2018).

During the COVID-19 pandemic the various stressors that exist and how individuals cope with their stressors or
how the coping they use will also affect whether and how they comply with health professional advice. During the
COVID-19 pandemic, the health protocol implemented in Indonesia is following the Decree of the Minister of
Health of the Republic of Indonesia Number HK.01.07 / MENKES / 382/2020 (Minister of Health of the Republic of
Indonesia, 2020) regarding health protocols for the public in public places and facilities for prevention and control
of coronavirus disease 2 019 (COVID-19) is 3M, namely wearing masks, washing hands, and maintaining distance.
Even though there is a health protocol, in fact in Indonesia there are still a lot of people who violate this protocol.
Some of these violation phenomena include the gathering of the public at the closure of McDonald's outlets in
Jakarta, the increase in airplane passengers, to COVID-19 patients who refuse to be treated and try to escape from
the hospital, while the rate of positive cases continues to increase and the death of medical personnel is getting
higher (CNN, 2020).

The existence of this physical distancing rule is taken as a preventive action in anticipating the risk of wider
transmission. Even so, why are so many people ignoring these health protocols? Things like this will certainly be an
obstacle to government programs to reduce the number of COVID-19 fatalities in Indonesia. Complying with the
health protocols established by the government is very important to reduce the spread of the COVID-19 virus.

Adherence or adherence can be defined as the extent to which a person's behavior (in terms of taking medication,
following a diet, or implementing lifestyle changes) coincides with medical or health advice (Rapoff, 1998).
According to WHO (2003), although most studies focus on medication adherence, adherence also includes many
health-related behaviors where it is not just the use of prescribed drugs. In the context of health psychology,
adherence refers to situations when a person's behavior is commensurate with the recommended action or advice
proposed by a health practitioner or information obtained from some other source of information such as advice
given in a health promotion brochure through a mass media campaign ( Ian & Marcus, 2011, in Kurniati, 2018)

Park et al. (2020) researched adherence to implementing health protocols during the COVID-19 pandemic in
America. From these studies, it was found that adherence to health protocols in America was generally quite high.
Participants reported a high average level of adherence to several aspects of social distancing, including avoiding
eating out or gathering in bars/restaurants (95.10%) and avoiding visiting nursing homes (94.38%). Lower
adherence was in the aspects of maintaining social distancing, such as business trips (89.74%) and maintaining a 6-
foot distance (87.42%), adherence not to touch the face, nose and mouth (77.87%), and cleaning the house with
disinfectants (74.68%). From this study, it was also found that older age, female individuals, and individuals with
good financial status were the most consistent predictors of adherence to health protocol adherence during the
Covid-19 period (Park et al., 2020).

Adherence to implementing health protocols is also influenced by how individuals have a perception or cognitive
appraisal of health protocols during the COVID-19 pandemic (Wright et al., 2020). Wright et al. (2020) explained
that if individuals perceive health protocols as pleasurable, improve well-being, and can spend a lot of time at home
then the likelihood of adherence will be higher. On the other hand, if obedience is perceived as a loss that hinders
activities outside the home, such as hindering work and careers that require activities outside the home, then
compliance will be lower.

Problems related to stress and coping strategies are increasingly widespread, and have become relevant to public
health in recent years in dealing with emerging problems, for example community preparedness in the face of
natural disasters, more and more people are survivors of deadly diseases, and this is no exception. compliance with
health protocols during the COVID-19 pandemic. A recent American study conducted by Park et al. (2020) found
that there is a relationship between high-stress levels with less adaptive coping and behavior that is not adherent to
spreading prevention.

Several studies in other countries have shown evidence of a link between stress, depression, and anxiety and health-
related behaviors in society. Depression affects medication compliance in patients with TB ( Basuki, Ridhani, &
Budhiarti, 2014). Besides, there have been studies examining stress and adherence to health protocols in America
during the COVID-19 pandemic in April 2020 (Park et al., 2020). The study shows that there is a link between
higher stress and lower adherence to behaviors to prevent the spread of COVID-19. In addition, the term '
pandemic fatigue ' is now emerging , or the phase where enthusiasm and enthusiasm to ward off the pandemic crisis
is replaced by fatigue (Murphy, 2020). In this phase, the individual experiences a change from acute stress to
chronic stress, the initial high adrenaline levels are decreasing, thus increasing the likelihood that the individual is
getting tired with a pandemic situation that does not show improvement to become non-compliant with the COVID-
19 health protocol.
In Indonesia, studies conducted in the community have not been found on the relationship between stress,
depression, and anxiety and behavior in compliance with health protocols during the COVID-19 pandemic.
Therefore, researchers want to conduct a study on the relationship of stress, depression, anxiety to adherence to
implementing health protocols during the COVID-19 pandemic. In particular, this research focuses on the
Jabodetabek community. This is done because the DKI Jakarta area, especially Central Jakarta and North Jakarta,
is the region with the highest rate of positive COVID-19 cases in Indonesia (CNN, 2020). In more detail, here is the
distribution of positive COVID-19 cases in the Jakarta area: Central Jakarta 2,213 cases, North Jakarta 1,775
cases, South Jakarta 1,309 cases, East Jakarta 1,305 cases, and West Jakarta 1,268 cases (CNN, 2020). Jakarta's
buffer cities, namely Bodetabek (Bogor, Depok, Tangerang, South Tangerang, and Bekasi) were also selected as the
focus areas in this study because these areas were the most affected by the DKI Jakarta PSBB regulations. In
addition, many Bodetabek people also have activities in the DKI Jakarta area.

METHOD

This study used a correlational quantitative design, with the sampling technique being convenience sampling. Data
was collected through online surveys using Google Form through various social media platforms such as Instagram
and Whatsapp. This online data collection was carried out to prioritize the physical distancing protocol that was
urged by the government. The data analysis method used in this study used descriptive statistics to see respondent
data based on demographic data. Then use the Spearman Rank analysis technique with the help of the Statistical
Product and Service Solutions (SPSS) program to determine the correlation between the two variables.

Participants

The population of this research is all people who live in Jabodetabek and aged 18 years and over. Thus, the
characteristics of the participants in this study are those aged 18 years and over, and who are people who live in
the Jabodetabek area, and express their willingness to become research participants. From the calculation of the
sample size using OpenEpi software for a random sample with a population of 31,131,289 million people with the
desired absolute accuracy rate of 5%, it was found that the minimum number of participants who had to be obtained
in this study was 271 participants (openepi.com).

Measuring instrument

In this study, the variables of depression, anxiety, stress, and adherence to the COVID-19 health protocol were
measured using two measuring instruments. The DASS ( Depression Anxiety Stress Scales ) measuring instrument
developed by Lovibond & Lovibond (1995) was used to measure depression, anxiety, and stress. The measuring
instrument consists of a total of 42 items (14 items on each scale) and uses a Likert scale of 0-3 (0 = "none or
never" and 3 = "very much in accordance with what is experienced, or almost every time") . The levels of
depression, anxiety, and stress are each categorized into five levels depending on the number of scores the
individual gets on each scale. For the depression scale, the categories were: normal (score 0-9), mild (10-13),
moderate (14-20), severe (21-27), and very severe (> 28). For the anxiety scale, the categories were: normal (score
0-7), mild (8-9), moderate (10-14), severe (15-19), and very severe (> 20). For the stress scale, the categories are:
normal (score 0-14), mild (15-18), moderate (19-25), severe (26-33), and very severe (> 34). Each scale on the
DASS measuring instrument has good internal reliability, (α =, 940 for the depression scale; α =, 874 for the
anxiety scale; and α = 932 for the stress scale).
The CDC Guideline Compliance measure compiled by Park et al. (2020) was used to measure adherence to the
COVID-19 health protocol. The measuring instrument consists of a total of 12 items using a Likert scale of 1-10 (1
= "never" and 10 = "every time"). In Park's study (2020) the final score obtained by individuals is not categorized
into levels. For this study, the researcher took the initiative to divide the level of adherence into five categories: very
low (score 12-24), low (25-48), moderate (49-72), high (73-96), and very high ( 97-120). The CDC Guideline
Compliance measurement tool also has good internal reliability (α =, 823). The data obtained in this study were
analyzed using descriptive statistics to see respondent data based on demographic data. The data were analyzed
using the Rank Spearman analysis technique with the help of the Statistical Product and Service Solutions (SPSS)
program to determine the correlation between the two variables.