HERBAL PRODUCTS AND FOOD SUPPLEMENTS CONSUMPTION AND BELIEF DURING THE COVID-19 PANDEMIC: A STUDY IN JAVA ISLAND, INDONESIA

ABSTRACT


INTRODUCTION
The outbreak of a novel coronavirus began in the city of Wuhan in Hubei Province of China in late 2019. The World Health Organization later officially named Coronavirus Disease  for the new coronavirus 2019 infection, and the virus has been categorized as SARS-CoV-2 (Yuen et al., 2020). At the end of January 2020, The World Health Organization has declared COVID-19 is a worldwide health emergency. Currently, the global situation of COVID-19 has more than a hundred million confirmed cases and over a million deaths.
The first emergence of COVID-19 cases in Indonesia was found in West Java on Java Island early in March 2020. Since then, the number of confirmed cases has been widely reported every day. The government implemented several actions to prevent the rapid transmission of the infection. However, the disease's transmission has dramatically increased and peaked in July 2021. Moreover, the highest COVID-19 cases were accumulated on Java Island because it is the most densely populated island in Indonesia (Prasetya et al., 2021).
The COVID-19 infection causes a variety of symptoms, ranging from asymptomaticmild symptoms to severe illness and leads to death. The patients infected by COVID-19 have a fever, cough, shortness of breath, muscle ache, confusion, headache, sore throat, rhinorrhea, chest pain, diarrhea, and nausea and vomiting (Chen et al., 2020). COVID-19 causes an inflammatory, immunological response. In cases with COVID-19, the release of inflammatory cytokines causes cytokine storm and disrupted immunity, as well as acute respiratory distress syndrome and multiorgan dysfunction (Demeke et al., 2021).
Vaccines against the COVID-19 pandemic are reportedly available in a variety of types. However, the effectiveness and safety of these vaccinations are still being evaluated, and their impact on altered virus strains is yet unknown. Therefore, numerous studies suggest that herbal products and vitamins can be used to prevent contracting COVID-19 (ALkharashi, 2021;Chaachouay et al., 2021;Charoenngam et al., 2021;Lu et al., 2021). Various herbal products, such as herbal syrup, traditional herbal drinks, herbal powder instant, and herbal capsules, are well-known. The natural herbs of traditional Chinese medicine exhibit benefits in strengthening the immune system, helping to build resistance against viral infections, and to control the immune system's response after significant viral replication. Several herbal products are strongly recommended for the treatment of COVID-19 because they aim to remove dampness, heat, toxins, stasis, deficiency, and closure (L.  . Herbs contain secondary plant metabolites, including terpenoids, polyphenols, and flavonoids, which could be against the COVID-19 virus. Polyphenols/Flavonoids and Terpenoids Have the Potential to Enhance Immuno-Modulatory Responses to COVID-19. Polyphenols could improve the immunity of cells to foreign infestations. Cellular accumulation of polyphenols triggers signaling cascades and initiates immune responses. Flavonoids like rutin, apiin, hesperidin, diosmin, and diacetyl curcumin inhibit COVID-19 Mopar(protease) activity. Therefore, Terpenoids have a vital role in modulating the cellular metabolism, specifically the biosynthesis of sterols, and have a significant level of antiviral activity (Khanna et al., 2021).
Honey has a number of health benefits that may help protect against COVID-19. It boosts the immune system. Honey has an antimicrobial, antioxidative, antiinflammatory, anti-diabetic, antihypertensive, and cardioprotective effect (Hossain et al., 2020). Probiotics are also an effective treatment strategy for COVID-19 patients since they can decrease secondary infection and modulate immunity (Rozga et al., 2021) . Vitamin C has anti-inflammatory and antioxidant properties that help to improve the immune system (Iddir et al., 2020). Vitamin D affects B and T cells, macrophages, monocytes, and dendritic cells, among other immune cells. The final result is the regulation of the immune response (Vassiliou et al., 2021). B vitamins are embroiled in many energy-related enzymatic processes. Vitamins D and C are considered to play a significant role in determining the results of COVID-19 in various research conducted to evaluate the effectiveness of vitamins in the prognosis of COVID-19 (Brito et al., 2021;Çimke & Yıldırım Gürkan, 2021;Iddir et al., 2020).
The use of herbal products and vitamins appears to have an advantage in preventing COVID-19 infections. However, the use of this product during the pandemic COVID-19 and people's belief that it can help increase immunity and reduce the chance of exposure risk to  has not yet been reported in Indonesia. The aim of this study was to examine Indonesians' use of herbal products, probiotics, and vitamins to boost their immune responses, as well as their beliefs about the use of herbal products, probiotics, and vitamins to prevent COVID-19 infection, using Java Island as an example.

METHODS
An internet survey of the cross-sectional study was conducted in Java Island, Indonesia, between July 21st and August 8th, 2021. The aims of this study, protocols, and voluntary participation were all mentioned on the questionnaire's page; therefore, they were not required to provide written informed consent. The questionnaire was delivered via social media groups such as WhatsApp, Facebook, and Instagram to qualified individuals. The following were the inclusion criteria: a) participants must be 18 years old or older and currently reside in Java Island of Indonesia. Participants were not allowed to participate if they were: a) under the age of 18, and b) had never taken herbal or food supplements throughout the COVID-19 epidemic.
The survey questionnaire was created with thorough literature evaluations on the COVID-19 pandemic and herbal or food supplement usage (Alyami et al., 2020;Bhushan et al., 2021;Bottari et al., 2021;Sundararaman et al., 2020). The survey instrument included twenty-six questions, divided into three sections. The first section included socio-demographic information such as age, gender, education, income, history of chronic diseases, and respondents' commitment to the Ministry of Health or COVID-19 Response Acceleration Task Force instructions on COVID-19 pandemic health protocol. The second section questioned herbal or food supplement use (natural source extracts, vitamins, and immune-boosting) during the COVID-19 pandemic. The supplements were chosen based on recent research that showed their beneficial benefits in the prevention or management of COVID-19 infection (Abedi et al., 2021;Baud et al., 2020;Borujerdi et al., 2022;Khabour & Hassanein, 2021;Kurniasih & Juwita, 2021). The final segment included questions about participants' beliefs about the use of herbal and food supplements known to improve immune system function and lessen the risk of COVID-19 infection. Herbal and food supplements in the study were divided into ten categories: herbal syrup, instant herbal drink, traditional herbal drink (dried herbal plants), herbal capsule, probiotic drink, vitamin C, vitamin D, vitamin B complex, and multivitamin. Google forms were exported to an Excel spreadsheet and examined using the Chi-square test. Crosstabulation was performed (age, sex, income, and education). The threshold for statistical significance was fixed at 0.05.

RESULT AND DISCUSSION
A total of 485 individuals participated in this study and completed the questionnaire. Around one-third of all respondents were males and approximately 69.7% (n = 338) were females. More than 68.5% (n = 332) of the participants were aged 25 -39 years. The majority respondents were completed higher education level (92.6%, n = 449), 69.5% (n = 337) were employed, and living in Central Java provinces (26.2%, n = 127). About 3.3% (n = 16) of them reported that they have a history of chronic diseases and 24.7% (n = 120) admitted that they had been or were currently infected with COVID-19. When asked if they are entirely dedicated to the Indonesian COVID-19 Response Acceleration Task Force directives, 77.5% (n = 376) said yes, 14.8% (n = 72) said yes most of the time except in emergencies, and surprisingly not a single participant answer no commitment at all according to the study (Table 1). When asked if they are entirely dedicated to the Indonesian COVID-19 Response Acceleration Task Force directives, 77.5% (n = 376) said yes, 14.8% (n = 72) said yes most of the time except in emergencies, and surprisingly not a single participant answer no commitment at all according to the study (Table 1).  The findings of our study confirm the level of participants' commitment to the regulatory body instructions regarding the COVID-19 pandemic. Socio-demographic attributes such as gender, age, residential area, education level, and employment status are related to the level of commitment of participants. According to a previous study, female respondents are committed to the government's regulations and health procedures (Alyami et al., 2020). The level of commitment to the Indonesian Task Force's COVID-19 guidelines was also reported in the early stages of the pandemic, from January to March 2020. Social distancing, handwashing more frequently, and staying at home, later known as work from home or school from home, are the most visible changes in public responses and behavior to mitigate COVID-19 infection (Djalante et al., 2020). This study investigated beliefs about the consumption of herbal products and food supplements during the COVID-19 pandemic among the inhabitants of Java Island, Indonesia. The participants were asked about their use of herbal products or food supplements before and during the COVID-19 period. Herbal items included herbal syrup, instant herbal drinks, dried herbal plants (a traditional herbal drink), herbal powdered capsules, and honey. Food supplements had probiotic drinks, vitamin C, vitamin D, vitamin B complex, and multivitamins (Table 2). Before the COVID-19 pandemic, 96.1 percent (n = 470) of all participants admitted to taking herbal products or food supplements. The number reflects Indonesians' trust in the wellknown health benefits of traditional drinks such as herbal items and food supplements, particularly on Java Island. Herbal syrup, instant herbal drinks, dried herbal plants, and herbal powdered in capsules are all known as jamu in Indonesia. Along with various types of food such as fruits and vegetables, or food supplements such as vitamins and honey, jamu is believed to reduce COVID-19 symptoms and improve the immune system (Lesmayati et al., 2021).
Among the different types of herbal products and food supplements (Table 2), honey (n = 97, 20%) and probiotic drinks (n = 88, 18.1 percent) are the most popular before the COVID-19 pandemic. During the pandemic, however, this consumption pattern shifts. Some herbal goods or dietary supplements gain popularity, such as dried herbs plants (n = 81, 16.7%) and vitamin C (n = 87, 17.9%), while others, such as honey (n = 90, 18.6%) and probiotics drink (n = 47, 9.7%), lose popularity statistically. The majority of participants reported that they consume herbal products or food supplements on a daily basis (n = 194, 40%), in the morning (n = 227, 46.8%), on the advice of friends or relatives (n = 248, 51.1%), and get the most of it from a supermarket or minimarket (n = 154, 31.8%). Based on the statistics in Table 2, it is clear that Indonesians have firm beliefs in honey's favorable health effects. No fewer than 90 participants said they took honey before and throughout the pandemic. This tendency is likely fueled by the religious belief in honey and its health benefit promotion in Muslimmajority countries, Indonesia included (Kamarulzaidi et al., 2014;Wijayanti et al., 2019). Honey is a complex liquid sugar mixture with unique antibacterial and antioxidant properties. Honey produced by the Apis mellifera bee is said to be one of the earliest forms of traditional medicine. Honey's characteristics are also thought to have potential as a curative and preventative agent for chronic diseases, which has been proven (Iqbal et al., 2021). According to a recent study, honey's key components have the capacity to regulate the molecular targets involved in the virus's attachment and entry into the host cell, as well as its RNA replication. Honey and its constituents may influence cellular signaling pathways such as oxidative stress, inflammation, and apoptosis (Abedi et al., 2021).
Dietary or herbal supplements other than honey, such as lemon, orange, ginger, vitamin C, black seed (Nigella sativa), peppermint, costus (Saussurea costus), and turmeric, have been utilized in prior research among COVID-19 patients who did not receive treatment at the hospital (Aldwihi et al., 2021). Another study in Sleman, Indonesia, found that the most consumed herbs during the COVID-19 pandemic were ginger, orange, and turmeric (Kurniasih & Juwita, 2021). Ginger, honey, garlic, and perilla (Perilla frutescens (L.) Britt.) were the most common herbal plants or food supplements in Vietnam against COVID-19 symptoms such as sore throat, cough, nasal congestion, and fever (Nguyen et al., 2021) . The natural component isolated from herbal plants, including Echinacea, Cinchona, Curcuma longa, and Curcuma xanthorrhiza, may be able to regulate the synthesis and release of proinflammatory cytokines, as well as interfere with virus formation and affect certain molecular pathways (Nugraha et al., 2020). According to another study, cinnamon, as herbal medication, is the third most widely utilized dietary supplement, after fish oil and vegetables or fruits (Kamarli Altun et al., 2021). Table 3 showed that participants' belief to use herbal products could help increase immunity and reduce the chance of exposure risk to         No or weak associations were observed in relation to other herbal products, such as traditional herbal drinks, herbal powders, herbal capsules, and honey. The results of this study show that honey (91.3%) was chosen by most participants who believe that consuming honey can increase immunity and reduce the risk of exposure to COVID-19 compared to other herbal products. Because of its ability to reduce acute inflammation by enhancing immune response, honey and its compounds are gaining popularity as a natural therapy. Several studies have shown that it has the potential to heal a variety of chronic diseases and conditions, including pulmonary disorders, cardiac disorders, diabetes, hypertension, autophagy dysfunction, bacterial infections, and fungal infections. Honey has also been shown to have virucidal properties against several enveloped viruses, including HIV, influenza, herpes simplex, and varicella-zoster virus. Honey may help patients with COVID-19, an enveloped virus caused by SARS-CoV-2, by boosting the host immune system, improving comorbid conditions, and having antiviral properties (Hossain et al., 2020).
There are many herbal products in the Indonesian market, particularly on Java Island. An herbal product can be made up of one or more herbal plants as ingredients. The herbal products have been utilized since ancient times and cover a wide range of diseases. They have abundant biological activities, such as anti-inflammatory, antioxidant, antivirus, antibiotic, fungicidal, anti-cancer, antimicrobial against human pathogenic bacteria, and Sars-CoV (Chaachouay et al., 2021). Because of their antiviral properties have been recognized as effective therapeutic medicines against a wide range of viral infections. Essentially, these formulations are made up of a large number of phytochemicals such as terpenoids, alkaloids, flavonoids, phenols, tannins, polyphenol, saponin, polysaccharides, proteins, lipids, and peptides, all of which have a variety of functions in terms of preventing viral invasion, penetration, replication, expression, assembly, and released (Chaachouay et al., 2021). Furthermore, since the outbreak of the disease, medicinal plants, and their natural ingredients have proven to be the most promising alternatives for preventing or curing the infection and spread of the disease. During the COVID-19 pandemic, nearly 70% of participants in a study in Vietnam believed herbal medicines were safe, had fewer side effects than conventional medicines, and were effective for minor health conditions (Nguyen et al., 2021). Similarly, In Saudi Arabia, the general population's consumption and belief in herbal products have increased in order to protect them from disease (ALkharashi, 2021; Alyami et al., 2020).
The participant belief that vitamin C, D, B complex, multivitamin, and probiotic drinks could help increase immunity and reduce the chance of exposure risk to COVID-19. This result is shown by the percentage of yes answers was higher than no answers for all samples of vitamin and supplement. According to Table 4, vitamin C was believed by 94% of participants. The belief that consumption of multivitamins was strongly correlated with education level (P<0.05). On the other hand, participants' belief of consumption vitamin B complex was highly associated with monthly income (P<0.05). Gender, residence area, and monthly income were strongly related to probiotic drinks. According to gender, females (78.1%) more believe that consuming probiotic drinks could boost the immune system than males (65.3%). Moreover, West Java Province had a higher percentage of the participants who believed that probiotic drinks help increase immunity compared to the other provinces. In terms of monthly income, people who earn Rp 4.001.000 -Rp 5.000.000 per month had a higher percentage (81.3%) to believe that drinking probiotic drinks could help increase immunity and reduce the chance of exposure risk to COVID-19.
Vitamin C and D had no or weak association with parameters such as gender, ages groups, residence area, education level, employment status, and monthly income. Vitamin D is well-known for its biological effects on a variety of organ systems, in particular to bone health. Vitamin D supplementation has been shown to protect against the risk of acquiring an acute respiratory viral infection and may improve outcomes in sepsis and critically ill patients before the COVID-19 pandemic (Charoenngam et al., 2021). Vitamin D is a crucial regulator of the renin-angiotensin system that SARS-CoV-2 exploits for entry into the host cells.
Furthermore, vitamin D modulates multiple immune system mechanisms to contain the virus, including dampening SARS-CoV-2 entry and replication, reducing proinflammatory cytokines and increasing antiinflammatory cytokines, increasing the production of a natural antimicrobial peptide, and activating defensive cells like macrophages that can destroy SARS-CoV-2 (Kumar et al., 2021;Nabi-Afjadi et al., 2021).
Probiotics have been proposed as a potential method of modulating the immune system to improve outcomes in patients infected with COVID-19, such as ventilatorassociated pneumonia. There is no direct evidence that probiotics improve outcomes in COVID-19 or other similar viral infections at this time (Rozga et al., 2021). This result was supported by a previous study that reported probiotics could prevent ventilator-associated pneumonia (Fan et al., 2019). B. longum, L. bulgaricus, S. thermophilus should be the first choice for VAP prevention. At the same time, Synbiotic 2000FORTE has the potential to reduce in-hospital mortality and ICU mortality, according to efficacy rankings. The other reference explained that Although probiotics could not reduce elevated interleukin-6 (IL-6) levels, they could moderate immunity and reduce the incidence of secondary infection (Q. . Probiotics' possible mechanism of action in COVID-19 is due to their role in combating various diseases in terms of enhancing epithelial barrier function, acting as an anti-inflammatory, improving gut microbial diversity, acting as antagonists for various harmful bacterial strains in the gut, blocking or enhancing multiple signal pathways such as NF-kB, and producing metabolites such as SCFAs, which can work to lessen the severity of various diseases (Din et al., 2021). Besides, multivitamins have a higher potential for acting as a defensive measure against activityinduced changes in immunity and lipid peroxidation than vitamin C (Arshad et al., 2020;Khabour & Hassanein, 2021).

CONCLUSION
This study reveals that the general population of Java Island, Indonesia, has a broad understanding of COVID-19-related knowledge. Honey was the most popular herbal product and nutritional supplement before the pandemic, whereas multivitamins were the most preferred during the epidemic. Herbal products and food supplements are used because they are thought to lower the risk of viral infections and reduce COVID-19 symptoms. The efficacy of herbal products and food supplements, on the other hand, must be established by more in-depth research.