Health Literacy of Children among Parents in "Puspa Sehat UNPAD" Daycare During COVID-19 Endemic Period

Background. Parents at Puspa Sehat UNPAD daycare are adopting various strategies to maintain the health of early-age children. According to interviews, there is a consensus that imparting early health education can contribute to positive health outcomes. In response to the demanding schedule of parents, Puspa Sehat UNPAD provides a range of essential services, including childcare, healthcare, and developmental stimulation. This institution was established to address healthcare challenges and provide a conducive growth environment. It recognizes the susceptibility of babies and children under the age of 5 to diseases due to immature immune systems. While most childhood diseases are categorized as non-threatening, it is important to acknowledge that some can pose life-threatening risks. The effective management of these diseases necessitates a multifaceted approach, comprising symptom control, prevention of triggers, and the administration of antibiotics for diseases triggered by bacteria. The World Health Organization (WHO, 2023) emphasizes that health literacy plays an important role in enhancing individuals' well-being, improving health quality, and mitigating health disparities. Meanwhile, children possess the inability for self-protection, necessitating the need for parental guardians to maintain health. This guidance can be provided through the cultivation of strong health literacy skills, including the ability to comprehend health information. The adopted skills can influence social, emotional, and cognitive development (Apriliani & Utami: 2021, Bamicha & Drigas: 2022). Consequently, parents bear a critical responsibility to protect the health of their children. Megawati et al (Megawati et al., 2018) showed that healthy lifestyle behavior is related to predisposing and reinforcing factors, including knowledge, education, socio-economic status, and the role of healthcare providers. In addition, a lack of parental knowledge about proper handwashing affects the growth and development of children during the endemic period. This is because hands are carriers of contagious pathogens that can spread both through direct and indirect contact. Dutta-Bergman showed that early-age children who receive health information from their parents tend to possess better health knowledge (Arnawati, 2017). A report written by WHO, IRFC, & Unicef (2020) stated the guidelines for maintaining health during the pandemic, and these rules remain applicable in the endemic period. Children, parents, families, and teachers were advised to focus on good health behaviors such as covering the mouth when coughing, sneezing with the elbow, and frequent handwashing with soap for 20 seconds using running water. Other safety practices during the pandemic include the use of hand sanitizer, dolls when feeling unwell, and maintaining social distancing. Results from pre-study and observations show that some parents at Puspa Sehat UNPAD adhere to health protocols such as wearing masks. However, during the current endemic period, not many implemented these health protocols as required. A review by (Steere-Williams, 2022) showed that hospitals worldwide were operating at maximum capacity for patient admission, with a higher percentage of occupied beds dedicated to children under the age of 5 compared to adults. In endemic conditions, the virus is said to have been prevalent for the past 3 years and is now considered similar to seasonal flu viruses with predictable features. As a result, the government implemented a strategy of providing free COVID-19 vaccination for individuals aged 6 and above. In November 2023, the first dose vaccination rate for the 6-11 age group was 82.22%, while the second dose vaccination rate for the same age group reached 66.81%. Figure 1 COVID-19 Vaccination Data Sources: Ministry of Health of the Republic of Indonesia, 2023 Problem. The study raises concerns about the inability of children to defend and maintain their health. It further emphasized the role of parents in addressing the issues, which begins with the cultivation of good health literacy skills, specifically in the current endemic period where COVID-19 persists. Despite the government announcing an end to the pandemic, parents should continually keep up-to-date on health-related information and refine their health literacy skills. Previous Literature Review. In the context of the Cintamulya village community, health literacy for mothers and children is deemed imperative. To address this challenge, a health expert-led educational program was introduced, supplemented by a health-related book grant initiative aimed at continuously enhancing maternal knowledge. Additionally, a storybook grant program was implemented to cultivate a love for reading in children from an early age. These initiatives increased awareness and disseminated information on the vital importance of maintaining health, particularly for mothers and children (Perdana & Herawati, 2018). The application of early childhood health literacy during the pandemic is evident in capacity of parents to filter, apply, and disseminate health information to close contacts (Apriliani & Utami, 2021). Health literacy of children can be enhanced through the provision of hygiene promotion storybooks (Burhan et al., 2022). Handwashing dance is an effort to maintain the health of young children in a way that is not boring (Nirmala et al., 2021). Another research conducted at SDN 1 Tawangrejeni showed that during the service results showed that 80% of students were able to practice washing their hands correctly and sequentially (Sari, 2023). Implementing health literacy during the endemic period in early childhood at school can be done by putting up educational posters around the school, encouraging them to bring supplies from home, washing their hands before and after eating. The school also created a special program using educational games to carry out health literacy-based learning activities at school (Fachrurrazi & Affrida, 2023). Furthermore, family communication, comprising various functions such as social-cultural, reproductive, nurturing, religious, love and affection, socialization and education, and economic aspects, has positively influenced the health of children during the COVID-19 pandemic (Althafi, 2022). Given the significant role of family clusters in contributing to cases during the pandemic, there is a pressing need for the application of health literacy (Nurhaeni, 2022). Further research shows that literacy support provided by parents to children can have a good literacy impact on children. Parents can provide assistance such as regularly providing reading books (Antasari, 2016). Research conducted by Dirmayanti et al. (2022) shows that the relationship between parental health literacy and clean and healthy living behavior in early childhood is 50.7%. This means that parents' health literacy influences the clean and healthy living behavior of young children. Statement of Scientific Novelty (State of The Art). This study showed a different theme compared to the explanation of previous investigations, which focused on the role of parents in maintaining family health with several functions. The results were centered on how parents obtain, decide, and apply health literacy skills, specifically among early-age children at Puspa Sehat UNPAD during the current endemic period. Therefore, a novel perspective that has not been explored previously was introduced. This research needs to be carried out to determine the health literacy skills of parents at the UNPAD Health Center. With a focus on finding out how parents obtain, decide, apply and present skills regarding children's health literacy. Objective. The objective of this study is to understand how parents obtain, decide, and apply health literacy skills at Puspa Sehat UNPAD.

This qualitative study used various methods to explore and understand the meanings inherent in individuals or groups arising from social or human phenomena or issues (Sugiyono, 2014). The subjects were parents with early-age children entrusted with the growth, development, and health care of Puspa Sehat UNPAD. Furthermore, informants were selected as data sources through purposive sampling (Handayani, 2020). A total of parents were selected from 20 at Puspa Sehat UNPAD. The inclusion criteria comprised children aged 2 months to 6 years who were entrusted to Puspa Sehat UNPAD. Additionally, adherence to health protocols, including mask-wearing, and maintaining permanent employment were prerequisites. This study used primary data obtained directly from in-depth interviews with informants, as well as printed and electronic literature studies, including previous examination, documentation, and other sources. Data were collected from November 2022 to June 2023, both online and offline, at the Healthy Child Care Center located in the Padjadjaran University environment, Old Pedca Building, Hegarmanah, Jatinangor District, Sumedang Regency, West Java, 45363. Following this, screening was conducted using relevant answers to the topic.

To evaluate health information literacy skills possessed by individuals, a popular model known as The Big Six developed by Michael Eisenberg and Robert Berkowitz in 1987, was adopted. This model offers a systematic method of problem-solving by identifying and selecting appropriate information sources, evaluating their usefulness, as well as effectively organizing and presenting data. It comprises 6 stages, each closely related to the processes of information search, evaluation, and use (Nuraini, 2021). The Big Six model comprises 6 steps, totaling 12 stages. Based on field results, this study categorizes these steps into 3 main groups. Analyzing acquisition skills includes 3 steps, namely identifying needs, selecting optimal sources by careful evaluation, and allocating these resources, complemented by thorough searches to reidentify essential details. Decision-making on usage includes evaluating the use of stored and acquired information and extracting existing details. Application and presentation occur through the synthesis stage, systematically sorting information from various sources into a cohesive result and disseminating this obtained insight to others (Hidayah, 2017). Analysis of Information Extraction Skills. The evaluation of health literacy skills among parents at Puspa Sehat UNPAD is conducted in 3 key phases, commencing with an exploration of prevalent issues and the identification of pertinent information needs. In essence, this process of identification is instrumental in narrowing down the specific informational requirements of parents. According to reports, parents predominantly express an interest in information concerning their children's health. For those individuals with a higher educational background, pinpointing relevant keywords during information searches poses no significant challenge. In formulating the problem, parents take into consideration the overall health status of their children. Fundamentally, good health is gauged by active daily behavior and a well-balanced diet. This interpretation was in line with the definition put forth by the World Health Organization (WHO), which defines a child as healthy not merely in the absence of disease and disability but in terms of being physically, mentally, and socially well (WHO, 2023). Following the problem formulation stage, in accordance with The Big Six model, parents progress to identifying the health information necessary for their child. In cases pertaining to Clean and Healthy Living Behavior (PHBS), the requisite health information comprises various facets, including dental health, dietary intake, and nutrition, as well as skin health. Parents at Puspa Sehat UNPAD discern information based on current needs and existing details. Those endowed with information literacy skills demonstrate the capability to discover and comprehend information from diverse sources. The study shows several health concerns, including dental health, nutritional intake, and skin health. Data obtained from interviews with Puspa Sehat UNPAD staff showed that children tend to experience common problems such as coughs, colds, flu, and fever. Staff members require health information to maintain and care for the well-being of children. These include ensuring proper nutritional intake and implementing measures to uphold environmental cleanliness during the endemic period. Both parents and staff at Puspa Sehat UNPAD possess awareness and understanding of the current health information needs. Consistent with the results, The Big Six explained that in the identification stage, individuals should be able to set goals, including defining and discovering existing problems. This stage can be applied through 2 steps, namely defining the task, centered on the health of children, and identifying the needed information. The second step includes determining information search strategies. Searching for information about the health of children requires relevant, accurate, and credible sources. Based on interviews, it was discovered that parents identify sources before conducting searches. While the internet serves as a primary medium for obtaining information, it is essential to selectively choose reliable sources. These may include reputable health websites such as Halodoc, scientific articles, and social media accounts managed by healthcare professionals like doctors and nurses. Furthermore, validation of information can be achieved by consulting experts, such as nursing staff. This method was in line with feedback from interviews with Puspa Sehat UNPAD staff, who stated the commitment of the institution to regular training and discussions on child development and health. These sessions are conducted in collaboration with the Faculty of Nursing at Padjadjaran University. Consequently, it can be inferred that the circulating information can be deemed authentic and trustworthy. 158 INDONESIAN JOURNAL OF LIBRARIANSHIP Figure 2 Information on the Halodoc Website Sources: Halodoc Website, (Fadli, 2019) Figure 3 Information on the Halodoc Website Sources: Halodoc Website, (Fadli, 2023) Figure 4 Information on the Halodoc Website Sources: Halodoc Website, (Fadli, 2022) The above images show that parents use the Halodoc website as one of their information sources. The results show that parents are aware of and understand strategies needed to search health information for children. Consistent with The Big Six model, which outlines the information search process, individuals are guided to method the best sources during this stage and make decisions based on their needs. This includes creating a comprehensive list of potential sources, both online and offline, and conducting critical evaluations to determine their reliability and relevance. Additionally, decisions about consulting experts are made at this juncture. In the third step of The Big Six model, the focus is on determining the location and access to information. The sources identified in the previous stage play an important role in shaping the next step in accessing information. The search for information about the health of children will be easier when the identification of needs has already been conducted. While there are various sources available today, it is necessary to prioritize accuracy and accountability in the quest for information. These credible sources include experts, scientific articles or journals available online, and verified social media platforms. Parents predominantly turn to the internet, and social media such as Instagram, when searching for information. Additionally, they rely on trusted acquaintances, such as health educators, pediatricians, and Puspa Sehat UNPAD staff. Navigating the vast array of information online requires a careful selection of relevant and credible sources. Informants can determine primary information sources that are easily accessible and quick. The Internet is the preferred choice among informants due to its convenience and efficacy, particularly in urgent situations. Parents benefit from the wealth of information available online, enhancing their understanding of proper and correct applications of PHBS. In conclusion, the study shows that parents at Puspa Sehat UNPAD are aware of and understand strategies for searching health information for children. Contrary to the results, The Big Six explains that in the location and access stage, individuals are directed to go to public libraries to seek information needs. In the era of information and digital development, institutions like libraries are required to evolve with current trends by creating digital collections and uploading them on the internet. The digital collections provided greatly assist users who do not have the opportunity to come directly to the library. However, in this stage, informants and The Big Six model have a slight difference. This is because not all the informants engage in search through freely available scientific journals/articles on the internet. Despite this situation, parents are more than capable of discovering the needed information from the best sources available. The conclusion drawn from the stage of extracting health information for children is that both parents and staff demonstrate proficient extraction skills. These individuals are aware of current health information issues and possess knowledge regarding the various types of sources available. Analysis of Information Decision-Making Skills. The analysis of parental decision-making is accomplished by reading, viewing, and/or listening to health information for early-age children. These three basic skills will be combined with the ability to obtain relevant information and understand its content. The decision-making by parents at Puspa Sehat UNPAD is considered to determine the credibility of information. It is important to note that parents and staff are not indiscriminate in making decisions about health information for children. Therefore, the results show that there are several considerations in making decisions about health information. One consideration for parents at Puspa Sehat UNPAD is the origin of the information, as well as the credibility of the provider. A typical course of action for parents includes cross-verifying the discovered information by comparing it with similar content from reputable sources, such as scientific journals and articles. Additionally, the information is constantly verified by experts. Health decision-making is conducted after parents feel confident that the previously discovered information is good, relevant, and credible. This was in line with The Big Six, stating that parents and staff should have the ability to read, view, and hear information. It is important to note that information is sourced only when the need arises. The process of making decisions about the health of children can be conducted by determining the goal of the information search. The goal of most parents is to ensure that children have healthy lives during the golden years of growth and development. Various relevant information is needed while exploring other alternatives, provided the details are not useful for the present. The final step in the decision-making process is to take action by applying the acquired information appropriately (Layoan, 2022). Analysis of Information Use and Application Skills. The analysis of the application and presentation of child health information is accomplished through synthesis. This is a method used to present information to others, particularly within the family and close friends circle. The presentation will make those receiving the information aware and avoid mistakes. This has a positive impact because the more individuals present information, the more parents will be cautious and understand the medical basis of such activities. Additionally, practicing PHBS regularly and correctly can maintain the health of family members and the living environment. Information synthesis includes combining previously obtained information and disseminating it to others. Generally, several ways to synthesize information have been obtained, including narratives, poems, PowerPoint presentations, stories, texts, and more. During interviews, parents and staff always combine information obtained from various sources to be re-read, analyzed, and selected based on the current health needs. The product of this synthesis step is a pamphlet posted by Puspa Sehat UNPAD staff at the entrance and some on the walls of the building. PHBS, such as washing hands and feet, wearing masks, paying attention to the nutritional intake according to the growth and development needs of children, cutting nails, bathing and shampooing in the evening before going home, and various other activities, were directly implemented daily. Slightly different from the implementation and presentation of information by staff, parents tell stories to family, close friends, colleagues, and neighbors, either orally or through social media such as WhatsApp. The information was presented to maximize the benefits of addressing health issues for children, with the hope that they can grow well. Discussion of Results. The study showed that individuals with higher education levels had greater ease in searching for and accessing information sources. It is important to note that parents serving as informants possessed higher education qualifications compared to the staff at Puspa Sehat UNPAD. Consequently, accessing health information for early-age children is more straightforward for parents, who could easily consult child health experts and benefit from their established relationships. In contrast, the staff at Puspa Sehat UNPAD faced limitations in accessing information due to technological constraints and a lack of avenues for making consultations beyond the institution. The difference in this study compared to the previous analysis lies in the subjects addressed. No report focused on the theme of health information literacy for early-age children at Puspa Sehat UNPAD. Discussion of Other Interesting Results. The study was conducted in response to a contemporary phenomenon and was guided by The Big Six theory. According to The Big Six, the synthesis stage emphasizes the importance of individuals noting key information for easy retrieval later. In this case, the product of this synthesis was a pamphlet shown at Puspa Sehat UNPAD. However, in light of advancing technology, fewer individuals opt for traditional paper-based methods to store or record important information. Social media platforms such as WhatsApp, Facebook, Instagram, and Google offer features for saving, bookmarking, and starring information, streamlining the process of retrieving saved data from previous searches. Despite the evolving technological landscape, the disparity between the theoretical concept and the observed field results does not render The Big Six obsolete. The theory remains pertinent in this context, particularly given the widespread use of smartphones. With the prevalence of digital methods, some individuals still prefer jotting down information on paper. It is important to note that qualitative study is not used to prove theories/concepts but to describe phenomena in the field as deeply as possible.

In conclusion, parents demonstrated health literacy skills by effectively acquiring essential health information for their children. The process comprised various steps, with the initial being the identification of the information problem. At Puspa Sehat UNPAD, parents had a commendable awareness of their information needs, making the identification phase relatively straightforward. Once the information needs were identified, relevant sources were determined. This included consulting experts, reading scientific articles, visiting the Halodoc website, checking verified Instagram accounts, seeking guidance from Puspa Sehat UNPAD staff, and consulting acquaintances or experts. Parents decision-making comprised a thorough search, often requiring the verification of previously obtained health information. This verification process typically included consultations with experts in children's health, comprising both practitioners and academics. Decision-making considerations were exclusively guided by information needs. Specifically, the acquired information was put to use when proved necessary. The application of information skills did not show specific differences in communication patterns. Parents had the skill to apply and communicate health information. The results showed that parents at Puspa Sehat UNPAD implemented information after a careful decision-making process. This implementation, particularly in child health, was linked to the preceding decision-making steps. The study concluded that the quality, relevance, and credibility of information positively influenced the application process. Parents conscientiously shared information obtained through platforms such as WhatsApp and effective communication methods, by storytelling and sharing personal experiences. Future Study Direction (Future Work). Health literacy skills related to the well-being of early-age children comprise the capacity to comprehend health information and make informed decisions regarding health and healthcare. According to the study, it is evident that parents and staff at Puspa Sehat UNPAD have commendable literacy skills and proficiency. A recommendation for future study is to explore deeper into this subject by assessing the specific levels of health literacy skills possessed by parents and staff at Puspa Sehat UNPAD.