Hrev_master Healthcare in Low-resource Settings 2023; volume 11:11795 Factors affecting individual beliefs associated with the quality of life of traditional divers in the coastal area Dhian Satya Rachmawati, Nur Chabibah, Muh. Zul Azhri Rustam Sekolah Tinggi Ilmu Kesehatan Hang Tuah Surabaya, Indonesia Abstract Traditional divers in Surabaya’s coastal area face challenges despite the abundance of marine resources. This study aims to explore the factors that related to the quality of life among these divers. The research followed an observational analytic approach with a cross-sectional design. The study involved 31 traditional divers from Kedung Cowek Village in Surabaya, randomly select- ed based on specific criteria. The research utilised the Health Belief Model theory to assess individual beliefs and the WHO- QOL-BREF tool to measure their quality of life. The individual beliefs were categorised into five indicators: perceived vulnerabil- ity, perceived severity, perceived obstacles, perceived benefits, and self-efficacy. Out of these factors, two had a significant influ- ence on the quality of life of traditional divers: perceived benefits (p = 0.009) and self-efficacy (p = 0.020). The study concludes that the quality of life for traditional divers in the Surabaya coastal area is primarily influenced by perceived benefits and self-efficacy. It suggests that nearby healthcare facilities could offer health educa- tion to traditional divers, focusing on specific protective measures to reduce the risks associated with diving, such as barotrauma and decompression sickness. Introduction Indonesia possesses vast marine and coastal resource poten- tial.1 However, this potential is not paralleled by the quality of life of traditional divers in coastal regions. A significant portion of coastal residents engage in traditional diving as their primary livelihood.2–4 Traditional divers are men who use rudimentary equipment and breath-hold diving or surface-supplied air via com- pressors to search for marine resources in the sea.5 Unfortunately, the quality of life for traditional divers is often subpar.6 The gov- ernment has been striving to enhance the welfare of traditional divers, with a particular focus on the health sector. These efforts include promoting preventative measures, such as ensuring work safety, improving nutrition, enhancing basic sanitation, providing clean water, addressing maternal and child health, and managing infectious and noninfectious diseases, in addition to empowering traditional divers.7 Welfare is gauged by the overall quality of human life.8 While a significant number of traditional divers has the poten- tial to sustainably manage marine resources, low quality of life could diminish the resource management potential of traditional divers9. The decline in the quality of life of traditional divers also hampers the achievement of Sustainable Development Goals (SDGs), particularly Goal 1 (no poverty) and Goal 3 (good health and well-being).10 In fact, the Indonesian government aims to eradicate extreme poverty, targeting a reduction to zero percent by 2024, as outlined by the President of the Republic of Indonesia on March 4th, 2020.11 The actual extent of poverty affects society in both urban and rural areas,12 with a particular impact on coastal regions.13 The government’s programs have shown promising results, with poverty rates dropping to below double digits, stand- ing at 9.66% or approximately 25.7 million people as of September 2018, marking a decrease of 1.78 million individuals or 1.14%.14 Despite these advances, the quality of life of tradition- al divers still remains at a low level, approximately 73.3%.6 Correspondence: Nur Chabibah, Sekolah Tinggi Ilmu Kesehatan Hang Tuah Surabaya, Surabaya, Indonesia. E-mail: nhbienajah@gmail.com Key words: individual belief; quality of life; traditional divers; coastal area. Contributions: DSR, conceptualization, methodology, validation, visualization, resources, writing – original draft; NC, resources, methodology, writing – original draft, visualisation, review & edit- ing, supervision; MZAR, methodology, data curation, formal analy- sis, validation. Conflict of interest: the authors declare no conflict of interest. Ethics approval and consent to participate: the research has received ethical approval from the Health Research Ethics Committee of the Sekolah Tinggi Ilmu Kesehatan Hang Tuah Surabaya, Indonesia based on the ethical certificate number PE/119/VIII/2023/KEP/SHT. During the research, the researcher pays attention to the ethical prin- ciples of information to consent, respect for human rights, benefi- cence and non-maleficence. Patient consent for publication: written informed consent was obtained for anonymised patient information to be published in this article. Funding: this research did not receive external funding. Availability of data and materials: All data generated or analysed during this study are included in this published article. Acknowledgement: this research was supported by a Sekolah Tinggi Ilmu Kesehatan Hang Tuah Surabaya Indonesia. Received: 13 September 2023. Accepted: 6 November 2023. Early access: 17 November 2023. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2023 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2023; 11:11795 doi:10.4081/hls.2023.11795 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affili- ated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 146] [Healthcare in Low-resource Settings 2023; 11:11795] Non -co mmerc ial us e o nly Efforts to elevate the quality of life of traditional divers demand considerable attention.15,16 Boosting the motivation of tra- ditional divers can be a key strategy to fulfill their basic needs.13 One approach to increasing the motivation of traditional divers is the application of the Health Action Process Approach (HAPA).17 HAPA is anticipated to improve the quality of life of traditional divers, potentially serving as an intervention to empower tradition- al divers in achieving a higher quality of life.18 The application of the HAPA model posits that the adoption, initiation, and maintenance of health behavior must be understood as a process comprising a motivational phase and a volitional phase, further divided into planning, action, and maintenance phas- es, with self-efficacy being a critical condition at all stages along with other cognitive elements.19 For instance, risk perception pri- marily facilitates the early stages of the motivational phase but no further. Similarly, outcome expectations are particularly influential in the motivational phase when individuals weigh the pros and cons of behavioral consequences, but their predictive power wanes after personal decisions are made.20 Ultimately, if an individual lacks confidence in their ability to perform a desired action, they may fail to adopt, initiate, and maintain it.21 Given this back- ground, the objective of this study was to analyse the individual belief factors associated with the quality of life of traditional divers in the Surabaya coastal area. Materials and Methods Research design This study employed a cross-sectional approach. The sample was selected through simple random sampling, applying prede- fined inclusion and exclusion criteria. The inclusion criteria included active traditional divers who were willing to participate, residing in Kedung Cowek Village, Indonesia, and engaged in tra- ditional diving. Traditional divers were defined as individuals actively hunting at sea without modern equipment, using breath- hold diving or air supply provided through surface compressors. They operated boats measuring 5 meters in length, 1 meter in width, and 0.5 meters in height, with a maximum passenger capac- ity of 2 individuals, powered by an outboard engine with a capacity of 5.5 Paarden Kracht (P.K.). Data collection was conducted by the researchers, and the collected data was analysed using a linear regression test. Study participants The participants in this study were traditional fishermen, specifically traditional divers, from Kedung Cowek Village in Surabaya, Indonesia. The study population consisted of all tradi- tional divers between the ages of 20 and 80 residing in Kedung Cowek Village, Surabaya. The sample included 31 traditional divers randomly selected from a total population of 34, based on predefined inclusion and exclusion criteria. Variable, instrument, and data collection This study examined the individual beliefs of traditional divers and their quality of life. Additionally, demographic factors, includ- ing age, gender, education, occupation, religion, economic status, and marital status, were assessed. The research employed a ques- tionnaire to measure the individual beliefs and quality of life of tra- ditional divers. The individual beliefs questionnaire was adapted from the Health-Belief Model theory developed by Victoria et al. (2008)22 and transformed into a questionnaire format. These indi- vidual beliefs encompassed five indicators: perceived susceptibili- ty, perceived severity, perceived barriers, perceived benefits, and self-efficacy. The validity and reliability of the questionnaire for individual beliefs were assessed before data collection, confirming their validity. The reliability testing resulted in correlation coeffi- cients ranging from 0.679 to 0.971. The instrument used to mea- sure the quality of life was the WHOQOL-BREF. This standard- ised instrument, acquired from Kiling et al. (2019),23 did not require validity or reliability testing. Data were collected in the first and second weeks of July 2023, and participants provided their responses by filling out the questionnaires. Data analysis The collected data were analysed using a linear regression test, assuming the data met the normal distribution requirement. The linear regression aimed to investigate the factors associated with the quality of life of traditional divers in the Surabaya coastal area. Quality of life was measured using the WHOQOL-BREF instru- ment. The analysis involved assessing the significance of the t-test. The significance value of the t-test was compared with a prede- fined threshold value of 5%. If the obtained significance value of the t-test was smaller than the threshold value, it indicated a signif- icant influence between individual beliefs and the quality of life of traditional divers. Ethical clearance This research received ethical approval from the Health Research Ethics Committee of Sekolah Tinggi Ilmu Kesehatan Hang Tuah Surabaya, Indonesia, granted under ethical certificate number PE/119/VIII/2023/KEP/SHT. Throughout the research process, ethical principles, such as informed consent, respect for human rights, beneficence, and non-maleficence, were observed. Results Distribution of demographic characteristics in tra- ditional divers Based on Table 1, the demographic data of traditional divers on the coast of Surabaya are presented. The results indicate that over half of the traditional divers fall within the age range of 23-45 years (58.1%). All divers in the study are male, with 38.7% having received no formal education. The majority of these divers have been engaged in traditional diving to catch fish and shellfish for over four years (93.5%), and their average monthly income is below the regional minimum wage (74.2%). Furthermore, 93.5% of them are married, with 61.3% serving as the primary breadwin- ners. The average household consists of two individuals, making up 51.6% of the sample. This study presents descriptive statistics to characterise the research variables, encompassing the lowest and highest values, the mean, and the standard deviation. The summary of the descrip- tive statistics for the research variables influencing individual beliefs on quality of life is presented in Table 2. Table 2 displays the individual belief factors in traditional divers, involving 31 participants. The average score for these fac- tors is 88.71, considering the maximum quality of life score, with a standard deviation of 10.7%. Specifically, the average score for perceived susceptibility to the quality of life among traditional [Healthcare in Low-resource Settings 2023; 11:11795] [page 147] Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Non -co mmerc ial us e o nly divers is 15.90 out of a maximum of 22.00, indicating a relatively high perception of susceptibility. The perception of severity, which also affects the quality of life, has an average score of 16.26 out of a maximum of 22.00, signifying a relatively high perception of severity compared to susceptibility. In the context of barriers affecting quality of life, an average score of 12.35 is achieved from a maximum score of 17.00, with a standard deviation of 3.4%. In contrast, perceived benefits yield an average score of 9.13 from a maximum score of 14.00, while self-efficacy results in an average score of 7.68 out of a total of 13.00, accompanied by a standard deviation of 2.5%. These findings suggest that both perception and self-efficacy have a noteworthy impact on changing the quality of life for traditional divers. Individual belief analysis of quality of life in tradi- tional divers Table 3 reveals that the significance values for perceived bene- fits and self-efficacy are 0.009 and 0.020, respectively. These val- ues are smaller than the tolerance limit of 5%, indicating that both perceived benefits and self-efficacy have a significant influence on quality of life. On the other hand, the ANOVA test results in a sig- nificance value of 0.071, suggesting that there is no significant influence when considering perceptions of susceptibility, severity, barriers, benefits, and self-efficacy simultaneously on the quality of life of traditional divers. Furthermore, the R-squared value is 0.319, signifying that the impact of individual beliefs, which encompass perceptions of severity, susceptibility, barriers, benefits, and self- efficacy, on the quality of life of traditional divers amounts to 31.9%. The remaining factors contribute to the remaining variance. Discussion Factor individual beliefs associated with tradition- al divers in the surabaya coastal area Individual beliefs are essentials particularly in shaping their attitudes and behaviours. In this research, individual beliefs pertain to the traditional divers’ beliefs regarding their own health and how these beliefs affect their attitude towards their well-being. This study measures five factors within individual beliefs: perceived susceptibility, perceived severity, perceived barriers, perceived benefits, and self-efficacy. According to Table 2, the perception of benefits and self-efficacy significantly impacts the quality of life of traditional divers. Traditional divers are confident that their work benefits not only themselves but also their families and the envi- ronment. They provide marine products to the community, which leads to economic success, aligning with the findings of Ghani et al. (2017)24 which suggests that the more traditional divers catch, the more they can provide for the community and their families.24 Furthermore, self-efficacy also influences the quality of life of traditional divers, as their educational status affects their job opportunities. Those with lower levels of education may find it challenging to secure better job opportunities. This aligns with the assumption that the level of education significantly influences [page 148] [Healthcare in Low-resource Settings 2023; 11:11795] Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Table 1. Distribution of Demographic Characteristics in Traditional Divers (n=31). Characteristic Demographic Frequency (f) Percentage (%) p Age 23-45 years 18 58.1 46-77 years 13 41.9 Gender Male 31 100 Female 0 0 Graduation Not finished elementary school 12 38.7 Elementary school 11 35.5 Junior high school 5 16.1 Senior high school 3 9.7 Bachelor 0 0 Timer working as traditional divers 1-3 years 2 6.5 > 4 years 29 93.5 Marital status Married 29 93.5 Not Married 2 6.5 Income (Monthly) < the regional’s minimum salary 23 74.2 > the regional’s minimum salary 8 25.8 Is there a family member other than the respondent who is working? Yes 12 38.7 No 19 61.3 Number of Family members in a household 1 8 25.8 2 16 51.6 3 7 22.6 Non -co mmerc ial us e o nly human resources. Traditional divers are often reluctant to attempt new activities unless they believe they are capable of doing them. They believe in the benefits of these new behaviors but may not have the confidence to try them. In many cases, the younger gen- eration of traditional divers is compelled to support their families economically.25 Quality of life of traditional divers There are various definitions of the quality of life. In this research, the quality of life pertains to that of traditional divers and based on five perception factors: perception of susceptibility, per- ception of severity, perception of barriers, perception of benefits, and self-efficacy. These results indicate no simultaneous influence of perceptions of susceptibility, severity, barriers, benefits, and self-efficacy on the quality of life of traditional divers.24 Quality of life can be measured through various influencing factors, including education, health, and economic status. Low quality of life often results from deficiencies in human resources, health, and the econ- omy.6 The researcher’s assumption is that the level of education can significantly influence the quality of life of traditional divers. A low level of education tends to result in diminished human resources, which, in turn, leads to a lack of skills and an inability to perceive and adopt behaviors that support a good quality of life. Our finding highlights that two factors influence the quality of life of traditional divers. Specifically, perceived benefits and self- efficacy are linked to the low educational levels of traditional divers, which in turn affect family income and economic factors. Traditional divers often encourage their children to assist in increasing family income and alleviating family burdens. Many traditional divers appreciate the benefits of their work and feel grateful for their improved lives, partly due to increased govern- ment and social institution attention to traditional fishermen, espe- cially traditional divers. This perspective aligns with previous research that considers the concept of quality of life as an amalga- mation of opportunities, human needs, and welfare.26,27 Quality of life pertains to the extent to which human needs are met and can be evaluated objectively and subjectively. Essential human needs include safety, self-sufficiency, and reproduction.28 Moreover, self- efficacy factors significantly impact the quality of life of tradition- al divers. These divers are particularly susceptible to illnesses such as decompression sickness and barotrauma, and some of them mis- takenly believe that these illnesses will naturally heal. They have confidence that their families will continue to support them through such hardships.24 The impact of self-efficacy on the quality of life of traditional divers aligns with previous studies. For instance, traditional divers who engage in extended dives, exceeding 10.5 hours per week, and have over 2.6 years of diving experience are at higher risk of decompression sickness.29 The accumulation of nitrogen in the body over longer dives is a contributing factor, and this condition necessitates treatment as it does not resolve spontaneously.30 Research conducted in the west coast region of Malaysia further supports the idea that the quality of life of traditional divers can be improved with special attention from the government, including the adoption of effective technology in marine fishing activi- ties.24,26,27 [Healthcare in Low-resource Settings 2023; 11:11795] [page 149] Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Table 2. Descriptive data analysis on traditional divers. Variable N Min. Max. Mean Deviation Std. Quality of life 31 71 105 88.71 10.759 Perceived severity 31 9 22 16.26 2.792 Perceived susceptibility 31 9 22 15.90 2.914 Perceived barrier 31 0 17 12.35 3.382 Perceived benefit 31 4 14 9.13 2.566 Self-efficacy 31 4 12 7.68 2.508 Table 3. The Result of analysis the infuence of individual beliefs on quality of life in traditional divers. Variable Unstandardised coefficients Standardised t Sig.*) B Std. Error coefficients beta (Constant) 92.062 14.319 6.430 0.000 Perceived Susceptibility 0.160 0.752 0.043 0.212 0.834 Perceived Severity -0.441 0.769 -0.114 -0.574 0.571 Perceived Barrier -0.306 0.567 -0.096 -0.539 0.595 Perceived Benefit 2.113 0.745 0.504 2.838 0.009 Self-Efficacy -1.855 0.744 -0.432 -2.494 0.020 Sig.**) 0.071 Normalitas Test ***) 0.525 R Square 0.319 *linier regression tes; **anova test; ***Shapiro-Wilk test. Non -co mmerc ial us e o nly Conclusions In this research, individual beliefs encompass five factors: per- ceived susceptibility, perceived severity, perceived barriers, per- ceived benefits, and self-efficacy. Among these factors, two signif- icantly impact the quality of life of traditional divers: perceived benefits and self-efficacy. To comprehensively understand the fac- tors influencing the quality of life of traditional divers in the coastal areas of Surabaya city, further research is needed to identi- fy and explore additional contributing factors. The research implies that the nearest health facilities should offer health educa- tion programs tailored to traditional divers. These programs should provide specific protective measures to mitigate the risks associat- ed with diving activities, such as barotrauma, decompression sick- ness, and other related health concerns. References 1. Suryadi AM, Sufi S. Strategi Pemberdayaan Masyarakat Nelayan Dalam Peningkatan Kesejahteraan Nelayan (Studi di Kantor Camat Muara Batu Kabupaten Aceh Utara). Negot J Ilmu Adm Bisnis 2019;2:118. 2. Goso Goso, Anwar SM. Poverty Of Traditional Fisherman As Well As The Influence Toward Dirty Village. In: Natural and Social Science (ICONSS) 2017. p. 81-9. 3. Zain MA, Suhaimi J, Dahlui M, et al. What are the outcomes of marine site protection on poverty of coastal communities in Southeast Asia? A systematic review protocol. Environ Evid 2022;11(1). 4. Sudarso, Keban PE, Mas’udah S. Poverty, lack of awareness of gender education, and patriarchy among Javanese coastal women. Opcion 2019;35:2899-921. 5. Prasetyo AT, Soemantri JB, Lukmantya L. Pengaruh kedalaman dan lama menyelam terhadap ambang-dengar penyelam tradi- sional dengan barotrauma telinga. Oto Rhino Laryngol Indones 2012;42:69-76. 6. Trijayanti E, Mutaali L. Kualitas hidup nelayan Desa Kemadang, Kecamatan Tanjungsari, Kabupaten Gunungkidul. J Bumi Indones 2017;6:1-9. 7. Latif I. Analisis Deskriptif Masalah Kesehatan Masyarakat Pesisir Desa Karangsong - Indramayu. J Kesehat Indra Husada 2017;4:29-36. 8. Laratmase AJ. Pengembangan Alat Ukur Kualitas Hidup Nelayan. J Ilm Pendidik Lingkung dan Pembang 2016;17:34-41. 9. Paskarini I, Alwi MNM, Martiana T, Mahmudah, Arini SY, Dwiyanti E. The Decrease in the Quality Life of Fishermen Due to Covid-19 Widespread. Malaysian J Med Heal Sci 2022;18:79-85. 10. Tain A. Penyebab kemiskinan rumah tangga nelayan di wilayah tangkap lebih jawa timur [Causes of household poverty among fishermen in the East Java fishing grounds]. Humanity 2011;7:1- 10. 11. TNP2K. Penentuan Wilayah Prioritas Kemiskinan Ekstrem 2021-2024. 2022;1-20. 12. Laksono AD, Wulandari RD, Efendi F. Determinants of hospital utilisation among urban poor societies in Indonesia. Int J Innov Creat Chang 2020;12:375-87. 13. Tamboto HJ., Manongko AAC. Model Pengentasan Kemiskinan Masyarakat Pesisir. 2019. 157 p. 14. BPS 2020. Statistik Indonesia 2020. Stat Indones 2020. 2020;1101001:790. 15. Saroinsong RP. Peran Pemerintah Desa Dalam Penanggulangan Kemiskinan Nelayan Di Desa Lantung Kecamatan Wori Kabupaten Minahasa Utara. Acta Diurna Komun 2014;3:1-12. 16. Alayyannur PA, Haqi DN, Zahroh F, Munib TA, Alhakim MM, Ningrum DP. Relationship Between Individual Characteristics and the Risk of Exposure to Heat Stress in Indonesian Fishermen. Pharmacogn J 2023;15:294-7. 17. Malik K, Amir N, Kusumawardhani AAAA, Lukman PR, Karnovinanda R, Melisa L, et al. Health Action Process Approach (HAPA) as a Framework to Understand Compliance Issues With Health Protocols Among People Undergoing Isolation at Emergency Hospital for COVID-19 Wisma Atlet Kemayoran and RSCM Kiara Ultimate Jakarta Indonesia. Front Psychiatry 2022;13:1-15. 18. Widyastuti SR, Hadisaputro S, Munasik M. Berbagai Faktor yang Berpengaruh Terhadap Kualitas Hidup Penyelam Tradisional Penderita Penyakit Dekompresi. J Epidemiol Kesehat Komunitas 2019;4:45. 19. El-Soud FAA, Alhoraim SA, Alammar BA, Alotaibi RS. Quality of Life, Self-Rated Health and Social Support Among Older Adult in the Saudi Community. Malaysian J Nurs 2020;11:13- 25. 20. Abbas A, Ekowati D, Suhariadi F, Fenitra RM. Health Implications, Leaders Societies, and Climate Change: A Global Review. Springer Climate. Department of Economics and Business, Jawa Timur, Surabaya, Indonesia. Springer Science and Business Media B.V.; 2022. p. 653-75. 21. Manab A. Memahami regulasi diri: Sebuah tinjauan konseptual. Psychol Humanit 2016;7-11. 22. Champion VL, Skinner CS. The health belief model. In: Glanz K, Rimer BK, Viswanath K, editors. Health behavior and health education: Theory, research, and practice. 4th ed. San Francisco, CA, US: Jossey-Bass; 2008. p. 45-65. 23. Kiling IY, Kiling-Bunga BN. Pengukuran dan Faktor Kualitas Hidup pada Orang Usia Lanjut. J Heal Behav Sci 2019;1:149- 65. 24. Ghani NA, Raub MA, Adam F, Abdullah B, Afgani@Eusoff Y, Ali Puteh DAHM. Quality of Life (QoL) of Fishermen in the West Coast States of Peninsular Malaysia. Int J Acad Res Bus Soc Sci 2017;7(4). 25. Gai AM, Soewarni I. The Characteristics and Poverty Level of People in Sukolilo Fisherman Village Surabaya Based on Sustainable Livelihood Approach. J Econ Sustain Dev 2017;8(20). 26. Dahlui M, Azzeri A, Zain MA, et al. Health status, healthcare utilisation, and quality of life among the coastal communities in Sabah: Protocol of a population-based survey. Medicine (Baltimore) 2020;99:e22067. 27. Putra MM, Sari NPWP. Model Theory of Planned Behavior to Improve Adherence to Treatment and the Quality of Life in Tuberculosis Patients. J Ners 2020;15(2). 28. Zain RM, Kamarudin MKA, Saad MHM. Assessment of Quality of Life on Fishermen Community in Kuala Terengganu, Malaysia: A Review. Int J Acad Res Bus Soc Sci 2018;8:640-50. 29. Chabibah N, Mayasari AC, Rachmawati DS, Said FBM. The Impact of Frequency and Duration of Diving Activities on the Occurrence of Decompressive Sickness. Malaysian J Nurs 2022;14:75-81. 30. Widyastuti SR, Hadisaputro S, Munasik M. Berbagai Faktor yang Berpengaruh Terhadap Kualitas Hidup Penyelam Tradisional Penderita Penyakit Dekompresi. J Epidemiol Kesehat Komunitas 2019;4:45-54. [page 150] [Healthcare in Low-resource Settings 2023; 11:11795] Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Non -co mmerc ial us e o nly