Healthcare in Low-resource Settings 2025; volume 13:13123 Model for determining the adequacy of drinking water intake in the Nambo coastal area of Indonesia Tasnim Tasnim, La Ode Saafi, Kadek Ayu Karuniawati, Fitri Fitri, Nuzul Wahyuning Tias, Ririn Putri Handayani, Indriani Indriani, Eka Putri Saripati, Wa Ode Fitra Saripati Department of Public Health, University of Mandala Waluya, Kendari, Indonesia Abstract The availability of drinking water in the Nambo coastal area is still challenging, leading to inadequate water intake. This research investigates a model for evaluating the adequacy of drinking water consumption in the Nambo coastal area. The study employs a quantitative cross-sectional design involving 100 participants aged 15 years and older. Data analysis was conducted using the partial least squares structural equation modeling (PLS-SEM). The findings indicate that a person’s belief has a positive and mod- erate effect on their water intake (p=0.000; R2=0.352; CI 97.5%: 0.179-1.531). This belief mediates the person’s knowledge and attitudes about the importance of staying hydrated (p=0.046; R2=0.226; CI 97.5%: -0.005-0.440). Additionally, knowledge pos- itively and moderately affects individual attitudes (p=0.000; R2=0.369; CI 97.5%: 0.226-0.635). Belief also has a positive and moderate influence on health maintenance (p=0.000; R2=0.428; CI 97.5%: 0.189-0.604). In conclusion, personal beliefs about the benefits of drinking water are critical to increasing water intake. Confidence in these beliefs stems from knowledge and positive attitudes toward the health benefits of water. Introduction Lack of water intake can cause disorders of the body’s organs, including chronic kidney disease (CKD).1-4 Chronic kidney dis- ease is often referred to as a “silent killer” because patients are usually unaware of it until it advances to a more severe stage.5-8 This disease has led to numerous deaths around the world, includ- ing in the coastal regions of Kendari City, Southeast Sulawesi, Indonesia. The prevalence of CKD is often hard to identify because many individuals do not seek early examination at health centers. As a result, the reported prevalence of CKD seems signif- icantly lower compared to other chronic diseases, such as hyper- tension and diabetes mellitus. For example, in 2018, the preva- lence of CKD in Southeast Sulawesi Province was 0.35%, show- ing an increase compared to 2013 (0.2%).9,10 The undetectability of chronic kidney sufferers makes it diffi- cult for policymakers and health service units to develop chronic kidney disease control programs. However, previous studies have shown that water consumption of less than 2000 mL a day is one of the main causes of chronic kidney function disorders in Kendari City.3,11-15 The insufficient water intake among residents in the coastal areas of Kendari City, Southeast Sulawesi, is closely linked to their access to drinking water sources. Specifically, certain coastal regions, such as the Nambo area, still struggle with limited access to these sources. However, this limited access may not be the only cause of insufficient water consumption, as people in these areas can still buy bottled water. Other factors affect adequate water intake in coastal communities, including knowledge and attitudes regarding the health benefits of drinking water for the body’s organs.16-20 In addition, confidence and motivation to make efforts to maintain health have been stated as determinants of water intake adequacy in individuals.21-25 Despite this, the specific ways in which these factors lead to inadequate water intake in the Nambo Coastal area of Kendari City, Southeast Sulawesi, Indonesia, have not been clearly described. Therefore, this study aims to develop a model for determining the appropriate level of daily water intake for residents in the Nambo coastal area of Southeast Sulawesi, Indonesia. It is hoped that the findings will serve as a reference for policymakers and health programs, ulti- mately increasing access to drinking water sources. Consequently, this should lead to an increase in water consumption among the local population. Correspondence: Tasnim Tasnim, Department of Public Health, University of Mandala Waluya, Kendari, Indonesia. E-mail: tasnim349@gmail.com Key words: attitude; belief; coastal; drink; water. Conflict of interest: the authors declare no potential conflict of interest. Ethics approval and consent to participate: this research received ethical approval from Mandala Waluya University Research Ethics Committee no. 12/KEP/UMW/V/2024 on 25 May 2024. Availability of data and materials: all relevant data are included in this published article. Funding: this research was funded by the Mandala Waluya Kendari Foundation, with contract number: 0399.B/UMW.01/IV/2024 on 6 April 2024. Acknowledgments: the authors would like to thank the Mandala Waluya Kendari Foundation for funding support for the research process. We also thank the Community Health Centre Management and coastal communi- ties in Nambo, Kendari City, Southeast Sulawesi, Indonesia, for partici- pating in this research. Received: 19 September 2024. Accepted: 30 November 2024. Early access: 14 February 2025. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2025; 13:13123 doi:10.4081/hls.2025.13123 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, 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. [Healthcare in Low-resource Settings 2025;13:13123] [page 123] Materials and Methods Study design The research employs a quantitative approach utilizing causal explanatory methods. This design aligns with the research objec- tives, as it effectively explains how one variable can influence or cause changes in other variables.26 Study setting This research was conducted in the Nambo Coastal area, Kendari City, Southeast Sulawesi, Indonesia, from May 2024 to July 2024. The research objectives and the limited access to ade- quate drinking water sources guided the selection of the location. Trends indicate that the percentage of households with access to sufficient drinking water has declined in Southeast Sulawesi, par- ticularly in coastal and rural areas. In 2022, the percentage was around 94.11%, which decreased to 93.88% in 2023.27 The Nambo Sub-district includes five villages: Petoaha, Nambo, Sambuli, Tondonggeu, and Bungkutoko. Sampling The study’s population consisted of 1788 households distribut- ed across five villages in the Nambo Sub-district. The households were allocated as follows: 420 in Petoaha Village, 310 in Nambo Village, 379 in Sambuli Village, 274 in Tondonggeu Village, and 405 in Bungkutoko Village. To select samples from this popula- tion, the study employed a cluster random sampling technique. The sample selection process began with determining the overall sam- ple size, followed by calculating the proportional sample sizes for each of the five villages. Sample size The study included a sample size of 100 participants, which was calculated using the Slovin formula. This formula considered a population of 1788 and an error margin of 10%. The calculation resulted in 95 participants; however, to account for potential dropouts, the researchers increased the sample size by 5% to 100 samples. Based on the sampling technique used, the participants were distributed as follows: 23 from Petoaha village, 17 from Nambo subdistrict, 21 from Sambuli village, 15 from Tondonggeu village, and 23 from Bungkutoko village. Data collection The data collection tool utilized a structured questionnaire that includes questions regarding knowledge, attitudes, beliefs, mainte- nance, and the amount of water intake. Valid knowledge questions include understanding the benefits of adequate water intake for regulating the body’s calorie consumption (P.11.B), protecting sen- sitive tissues such as the eyes (P.15.S), and preventing issues like dizziness or headaches (P.17.S). On the other hand, questions about attitudes focus on the effects of insufficient water consump- tion, such as muscle weakness (S.7.N), joint pain (S.8.N), and a dull or unattractive appearance of the skin (S.13.N). Questions regarding beliefs focus on the effects of insufficient water intake on the occurrence of kidney disease (K.19.N), body weakness (K.20.N), and joint pain (K.21.N). Maintenance-related questions include the maintenance of body fluids (PM.1P), the process of food digestion in the body (PM.2.N), and the circulation of body fluids (PM.4.P). A valid question about water intake is the amount of drinking water consumed in the morning and afternoon, mea- sured in glasses (each glass was converted to 250 mL). The instru- ment has been tested for validity and reliability before data collec- tion. Based on the results of the construct reliability and validity tests conducted with PLS-SEM using Smart PLS software version 3.0, it was determined that the instrument was reliable and the questions for each variable were valid. As shown in Table 1, the Cronbach’s alpha value is >0.6, the average variance extracted (AVE) value is >0.6, and composite reliability is >0.7. Participant characteristics The participants in this study were predominantly women, accounting for 78% of the total, while men comprised 22% (Table 2). The average age of participants was 33.8 years, with a standard deviation of 10.1 years. The highest level of education was high school (47%), and the least was higher education or above diploma (18%). Most participants were housewives (64%). Additionally, 21% were entrepreneurs, while only 9% worked in government roles. Outcome measures The variable measurement of the water intake level includes three categories: good, medium, and low. It is categorized as “good” if the value is >2000 mL per day, “medium” if the value is between 1000 and 1999 mL per day, and “poor” if the value is <999 mL per day. Knowledge and maintenance variables are mea- sured in three categories: good, average, and poor. The knowledge or maintenance category is “good” if the score is 3, “medium” if the score is 2, and “poor” if the score is 1. Measurements of atti- tudes and beliefs are also divided into three categories: good, aver- age, and poor. It is categorized as “good” if the score is between 9 and 12, “medium” if the score is between 5 and 8, and “poor” if the score is 4 or less. Data quality management Prior to conducting the interview, the research team received training on interview techniques and questionnaire comprehen- sion. Preparatory meetings were also held to divide tasks in data collection. After collecting the data, each team coordinated the number of respondents interviewed and created a form for entering the data into a master table in Excel. They also divided tasks for inputting the data into SPSS version 25. Before the master table was imported into SPSS version 25 and Smart PLS version 3.0, the accuracy of the data was thoroughly reviewed. Article Table 1. Construct reliability and validity. Variables Cronbach’s alpha* Validity Average variance extracted (AVE)* Reliability Attitude 0.739 Valid 0.656 Reliable Belief 0.823 Valid 0.736 Reliable Knowledge 0.682 Valid 0.605 Reliable Maintenance 0.767 Valid 0.682 Reliable Water intake adequacy 0.626 Valid 0.726 Reliable *PLS-SEM test. [page 124] [Healthcare in Low-resource Settings 2025;13:13123] Statistical analysis Data analysis uses partial least squares structural equation modeling (PLS-SEM) with Smart-PLS software version 3.0.28 PLS-SEM is used to predict endogenous latent variables or identi- fy main variables and develop a model for determining the adequa- cy of water intake in coastal areas. The process involves several steps. The first step is testing the outer model, which aims to estab- lish the relationships between the latent variables and their corre- sponding observed indicators. The outer model test results assess the data’s validity and reliability using three key metrics: Cronbach’s alpha, Average Variance Extracted (AVE), and com- posite reliability. The data is considered valid and reliable when the following conditions are met: Cronbach’s alpha is >0.6, the AVE is >0.6, and the composite reliability is >0.7.29,30 The second step consists of evaluating the inner model to understand the relationship between independent and dependent latent variables. Interpretation of the direction and strength of the relationship is based on the R-Square (R2) value; R2>0.67 is a strong relationship, R2=0.33-0.66 is a moderate relationship, and R2=0.19-0.32 is stated to be weak.31 Additional analyses were con- ducted using the Goodness of Fit approach to determine the model’s suitability. A model is considered fit if the NFI value is close to 1 and the SRMR value is <0.10.32,33 Results The results of the SEM-PLS analysis show that the level of water intake in the Nambo coastal area is directly influenced by the level of individual belief (Figure 1). The direction of the relation- ship between belief and adequate water consumption is positive and moderate (R2=0.352). Knowledge and attitudes are indirectly related to adequate water consumption, primarily through the influence of individual beliefs. Specifically, knowledge is connect- ed to beliefs both directly and indirectly. The indirect connection between knowledge and beliefs is mediated by attitudes. The rela- tionship between knowledge and attitudes is positive and moderate (R2=0.369). Similarly, the relationship between attitudes and beliefs is also positive but weaker (R2=0.198). Additionally, the direct relationship between knowledge and beliefs is positive but weak (R2=0.226). The belief variable is also related to the health maintenance variable. The direction and strength are positive and moderate (R2=0.428). In this case, the belief variable is also a mediating variable between knowledge and attitudes towards maintenance. The model used to determine adequate water intake has been deemed suitable because the NFI value is 0.529, which is close to 1, and the SRMR value is approximately 0.1 (Table 3). The Article Table 3. Path coefficients in the model of determining drinking water intake in the Nambo coastal area in 2024. Variabel relationships Original Sample Standard T statistics p Confidence Fit summary sample (O) mean (M) deviation (STDEV) (O/STDEV) intervals (CI) 2.5% 97.5% Knowledge and attitude 0.369 0.390 0.079 4.677 0.000 0.226 0.535 SRMR=0.10 Attitude and maintenance 0.305 0.315 0.975 4.052 0.000 0.172 0.460 NFI=0.529 Belief and maintenance 0.428 0.425 0.108 3.959 0.000 0.189 0.604 Chi-Sqare=268.300 Belief and water intake 0.352 0.360 0.090 3.916 0.000 0.179 0.531 Attitude and belief 0.198 0.192 0.090 2.217 0.027 0.009 0.359 Knowledge and belief 0.226 0.235 0.113 1.997 0.046 -0.005 0.440 *PLS-SEM test. Figure 1. Model for determining the adequacy of water intake in the Nambo coast in 2024. Table 2. Participant characteristics. Participant characteristics Frequency Percent Gender Male 22 22.0 Female 78 78.0 Age Group (Years) 15-24 18 18.0 25-34 35 35.0 35-49 39 39.0 50-59 7 7.0 60-65 1 1.0 Mean ± SD 33.8±10.1 Occupation Government employees 9 9.0 Entrepreneur/Private 21 21.0 Fisherman 3 3.0 Farmer 1 1.0 Honorary 2 2.0 Education levels Low (Under junior high school) 35 35.0 Medium (Senior high school) 47 47.0 High (Above diploma) 18 18.0 No working/ housewife 64 64.0 Total 100 100.0 SD, standard deviation. [Healthcare in Low-resource Settings 2025;13:13123] [page 125] calculated chi-square (χ2) value is 268.300, which is higher than the table value (χ2 table with df=99, alpha=0.05), which is 113.145. This indicates that the model is significant. Among the variables assessed, the R2 coefficient for the maintenance variable is the highest at R2=0.350, compared to the R2 values for attitude (R2=0.136), adequacy of drinking water (R2=0.124), and belief (R2=0.123). There are two key indicators of adequate water intake: morning and afternoon water consumption. The R2 coefficient value for afternoon water consumption is 0.881, which is higher than the morning water consumption value of 0.822. A significant indicator of belief is the perception of how inad- equate water intake influences the risk of kidney disease (K.19.N), physical weakness (K.20.N), and joint pain (K.21.N). The R2 value for belief about the effect of insufficient water intake on joint pain is the highest (R2=0.884), followed by belief regarding its impact on kidney disease (R2=0.850). In comparison, belief related to its effect on physical weakness is lower (R2=0.841). The indicators related to the knowledge variable include three main aspects: understanding the benefits of sufficient water intake for regulating the body’s calorie intake (P.11.B); the protection of sensitive tissues, such as the eyes (P.15.S); and the prevention of dizziness or headaches (P.17.S). Among these, the R2 for knowl- edge about regulating the body’s calorie intake is the highest (R2=0.789). This is followed by knowledge of the benefits of drinking enough water to avoid dizziness (R2=0.772), and knowl- edge regarding the protection of sensitive tissues like the eyes (R2=0.751). The indicators for the attitude variable consist of three aspects: attitudes regarding the effects of insufficient drinking water on muscle weakness (S.7.N), joint disorders (S.8.N), and skin dull- ness or poor appearance (S.13.N). Among these, the attitude towards the impact of insufficient water intake on joint disorders has the highest R2 coefficient value (R2=0.858), followed by atti- tudes about the effect of insufficient water on skin performance (R2=0.774), and the impact on muscle weakness (R2=0.797). The indicators for the maintenance variable include the following: maintenance of body fluids (PM.1P), digestion process (PM.2.N), and circulation of body fluids (PM.4.P), which is linked to ade- quate daily water intake. The coefficient for body fluid circulation maintenance is slightly higher (R2=0.859) than that for body fluid balance maintenance (R2=0.853). However, it surpasses the coeffi- cient for food digestion maintenance (R2=0.764). The relationship between variables results as follows: relationship between knowl- edge and attitude (p=0.000; CI 97.5%: 0.226-0.535); between atti- tude and maintenance (p=0.000; CI 97.5%: 0.172-0.460); between belief and maintenance (p<0.0001; CI 97.5%: 0.189-0.604); between belief and the adequacy of water intake (p<0.0001; CI 97.5%: 0.179-0.531); between attitude and belief (p=0.027; CI 97.5%: 0.009-0.359); between knowledge and belief (p =0.046; CI 97.5%: -0.005-0.440). The distribution of the R2 coefficient for the relationship between belief and daily drinking water adequacy ranges from 0.10 (low) to 0.60 (medium) (Figure 2). The highest proportion, approximately 60%, falls within the moderate range (R2=0.33-0.60), while about 40% are in the low range (R2=0.10- Article Figure 2. Path coefficients of the relationship between belief and drinking water intake in Nambo coastal area. Figure 3. Path coefficients of the relationship between belief and maintenance in Nambo coastal area. [page 126] [Healthcare in Low-resource Settings 2025;13:13123] 0.32). The distribution of the R2 coefficient for the relationship between belief and maintenance ranges from 0.07 (low) to 0.69 (strong) (Figure 3). The highest proportion, approximately 75%, falls within the moderate range (R2=0.33-0.66), while around 22% show a low relationship (R2=0.19-0.32), and only 3% exhibit a strong relationship (R2>0.67). The distribution of the R2 coefficient for the relationship between attitudes and beliefs ranges from -0.09 (low) to 0.48 (medium) (Figure 4). The proportions of low (R2<0.19-0.32) and medium (R2=0.33-0.48) relationships are almost identical, each representing about 50%. The distribution of the R2 coefficient for the relationship between knowledge and trust ranges from -0.20 (low) to 0.56 (medium) (Figure 5). The largest proportion, about 75%, falls within the low R2 range (R2<0.19-0.32), while approximately 25% show a medium relationship (R2=0.33-0.56). The distribution of the R2 coefficient for the relationship between knowledge and attitude ranges from 0.16 (low) to 0.61 (medium) (Figure 6). The highest proportion, around 75%, falls within the medium range (R2=0.33-0.61), while the remaining 25% have a low relationship (R2<0.19-0.32). The distribution of the R2 coefficient for the relationship between attitude and maintenance ranges from 0.09 (low) to 0.57 (medium) (Figure 7). The proportions of low (R2=0.19-0.32) and medium (R2=0.33-0.57) relationships are almost equal, with each representing around 50%. Discussion A person’s belief in the Nambo coastal areas directly influ- ences the adequacy of water intake. Individuals who have good belief about the benefits of drinking water, especially for joint health, body strength, and preventing kidney disease, will tend to drink water according to the standard, namely a minimum of 2000 mL per day. Conversely, people who do not believe in the benefits of drinking water tend to consume less water each day than need- ed. There are various perspectives on how individual belief influ- ences the adequacy of water intake in the Nambo coast area, rang- ing from low to moderate levels of belief. The community’s overall belief in the benefits of water is still at a moderate level, without being strongly ingrained. Several factors contribute to this, and the first is related to limitations in drinking water supply in coastal areas. People often rely on purchasing bottled water, which tends to be more expensive than in urban centers. However, many indi- viduals are already convinced of the health benefits of adequate water intake. Research suggests that behavioral changes, such as increased water consumption and adherence to healthy habits, are more likely to occur as individual belief strengthens.34,35 Water consumption in the Nambo coastal area is significantly higher in the mornings than in the afternoons. This aligns with the coastal environment, where the heat from the sea surface creates a strong need for hydration during the day. In contrast, the need for Article Figure 4. Path coefficients of the relationship between attitude and belief in Nambo coastal area. Figure 5. Path coefficients of the relationship between knowledge and belief in Nambo coastal area. [Healthcare in Low-resource Settings 2025;13:13123] [page 127] water in the Nambo coastal community decreases in the afternoon and evening as the weather cools, a change also influenced by sea air circulation. Additionally, the level of knowledge and attitudes among indi- viduals in the coastal area indirectly influences their drinking habits. People who are well-informed about the benefits of drink- ing water—such as its role in regulating calorie intake, protecting sensitive tissues, and preventing dizziness—tend to meet the rec- ommended daily intake of water, which is at least 2000 mL. People with good knowledge will immediately encourage their positive attitude toward the importance of drinking water for healthy mus- cles, joints, and skin. The individuals’ attitude in the coastal area is not only influenced by the health information that they have received but is also related to the weather of this area. This can be seen from their attitude towards skin health. The sun on the coast will directly impact the skin, which is why the response to the need to drink water is related to the appearance of the skin for coastal communities. Previous studies also stated that increasing water intake in the human body enhances skin extensibility and elastici- ty36 and increases the water content in the dermal layer.37 As a result, those who drink sufficient water have better skin perfor- mance than those who drink less. Good individual knowledge can also directly encourage the emergence of good beliefs about the benefits of water for joint health, body strength, and preventing kidney disease. Coastal com- munities’ beliefs about the importance of drinking enough water have also contributed to kidney disease prevention. Health mes- sages aimed at coastal areas have already been implemented and have had a positive impact on the management of chronic kidney disease. However, a study found that attitudes have a stronger influence in pushing individuals towards adequate water intake compared to knowledge.38 In this case, knowledge has less influ- ence due to the inaccurate information received by society. In con- trast, attitudes play a stronger role in influencing behavior because they directly shape individual beliefs. The development of personal attitudes and beliefs about water intake also affects health maintenance actions. Individuals with a positive attitude and belief in the benefits of drinking water are more likely to engage in health maintenance activities. Coastal communities rely on drinking water to maintain fluid balance and support digestion. These factors play a key role in encouraging individuals to drink sufficient water, particularly in the morning and afternoon. The importance of hydration is especially pro- nounced in maintaining the circulation of body fluids. This need is heightened during the day, when coastal communities lose a signif- icant amount of fluids through sweating. The warm coastal air encourages the body to sweat, increasing fluid loss. As a result, the body naturally requires more water to restore fluid balance. This phenomenon is observed in coastal regions worldwide, where drinking water is essential to replace fluids lost through perspira- tion.39 Consequently, this study highlights that the need for hydra- tion is the most influential factor in encouraging water consump- Article [page 128] [Healthcare in Low-resource Settings 2025;13:13123] Figure 6. Path coefficients of the relationship between knowledge and attitude in Nambo coastal area. Figure 7. Path coefficients of the relationship between attitude and maintenance in Nambo coastal area. tion, surpassing attitudes and beliefs in driving the motivation to drink enough water. There are several variable relationships that influence water intake in the Nambo coastal region. Firstly, the relationship between knowledge and individual attitudes leads to maintenance actions to prevent the lack of fluids in the body and smooth the process of food digestion. Moreover, people’s beliefs, shaped by acquired knowledge, promote the necessity of drinking water to support public health. The study indicates that approximately 75% of the influence of community beliefs has contributed to efforts to improve the physical health of the Nambo coastal population. Belief has a slightly stronger impact on promoting health mainte- nance behaviors than individual attitudes. Therefore, it can be con- cluded that fostering and sustaining the belief in the importance of drinking adequate water is key to improving the health of coastal communities. However, for drinking to be beneficial to public health, the dangers of physical, chemical, and biological contamination must be considered. Numerous contaminants are likely to occur in the drinking water supply in coastal areas, including contamination from wastewater from residential toilets, the discharge of toxic chemicals, including fluoride, and other anthropogenic activities, posing a risk of disease transmission.40,41 In light of these, it is essential to provide health education to the communities in the Nambo coastal area to improve their dietary habits, including prop- er water intake. Such education effectively enhances knowledge and attitudes toward healthy living.42 Limitations This study did not examine the type of water consumed. It focused solely on water intake among the Nambo coastal commu- nities. Additionally, the research did not assess public health status. As a result, this paper is unable to provide information about the relationship between beliefs, adequate water consumption, and health maintenance efforts. Future studies could address this gap, providing clearer and more in-depth evidence regarding the influ- ence of beliefs and sufficient water intake on health outcomes. Conclusions The beliefs held by coastal communities play a crucial role in ensuring that individuals drink sufficient water. When these beliefs are strong, they motivate people to take proactive steps to safe- guard their health. This research indicates that the community’s beliefs are influenced by health messages highlighting the benefits of drinking water for overall wellness. Consequently, this fosters a strong sense of trust within the coastal communities. Implications for health programs A strategic approach to increasing drinking water intake in coastal areas is building public awareness about water’s health benefits for body organs and tissues. One method is to provide training or health education, which serves as a form of health pro- motion. 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