Objective: To observe the relationship of perceived seriousness, perceived susceptibility, perceived benefits, perceived barriers and cues to action with adherence to coronavirus disease-2019 protocols among traders.
Methods: The descriptive, quantitative, cross-sectional study was conducted from July to August 2021, in Jember Regency, East Java, Indonesia, and comprised traders in a traditional market. Data was collected using a demographic questionnaire, a questionnaire based on the Health Belief Model, and a coronovirus disease-2019 protocol adherence questionnaire after confirming the validity and reliability of the instruments.
Results: Of the 332 subjects, 191(57.5%) were females and 141(42.5%) were males. The largest age group was 30-39 years 137(41.3%), followed by 40-49 years in 132(39.8%). Overall, 293(88.3%) subjects had no history of chronic diseases. The main sources of information related to coronavirus disease-2019 were family/friends 84(25.3%), social media 83(25%) and television 82(24.7%). There were significant relationships of perceived susceptibility (p=0.000; r=0.215), perceived seriousness (p=0.004; r=0.157), perceived benefits (p=0.003; r=0.163), perceived barriers (p=0.001; r=-0.178) and cues to action (p=0.002; r=0.168) with protocol adherence.
Conclusion: Perceived susceptibility, perceived seriousness, perceived benefits, perceived barriers and cues to action were found to affect a person’s adherence with coronavirus disease-2019 protocols.
Keywords: COVID-19 health protocols, Cues, Health belief model, Adherence. (JPMA 73: S-76 [Suppl. 2]; 2023)
Indonesia was among the countries that suffered badly in terms of the spread of coronavirus disease-2019 (COVID-19).1 Traditional markets became clusters of COVID-19 positivity in Indonesia, according to the Indonesian Market Traders Association (IKAPPI).2 This happened because the market was a place where many people gathered to make buying and selling transactions, increasing the risk of COVID-19 transmission.2 The government provided preventive facilities, such as a place to wash hands, distribution of free masks and face shields, billboards displaying orders to continue to apply health protocols, and a dedicated unit of officers tasked with supervising Tanjung Market, which is one of the largest traditional markets in Jember Regency, but the adherence level among the traders remained low.
In November 2020, there were 1,568 traders who tested positive and 65 people had died across 275 markets in Indonesia.3 Jember Regency, as of May 10, 2021, entered the orange zone4 and non-adherence of traders could have had an impact on the spike in the number of positive COVID-19 cases in Jember Regency.
Self-efficacy, perceived benefits, perceived barriers and perceived susceptibility have important roles in community adherence.5 Perception of susceptibility is an individual’s belief about a possibility or risk of developing a disease.6 Denial reaction to the prevention of COVID-19 was caused by the perceived risk/susceptibility, which is influenced by individual, community and cultural factors.7 If a person believes in the benefits he receives, then it can reduce susceptibility, seriousness of virulence, and risk of the virus to cause death.8 Other key factors are socioeconomic, territorial, political and individual factors.8
The Health Belief Model (HBM)9,10 aims at increasing an individual’s perception of the threat so that the individual may adopt healthy behaviour.11 Further research on perceived seriousness, perceived susceptibility, perceived benefits, perceived barriers and cues to action may help policy-makers in ensuring the promotion of COVID-19 preventive behaviour.7 Health promotion strategies regarding health protocol adherence should focus on the perceived seriousness, perceived risk and self-efficacy, and adapt from habits to reduce the risk.12 Perceived risk is influenced by several factors, such as individuals, communities and culture.7
The current study was planned to explore the relationship of perceived seriousness, perceived susceptibility, perceived benefits, perceived barriers and cues to action with adherence to COVID-19 protocols among traders in a traditional market.
Subjects and Methods
The descriptive, quantitative, cross-sectional study was conducted from July to August 2021, in Tanjung Market, Jember Regency, East Java, Indonesia. After approval from the ethics review committee of the Faculty of Nursing, Airlangga University, the sample size was calculated in line with literature (Figure).13 There were 1269 traders in the market; 730 on the second floor, and 539 on the first floor, and the sample included the required number of traders from each floor using the simple random sampling technique.
All those who met the inclusion criteria were given a number and a lottery was conducted to raise the sample. The inclusion criteria were: 1) Traders who are still actively selling in Tanjung Market; and 2) Traders who are more than 18 years old. Only one representative from each trade stall was selected. An informed consent sheet was given to the respondents under study. If respondents were willing, they filled out a questionnaire handed out by the researcher. If not willing, they were not obliged to do so.
Data was collected using a demographic characteristics questionnaire, based on the HBM theory9,10 and a COVID-19 health protocol adherence questionnaire. The validity and reliability were tested using Pearson Product Moment and Cronbach’s alpha respectively. The validity values for perceived susceptibility, perceived seriousness, perceived benefits, perceived barriers, and cues to action ranged from 0.546 to 0.833, which was more than r table (0.532), while Cronbach’s alpha values for perceived susceptibility (0.975), included seriousness (0.835), perceived benefits (0.919), perceived barriers (0.981), and cues to action (1) which indicated reliability. The validity value for the COVID-19 protocol adherence questionnaire was 0.536-0.642), and the reliability value was 0.789.
Fifty questionnaires were distributed daily. Efforts were made to prevent transmission of COVID-19 to other traders. Hand sanitizers were provided to prospective respondents, and they were asked to use face masks that were also provided to those who were not already using them. Body temperature of prospective respondents was checked using a thermogun, and they were asked whether they had complaints of cough, runny nose, fatigue, lethargy, sore throat, and shortness of breath. Anyone found to have at least three of these symptoms was excluded. Data was analysed using Spearman Rho test.
Of the 332 subjects, 191(57.5%) were females and 141(42.5%) were males. The largest age group was 30-39 years 137(41.3%), followed by 40-49 years 132(39.8%). Overall, 293(88.3%) subjects had no history of chronic disease. The main sources of information related to COVID-19 were family/friends 84(25.3%), social media 83(25%) and television 82(24.7%) (Table 1).
Majority respondents had a low perceived susceptibility 198(59.6%), low perceived seriousness 280(84.3%), low perceived benefits 284(85.5%), high perceived barriers 125(37.7%), and low cues to action 208(62.6%). Adherence to COVID-19 protocols was low 268(80.7%).
There were significant relationships of perceived susceptibility (p=0.000; r=0.215), perceived seriousness (p=0.004; r=0.157), perceived benefits (p=0.003; r=0.163), perceived barriers (p=0.001; r=-0.178) and cues to action (p=0.002; r=0.168) with protocol adherence (Table 3).
The findings suggested that average respondents agreed that they had the possibility of getting infected, but did not agree that their work might cause transmission of the virus.
A study explained that increasing adherence to the application of health protocols in individuals can be influenced by how the individual is aware of his or her susceptibility to the COVID-19 virus.14
One study reported that one of the many factors associated with health protocol compliance was education.15 Based on the results of the characteristics of the respondents in this study, it was found that the average trader had a final education level of Junior or Senior High School. Gender, exposure to information, attitudes toward COVID-19 preventive measures and perceived risk/vulnerabilities affected community adherence in targeting COVID-19 mitigation.16
Perceived seriousness was significantly related to protocol adherence in the current study, which found that the average respondents did not agree that they were afraid of COVID-19, and disagreed that they would lose their job if exposed.
Perceived seriousness can be formed on the basis of medical information and knowledge. A person’s level of understanding in receiving information is very important, because this affects the final response. A good level of knowledge leads to good behaviour.17
Someone who does not really understand or misinterprets the meaning of an instruction will not be able to follow the rules.18 Health promotion activities should be undertaken using interpersonal communication and language that is simple, clear and easy to understand, such as information for traders that hand washing with soap in clean running water is a sanitary measure to maintain hygiene.19 The perceived benefits have a positive effect on adherence with the application of health protocols, so the higher the perceived susceptibility that a person has, the higher the adherence.
Respondents in the current study generally disagreed that masks were able to prevent COVID-19 transmission, and strongly disagreed that washing hands and keeping social distance could prevent the transmission. Perceived benefits lead to a positive attitude towards COVID-19 prevention.14,20 If the disease is considered serious, people will take better action to prevent outbreaks.11 Another study stated that if a person believes in the benefits he stands to receive, it can reduce susceptibility, seriousness of virulence, and risk of virus–related death.21
Perceived barriers negatively affect protocol adherence22. Perceived barriers in the current study were significantly related to protocol adherence, which has been reported earlier as well.14
The current study found a number of respondents who had a high perception of barriers, but had a low level of adherence. This finding was in contrast with earlier research which stated that the perceived high barriers will increase the level of protocol adherence.14
Cues to action had a positive effect on protocol adherence in the current study. They indicate how the respondents might react to the support that has been provided by the government in an effort to prevent COVID-19 transmission23.
The current study found that the respondents received more information from friends/family and social media regarding hand-washing stations, provision of free masks and faceshields, etc.24 Health awareness promotes the spread of information about how to prevent COVID-19 in one’s environment.25
Further research should be conducted on more specific reasons between perception variables and behavioural cues.
The higher the levels of perceived susceptibility, perceived seriousness, perceived benefit and cues to action, the higher was the level of adherence. In contrast, the higher the level of perceived barriers, the lower was the level of adherence.
Acknowledgment: We are grateful to all the research participants.
Conflict of Interest: None.
Source of Funding: None.
1. Wahyuhadi J, Efendi F, Al Farabi MJ, Harymawan I, Ariana AD, Arifin H, et al. Association of stigma with mental health and quality of life among Indonesian COVID-19 survivors. PLoS One 2022;17:e0264218. doi: 10.1371/journal.pone.0264218.
2. Kuntardjo N, Sebong PH. Patterns of Interaction and Compliance with Health Protocols by Traders in Pasar X Semarang City: Explorative Qualitative Study. Jurnal Manajemen Kualitas Hidup 2020;1:1-10. doi.org/10.24167/vit.v1i1.2974
3. Widadio NA. IKAPPI: 1,568 market traders infected with Covid-19 in Indonesia. [Online] 2020 [Cited 2021 May 10]. Available from URL: https://www.aa.com.tr/id/nasional/ikappi-1568-pedagang-pasar-terinfeksi-covid-19-di-indonesia/2036744
4. Solichah Z. Orange zone, Jember Regent urges residents to pray Eid al-Fitr at home. News release. The Indonesia Media Centre. [Online] 2021 [Cited 2021 May 12]. Available from URL: https://www.antaranews.com/berita/2146970/zona-oranye-bupati-jember-imbau-warga-shalat-idul-fitri-di-rumah
5. Shewasinad Yehualashet S, Asefa KK, Mekonnen AG, Gemeda BN, Shiferaw WS, Aynalem YA, et al. Predictors of adherence to COVID-19 prevention measure among communities in North Shoa Zone, Ethiopia based on health belief model: A cross-sectional study. PLoS One 2021;16:e0246006. doi: 10.1371/journal.pone.0246006.
6. Becker MH. The health belief model and sick role behavior. Health Educ Monogr 1974;2:409-19. Doi: 10.1177/109019817400200407
7. Alqahtani MMJ, Arnout BA, Fadhel FH, Sufyan NSS. Risk perceptions of COVID-19 and its impact on precautionary behavior: A qualitative study. Patient Educ Couns 2021;104:1860-7. doi: 10.1016/j.pec.2021. 02.025.
8. Carvalho KM, Silva CRDT, Felipe SGB, Gouveia MTO. The belief in health in the adoption of COVID-19 prevention and control measures. Rev Bras Enferm 2021;74(Suppl 1):e20200576. doi: 10.1590/0034-7167-2020-0576.
9. Strecher VJ, Rosenstock IM. The health belief model. In: Baum A, Newman S, Weinman J, West R, McManus C, eds. Cambridge Handbook of Psychology, Health and Medicine, 1st ed. Cambridge, UK: Cambridge University Press, 1997; pp 113-6.
10. Rosenstock IM, Strecher VJ, Becker MH. Social learning theory and the Health Belief Model. Health Educ Q 1988;15:175-83. doi: 10.1177/109019818801500203.
11. Becker MH. The Health Belief Model and Personal Health Behaviour. Health Educ Monogr 1974;2:324-473.
12. Shahin MAH, Hussien RM. Risk perception regarding the COVID-19 outbreak among the general population: a comparative Middle East survey. Middle East Curr Psychiatry 2020;27:2-19. Doi: 10.1186/ s43045-020-00080-7.
13. Sugiyono. Quantitative, Qualitative and Research Development Research Design. West Java, Indonesia: Penerbit Alfabeta Bandung; 2019.
14. Afro RC, Isfiya A, Rochmah TN. Analysis of factors affecting health protocols compliance during Covid-19 pandemic in East Java Community: health belief model approach. J Commun Mental Health Public Policy 2020;3:1–10. Doi: 10.51602/cmhp.v3i1.43
15. Erawati AD. Factors affecting compliance in implementing health protocols to prevent COVID-19 in Indonesia: A cross-sectional study. Jurnal Ners 2022;17:56-61. doi: 10.20473/jn.v17i1.25618
16. Azene ZN, Merid MW, Muluneh AG, Geberu DM, Kassa GM, Yenit MK, et al. Adherence towards COVID-19 mitigation measures and its associated factors among Gondar City residents: A community-based cross-sectional study in Northwest Ethiopia. PLoS One 2020;15:e0244265. doi: 10.1371/journal.pone.0244265.
17. Shari WW. The Relationship Between Level of Knowledge and Behaviors of COVID-19 Prevention among Indonesian Population. Jurnal Ners 2021;16:155-61. Doi: 10.20473/jn.v16i2.21765.
18. Haryanti T, Azmiardi AA. Threat Perception with COVID-19 Prevention Behavior in Community in Sukoharjo. Jurnal PROMKES 2022;10:30-5. Doi: 10.20473/jpk.V10.I1.2022.30-35
19. Rachmat B, Kristanto AY, Sondari TR. Quality of Handwashing in Informal Workers in Indonesia. Jurnal Kesehatan Lingkungan 2022;14:55-62. Doi: 10.20473/jkl.v14i1.2022.55-62
20. Tong KK, Chen JH, Yu EW, Wu AMS. Adherence to COVID-19 Precautionary Measures: Applying the Health Belief Model and Generalised Social Beliefsto a Probability Community Sample. Appl Psychol Health Well Being 2020;12:1205-23. doi: 10.1111/ aphw.12230.
21. Carvalho KM, Silva CRDT, Felipe SGB, Gouveia MTO. The belief in health in the adoption of COVID-19 prevention and control measures. Rev Bras Enferm 2021;74(Suppl 1):e20200576. doi: 10.1590/0034-7167-2020-0576.
22. Shahnazi H, Ahmadi-Livani M, Pahlavanzadeh B, Rajabi A, Hamrah MS, Charkazi A. Assessing preventive health behaviors from COVID19: a cross sectional study with health belief model in Golestan Province, Northern of Iran. Infect Dis Poverty 2020;9:157. doi: 10.1186/s40249-020-00776-2.
23. Kim S, Kim S. Analysis of the Impact of Health Beliefs and Resource Factors on Preventive Behaviors against the COVID-19 Pandemic. Int J Environ Res Public Health 2020;17:8666. doi: 10.3390/ ijerph17228666.
24. Barile JP, Guerin RJ, Fisher KA, Tian LH, Okun AH, Vanden Esschert KL, et al. Theory-based Behavioral Predictors of Self-reported Use of Face Coverings in Public Settings during the COVID-19 Pandemic in the United States. Ann Behav Med 2021;55:82-8. doi: 10.1093/ abm/kaaa109.
25. Wiguna RI, Suhamdani H. Impact of the ‘Nola J Pender’ Health Promotion Model Towards the Level of Community Compliance in Implementing COVID-19 Health Protocols. Jurnal PROMKES 2022;10:85-92. doi: 10.20473/jpk.V10.I1.2022.85-92.