Factors Associated with Health Protocol Compliance Among Market

Traders: A Cross-Sectional Study in Tabanan City, Indonesia

Putu Ayu Lestarini

, I Ketut Swarjana

, I G. A. Rai Rahayuni

and I Nyoman Arya Mahaputra

Master of Nursing Program, Faculty of Health, Institute of Technology and Health Bali, Denpasar, Indonesia

Bachelor of Nursing, Faculty of Health, Institute of Technology and Health Bali,Denpasar, Indonesia

Keywords: COVID-19, Health Protocol Compliance, Market Traders, Tabanan City.

Abstract: COVID-19 is a disease caused by the SARS-CoV 2 virus. Because this disease is transferred from person to

person, it is easily disseminated in crowded places like marketplaces. The Indonesian Ministry of Trade has

published health protocols for these market areas; therefore, implementing health protocols in the market is

one way to prevent COVID-19. This study aimed to identify factors associated with market traders'

compliance with health protocols. This study used a cross-sectional design with stratified sampling as the

sampling technique and 232 samples in total. A questionnaire was used for data collection. Binary logistic

regression was performed to test the factors associated with health protocol compliance. The findings revealed

that only 23.3% of respondents complied with health protocols. Knowledge (p = 0.001; OR = 0.06) and the

involvement of community leaders (p = 0.006; OR = 2.67) were statistically significant with health protocol

compliance among market traders. In conclusion, the majority of market traders were not in compliance with

health protocols. This result is related with knowledge, the role of community leaders, and respondents’

attitude; therefore, improving their knowledge and increasing the community leaders’ involvement are

necessary to strengthen health protocol compliance in the market.

1 INTRODUCTION

COVID-19 is a recently-identified coronavirus that

causes an infectious illness. Obtaining accurate

information about the COVID-19 virus is the greatest

approach to prevent and halt its spread. It is

recommended to avoid touching the face by washing

hands with soap or using alcohol-based products as

often as feasible. When an infected individual coughs

or sneeze, the COVID-19 virus spreads through saliva

droplets, meaning coughing etiquette is critical

(WHO, 2021). Indonesia is one of the countries with

the largest populations. Although it is in a relatively

warm place and the temperature is quite high, there is

still a need to be vigilant (Giarno, 2021). Positive

confirmed cases reached 106,834 in Bali, Indonesia,

from August 31, 2021 to August 31, 2022, with 3,508

deaths (Satgas Covid Bali, 2021).

https://orcid.org/0000-0003-3715-1016

https://orcid.org/0000-0002-5975-1680

https://orcid.org/0000-0002-8463-8911

https://orcid.org/0000-0001-7135-4859

Coughing, fever, and shortness of breath are

common COVID-19 symptoms. These signs and

symptoms are comparable to those of the flu in

general. However, in a tiny number of instances, no

respiratory symptoms such as diarrhea, nausea, or

vomiting are present. With symptomatic and

supportive care, most patients infected with COVID-

19 will recover in a few days. Serious symptoms such

as bronchitis and severe pneumonia can also occur in

some people (Paules et al., 2020).

Individuals infected with COVID-19 have

suffered from hypoxic respiratory failure in 19% of

cases, while 14% progressed to severe cases needing

oxygen treatment, and 5% required mechanical

ventilation and ICU hospitalization (Wu &

McGoogan, 2020). According to another study, 67%

of 52 COVID-19 patients with severe symptoms had

acute respiratory symptoms, 63.5% needed high-flow

Lestarini, P., Swarjana, I., Rahayuni, I. and Mahaputra, I.

Factors Associated with Health Protocol Compliance Among Market Traders: A Cross-Sectional Study in Tabanan City, Indonesia.

DOI: 10.5220/0011938000003576

In Proceedings of the 2nd Bali Biennial International Conference on Health Sciences (Bali BICHS 2022), pages 20-25

ISBN: 978-989-758-625-5

 2023 by SCITEPRESS – Science and Technology Publications, Lda. Under CC license (CC BY-NC-ND 4.0)

oxygen tubes, 42% needed invasive mechanical

ventilation, and 52% needed non-invasive

mechanical ventilation (Yang et al., 2020). Some

individuals who had recovered from COVID-19 had

symptoms such as dyspnea, tiredness, cough, and

dysosmia that lasted longer (Miyazato et al., 2020).

Social distancing is one of the preventative

methods used to combat the spread of COVID-19.

Social distancing is a strategy for keeping sick

individuals apart from healthy people to decrease the

disease transmission risk. For example, canceling a

communal event or shutting down a public place, as

well as avoiding crowds (Pearce, 2020). To assist

COVID-19 transmission reduction, the Center for

Disease Control and Prevention (CDC) in the United

States suggests wearing a face mask in public if one

cannot keep a six-foot distance from others (CDC,

2021). Regular hand-cleaning with soap and water or

scrubbing with a hand sanitizer containing at least

60% alcohol is also necessary (Wimalawansa, 2020).

Although most healthcare professionals believe that

washing hands with hand sanitizer is fast, it is

ineffective and promotes dryness, according to a

study (Fatima et al., 2021).

Markets have traditionally been at the center of

city life. Markets continue to play an essential role in

the local food supply and regional economy, despite

the rise of commercial retail and internet shopping

(González, 2020). Markets are still in the spotlight in

many parts of the world when it comes to COVID-

related precautions. The market's crowded, open, and

public natures are thought to be the greatest danger of

uncontrolled virus transmission (Munster et al.,

2018). The COVID-19 pandemic has had a

significant impact on the income of traditional market

traders in Indonesia. The variable of trading hours

affects the traders’ income due to the social restriction

policies (PPKM), which limited the operating hours

for trading (Lathief Ilhamy Nasution, 2022).

The Indonesian Ministry of Trade published

Circular Letter Number 12 of 2020, which governs

the restoration of commercial activities disrupted by

the COVID-19 pandemic. The market area, also

known as traditional marketplaces, is one of the

places where commercial activities are being

recovered. When functioning, markets that sell items

for the community's fundamental requirements must

follow rigorous health protocols consisting of 11

principles to be followed by all market visitors,

including traders (Kemendag RI, 2020).

Until an effective and safe vaccine is developed,

community cooperation with health protocols is

essential in COVID-19 prevention. Because

compliance with preventative activities such as health

protocols is still lacking, changes to the community’s

behavior are needed(Ranjan et al., 2020). In a study

of public transportation facilities, it was discovered

that social distancing regulations were followed,

although mask usage still needed strict supervision

(Komla et al., 2020).

A study has confirmed that efforts to limit the

spread of human viruses to humans must be done

(Mege et al., 2020). There is a high risk of spreading

COVID-19 in the market area despite the health

protocols that have been implemented. Hence, the

objective of this study is to identify the factors

associated with market traders' health protocol

compliance; by knowing the related factors, the

spread of COVID-19 can be prevented.

2 MATERIAL AND METHODS

A cross sectional study was conducted on market

traders in four markets in Tabanan City, Bali,

Indonesia. Using the stratified sampling technique,

the sample size for this study was 232 respondents

consisting of market traders in four marketplaces in

Tabanan City. Simple random sampling was used to

choose respondents from each market, resulting in a

total of 58 respondents from each market based on the

proportions.

Traders in four traditional marketplaces in

Tabanan City who were still selling throughout the

COVID-19 pandemic and were willing to become

respondents by signing the informed consent form

were included in the study. Traders who did not have

reading skills, traders who agreed to participate but

did not finish the questionnaire, and traders who were

not actively trading during the COVID-19 pandemic

were all excluded.

A questionnaire was utilized as the research

instrument. The questionnaire was divided into three

sections. Part 1 comprised questions designed to

identify respondents' general characteristics, part 2

contained questions on following health protocols,

while part 3 had questions about variables that

affected following health protocols. An ordinal scale

was utilized in this study.

Prior to data collection, permission was requested.

The National Unity and Political Agency of Tabanan

Regency granted authorization for this study via letter

number 071/379/BKBP/2021, which was

subsequently dispositioned to the Tabanan Regency

Department of Industry and Trade. The Research

Ethics Commission of Bali Institute of Technology

and Health also gave its approval to this study, with

letter number 04.0341/KEPITEKES-BALI/IV/2021.

Factors Associated with Health Protocol Compliance Among Market Traders: A Cross-Sectional Study in Tabanan City, Indonesia

The data collection process was then resumed with

the delivery of questionnaires to respondents directly.

The questionnaire data were double-checked to

ensure that it was comprehensive.

The Statistical Package for Social Sciences

(SPSS) version 25 was used for data entry and

analysis. The frequency distribution and proportion of

each independent variable were determined using

univariate analysis. The chi-square test was used to

evaluate the components that were associated with

compliance in a bivariate study. The factors were

deemed related if the p-value was less than 0.05 (p <

0.05). To find the factors that were strongly related to

health protocol compliance, a multivariate analysis

using binary logistic regression was conducted based

on OR number, CI percentage, and p-value.

3 RESULTS

3.1 General Characteristics

Table 1: Respondents’ General Characteristics (n = 232).

Characteristics n (%)

1. Age (Year)

≤ 48 123 (53.0)

> 48 109 (47.0)

2. Sex

Male 54 (23.3)

Female 178 (76.7)

3. Education

Higher (diploma and above) 16 (6.9)

Middle (senior high school and

equivalent)

89 (38.4)

Lower (no education past junior

high school)

127 (54.7)

4. Marital Status

Married 223 (96.1)

Single 9 (3.9)

Table 1 shows that the majority of respondents were

under the age of 48 (53%), were female (76.7%), had

a low educational level (54.7%), and were married

(96.1%).

3.2 Compliance with Health Protocols

Compliance with health protocols was divided into

two categories, namely compliance and non-

compliance.

Figure 1: Compliance with Health Protocols (n = 232)

Figure 1 shows that 23.3% of respondents complied

with health protocols.

3.3 Factors Associated with Health

Protocols Compliance

Table 2: Factors Related to Compliance with Health

Protocols (n = 232).

Factors Compliance with

Health Protocols

Total

n (%)

p-Value

Compliance

n (%)

Non-

Compli

ance

n (%)

Knowledge <

0.001*

Adequate 40 (18.7) 174

(81.3)

214

(92.2)

Inadequate 14 (77.8) 4 (22.2) 18 (7.8)

Perception 0.282

Positive 37 (21.5) 135

(78.5)

172

(74.1)

Negative 17 (28.3) 43

(

71.7

)

(

25.9

)

Role of Community Leaders 0.005*

Positive 36 (31.0) 80

(

69.0

)

116

(

50.0

)

Negative 18 (15.5) 98

(

84.5

)

116

(

50.0

)

Attitude 0.003*

Positive 19 (39.6) 29

(60.4)

(20.7)

ative

35 (19.0) 149

(

81.0

)

184

(

79.3

)

Media Access 0.260

Enough 19 (19.6) 78

(80.4)

(41.8)

Less 35 (25.9) 100

(74.1)

135

(58.2)

Bali BICHS 2022 - The Bali Biennial International Conference on Health Sciences

Table 2 shows that three components were found to

be associated in the bivariate analysis using the chi-

square test, namely knowledge, the role of

community leaders, and attitude.

Table 3: Multivariate Analysis of Factors Related to

Respondents’ Compliance with Health Protocols (n = 232).

Variables Compliance OR 95% CI p-Value

Complian

n (%)

Non-

Compli

ance

n (%)

Knowledge

Adequate

40 (18.7) 174

(81.3)

0.06 0.02 –

0.20

< 0.001

Inadequate

14 (77.8) 4 (22.2)

Role of Community Leaders

Positive 36 (31.0) 80

(69.0)

2.67 1328 –

5356

0.006

Negative*

18 (15.5) 98

(84.5)

Table 3 shows that there were two characteristics

associated with health protocol compliance:

knowledge and the involvement of community

leaders

4 DISCUSSION

The results of the study found that 23.3% of market

traders in the traditional Tabanan City market were

compliant. A study by Komla (2020) found an

identical result with public transportation. The policy

on social distancing was abided by public

transportation users, however, the policy on mask use

still required careful supervision (Munster et al.,

2018). A study by González (2020) found that

preventive practices such as health protocols were

related to the progression of COVID-19, and

compliance with these practices was still

unsatisfactory (González, 2020). Compliance with

health protocols, especially in the market sector, was

poor, as evidenced by study results showing most

market traders did not follow health protocol

implementation effectively. Knowledge regarding

COVID-19 and the involvement of community

leaders in health protocol implementation were

shown to be variables associated with compliance in

this study.

Knowledge about COVID-19 and health

protocols, perception of COVID-19, the role of

community leaders, attitude toward health protocol

policies, and media access regarding COVID-19 were

the factors investigated regarding health protocol

compliance. Table 2 shows that three components

were found to be associated in the bivariate analysis

using the chi-square test, namely knowledge, the role

of community leaders, and attitude. COVID-19 was

well-known among the majority of respondents

(92.2%). COVID-19 was viewed positively by the

majority of respondents (74.1%). The proportion of

positive and negative views on the role of community

leaders was equal (50%). The majority of those polled

had a negative view of health protocol policies

(79.3%). The majority of traders had limited access to

information on COVID-19 (58.2%).

According to the results of the multivariate

analysis, there were two characteristics associated

with compliance with health protocols: knowledge

and the involvement of community leaders. Table 3

shows that knowledge regarding COVID-19 and

health protocols had an OR value of 0.06; thus, a 1-

OR formula was required to draw conclusions, and 1

- 0.06 = 0.94 was achieved. This led to the conclusion

that traders with strong knowledge of 0.94 times or

94% had a decreased chance of following health

protocols (OR = 0.06; 95% CI = 0.02 – 0.20; p =

0.001). Because the role of community leaders had an

OR of 2.67, traders who had a positive view of their

function were 2.67 times more likely to follow health

protocols than traders who had a negative view (OR

= 2.67; 95% CI = 1,328 – 5,356; p = 0.006).

On the knowledge aspect, this study discovered

that most market traders (92.2%) had a solid

understanding of COVID-19, and that this knowledge

was highly connected to market traders' compliance

with health protocols. Market traders, on the other

hand, were linked to a lack of attention to health

protocols. Hossain (2020) investigated the

relationship between knowledge and attitudes with

health protocols in adult respondents in Bangladesh,

claiming that adequate knowledge about COVID-19

and health protocols was needed to create behaviors

to prevent COVID-19 transmission (Hossain et al.,

2020). According to a study conducted on a group of

primary children in Wuhan, China, awareness of hand

cleanliness and the use of masks was extremely

helpful in reducing infectious illnesses (Chen et al.,

2020). However, in this study, having a strong

understanding of COVID-19 was not enough to get

market traders to follow health protocols. One of the

causes of ignorance to the introduction of new rules

might be markets that are identical to free or informal

settings. More qualitative in-depth studies on the

connection between COVID-19 knowledge and

compliance with health protocols is needed.

Factors Associated with Health Protocol Compliance Among Market Traders: A Cross-Sectional Study in Tabanan City, Indonesia

The importance of community leaders in ensuring

that health protocols were followed was also a key

issue. The function of community leaders was

evaluated from market traders’ perspective. The

majority of market traders who had a negative view

of community leaders’ roles did not follow health

protocols, according to this study. Rosidin (2020) has

mentioned that the forms of support provided by

community leaders were divided into emotional

support, appreciation support, instrumental support,

and informative support. Empathy, care, and concern

are examples of emotional support. Expressions of

respect and encouragement to continue forward are

examples of appreciation support. Instrumental

support includes direct help tailored to the

community’s needs. Advice, hints, suggestions, and

feedback are all examples of informative help. During

the COVID-19 pandemic, this type of assistance is

required (Rosidin et al., 2020).

Wright (2020) states that local governments also

have an important role in overcoming the impact of

COVID-19 (Wright, 2020). Market administrators,

which include coordinators, deputy coordinators, and

market collectors, are the closest community leaders

in the market. They are responsible for overseeing

and coordinating with their particular target market

regions. In addition, security officers known as

pecalang are stationed throughout Bali. Puspawati

(2020) argues that during the COVID-19 pandemic,

pecalang were assigned as COVID-19 mutual

cooperation task forces, with one of their assignments

being supervising health protocols (Puspawati et al.,

2020). Meanwhile, Auliya & Arif (2021) state that the

role of the Department of Industry and Trade under

the Indonesian Ministry of Trade also needs to be

increased during the COVID-19 pandemic (Auliya &

Arif, 2021). One of these roles is that of a facilitator,

who provides help, facilities, and educational support,

which in this case includes health protocols. As a

result, increased supervision from local community

leaders is required for health protocol

implementation.

5 CONCLUSION

The results of this study showed that traditional

market traders’ compliance with health protocols in

Tabanan City during the COVID-19 pandemic was

poor. This was found to be related to the market

traders' knowledge of COVID-19. Although these

market traders had good knowledge about COVID-

19, it was not enough to make them comply with

health protocols; therefore, further research is needed

on other factors that affect COVID-19 knowledge and

health protocol adherence. The involvement of

community leaders in the market's health protocol

application also needs attention. Increased

supervision of health protocol application is

suggested to market community leaders.

ACKNOWLEDGEMENTS

The authors acknowledge the cooperation of the

Department of Industry and Trade of Tabanan

Regency, the market management organizations, and

the data collection team.

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Factors Associated with Health Protocol Compliance Among Market Traders: A Cross-Sectional Study in Tabanan City, Indonesia