The Correlation between Self-Efficacy and Subjective Norm and its effect on Handwashing Behavior among School Students in Coastal Area

ABSTRACT


INTRODUCTION
Respiratory infection and diarrhea particularly transmitted to the environment of elementary schools since these are public places where students meet each others and do activities in the course of learning and playing together in the inside a classroom or outside a classroom, as well as the interaction among students within the close environment and often under crowded conditions.Crowded settings, sharing of objects, and lack awareness of daily self-care, these are the main factors for the transmission of pathogenic micro-organisms (Daniels, 2010) (CDC, 2017).
The most effective method of preventing the transmission of diseases through hands is handwashing that can protect including diarrhea and respiratory infection, because hands could potentially be the medium transmitting diseases causing pathogens which get passed on from one child to another and hand washing could effectively reduce diseases transmission and prevent contaminated hand which could potentially be infectious (Suci, 2016).Hands hygiene is also a key factor of reducing transmission of diarrhea in a community setting such as schools and particularly washing hands with soap could significantly reduce the risk of acute respiratory infection and diarrhea (Biran dkk., 2014).The handwashing behavior also recommended to prevent the pandemic diseases such as severe acute respiratory infection syndrome (Talaat dkk., 2011).
In identifying handwashing practice, we need the correlation factors to help us how effective the behavior has been implemented.The perceived related health perception that can be applied to identify the behavior are perceived self-efficacy and subjective norm.Perceived Self-Efficacy relate to People's beliefs about their ability to perform effects including behavior.Perceived self-efficacy is defined as people's beliefs abilities to produce performance that affect their lives.Self-efficacy beliefs determine how people feel, think, motivate themselves and behave (August Flammer, 2015).The second perceived is a social factor termed subjective norm.subjective norm refers to the perceived social pressure to perform or not to perform the behavior.Subjective norm is the perceived that influence the behavior, that reflect the expectation important others in the social environment (Ajzen, 2012).
In this study, perceived self-efficacy and subjective norm was implemented as the main factors to identify the correlation between perceived and handwashing behavior among elementary school students in the island area (Hayden, 2013).The other factors that also implemented are socio-demographic factors and handwashing knowledge.The study focused on identifying the correlation between self-efficacy, subjective norm, and handwashing behavior among school children who lives in the coastal area of Belitung Island (Elviani, 2013).10.47028/j.risenologi.2021.61a.218 The of self-efficacy is to lead the ability of individuals to do something.People generally do not try to do something new unless they think they can do it (August Flammer, 2015).Besides the self-efficacy, subjective norm also influence the health behavior of school children.Subjective norm reflect the expectation important others such as relative, parents, teachers, and friends are the strength of each normative that support or motivate individuals to comply behavior (Ajzen, 2012).
As the description above, the proper handwashing practice among school children are important to introduce as the strategy to improve the health status of children in the community.The proper strategy of implementing handwashing behavior could prevent the virus and bacteria in school children environment (Luby & Halder, 2008).

METHODS
The study was focused on the population group of the school students of Public Elementary Schools in the coastal area of Belitung district, Bangka Belitung Province, Indonesia.The sample population were seven Public Elementary School in the coastal area of the Belitung District.
The optimal sample size for this study as determined by the formula was to 130 and added by 10% allowance for missing data and drop-outs during study.Therefore, the number of sample size of this study was 150 participants.The design of this study is a quantitative research design with a cross-sectional research of study.The multistage sampling technique was used for the sampling method in this study.First stages, the researcher used purposive sampling to identify the seven Public Elementary Schools in the coastal area of Belitung District.Second stages, the researcher used proportionate sampling to ensure a true representation in each school.Further, through proportionate sampling and simple random sampling, the representative participants number of each Public Elementary School in coastal area were 16 participants in Petaling Public Elementary Schools, 26 participants in Gual Village, 8 participants in Gual island, 23 participants in Gersik island, 25 participants in Selat Nasik Island, 26 participants in Selat Village and 26 participants in East Selat Nasik island.The simple random sampling technique was conducted by gathering the whole sixth grade students who meet inclusion criteria in the school hall and asked them to pick-up the number as randomly.Then, the students who got number were decided to be participants in this study.
Data collection was begun after this proposal was approved by the Ethical Reviewed Board of the Health Polytechnic Pangkalpinang Ministry of Health, and permission by local authority that granted prior to conducting the study at the selected public elementary schools, the data collection was strictly follow the following procedures.The data collection was conducted on October 2020.A questionnaire for handwashing behavior was used in this study and permitted from original author (Kunkel & Barron, 2011), (Nazliansyah dkk., 2016).
The statistical analyze to examine the relationships between independent variables and dependent variable was Chi-Square tes, since the variables were nominal scale.Testing of Chi-square assumptions were conducted to ensure no violation of the assumptions of using Chi-square.

RESULTS AND DISCUSSIONS
Socio-demographic factors in this study were identified as general and specific characteristic of participants related to handwashing behavior.General characteristic of participants was identified as gender, father's occupation, and mother's occupation.Specific characteristics were identified as role of students at home, availability of handwashing facilities at schools and home.
Results in table 1 showed the participants were male (52%) and female (48%).In regard to parent's occupation characteristics, most of student's fathers, occupations were fisherman (67%), retail market (5%) civil servant (5%), and another occupation such as farmer, boat transportation service (23%) The results in table 2 show that the majority of participants (87%) had a role at home, and only 13 % of participants did not have a role at home.In regard to handwashing facilities at schools, the results show that the majority of clean water (96%), soap(91%), and handwashing stands for handwashing had available at the schools (94%).In the results study report only 4% of the facilities of handwashing did not available at schools.Regarding reason for not washing hands at schools, the large number of participants reported were forgetfulness (67.3%), laziness (16%), insufficient clean water (7.3%), no available soap (3%), lack of time (6%).The results of handwashing practice, most of the participants washed their hands all the time before having meals (85.6%) and after touching animals (73.5%)In terms of handwashing behavior level, majority (52.7%) participants still have lack of behavior of handwashing in the meaning that they were not always washing their hands in the critical time.About 11.3% of participants still low in handwashing practice.Majority of participants (88%) were proper in implementing handwashing behavior both at home and school.
The study showed that no correlation between socio-demographic characteristic and handwashing behavior of public elementary school students in the coastal area of the Belitung district.The results study showed that self-efficacy and subjective norm were significant correlation to handwashing behavior of public elementary school students in the coastal area of Belitung district (Tabel.3).The study revealed that no relationship between gender and handwashing behavior among public elementary school students in the coastal area of Belitung district.The results were similar to the previous research that described gender was not related to handwashing behavior among school students (Steiner-Asiedu dkk., 2011).The reason of this result study due to the availability of handwashing facilities at school leads the students both male or female to practice daily handwashing together.The results study also showed no correlation between the role of students at home with the handwashing behavior.The study was consistent to the previous study that described no correlation between the role of students at home and handwashing behavior (Setyautami dkk., 2012).The results study emphasized that both have or did not have a role at home in daily was not influenced the students in washing their hands.Besides, the availability of handwashing facility will help students to encourage their motivation in handwashing practice.
In terms of perception, the results study showed that self-efficacy was related to handwashing behavior.The resulting study similar to the previous study that described a positive correlation between self-efficacy and handwashing behavior (Aisha dkk., 2016).The high level of perceived self-efficacy encouraged the students of public elementary schools to perform handwashing behavior in every situation.The majority of students believe that they could perform handwashing practice automatically.Besides, the self-efficacy in handwashing caused by the handwashing campaign and handwashing education in the population, some of the research proved that continued education in handwashing could improve the self-efficacy of handwashing practice (Fries dkk., 2020).
The subjective norm also was positively related to handwashing behavior in this study.This condition means that the increase of subjective norms could increase the proper handwashing behavior among school children in the coastal area of the Belitung district.The results study is consistent with the previous study that showed the relationship between subjective norm and handwashing behavior among school children (Bartle dkk., 2019).The all components subjective norm, including parents, teachers, and peer friends accepted by school students in the coastal area of Belitung District as their expectation in daily living at school and home.They were felt that handwashing behavior is expected by their parents, friends, and teachers and influenced the activity daily living.
The another reason due to the students believed that they will make the interpersonal environment to be satisfied if they perform handwashing practice.Besides that, the subjective norm made the students felt their parents have a responsibility to keep health status thus they have followed the role (Biezen dkk., 2019).The subjective norm in children will be raise when the children interact with peer friends.The handwashing behavior will be the expected activity in the peer groups.A study conducted in Bangladesh revealed that when the school children washed their hands together at school, the behavior significant increase to 30% compared if they wash their hands alone (Ozcan dkk., 2020).

CONCLUSIONS
The objective of the study aims to identify the relationship between socio-demographic characteristics, selfefficacy, and subjective norms with handwashing behavior among elementary school students in the coastal area of Belitung District.The construct of Health Belief Model Theory is the concept used in this study.150 sixthgrade students participated in the study, A quantitative research design with cross-sectional research was employed in the study.The multistage sampling technique was used for the sampling method in this study.A questionnaire for handwashing behavior was used in this study for identifying handwashing practices the school children.The results study reveals that self-efficacy and subjective norm were significantly related to handwashing behavior.
The health service providers in Belitung District can develop the specific program using this research finding to support self-efficacy and subjective norm.The health promotion at schools related handwashing behavior need more activated by involving parents, teachers, and peer groups.Moreover, the results of the study can be applied to educate the school children in the community in term of enhancing hygiene behavior since the handwashing is the effective way in protecting hand to hand infection including Covid-19.

Table 2 .
Characteristics of Socio-specific Demographic

Table 3 .
The relationship between perceived and handwashing behavior