Identification of Work-related Diseases in Small-scale Fishermen in Batam Island, Indonesia

: Background: Small-scale fishermen's work activities are carried out in a marine environment which has the potential to cause certain work-related diseases. AIMS: This study aims to identify the incidence of work-related diseases among small-scale fishermen in Batam Island, Indonesia. Methods: This study used both quantitative and qualitative approaches involving 119 small-scale fishermen. Data was collected through questionnaires, observations, documentation, interviews, focus group discussions, and secondary data collection. Results: The results showed that all small-scale fishermen complained of diseases caused by threats in the chemical, physical, biological, psychological, and ergonomic factors group. Conclusion: Most fishermen complained about colds, fever, stings, blisters, skin allergies, and eye disorders/myopia. Most complaints were obtained from small-scale fishermen over 40 years old, especially the ones with smoking habits. Identification of work-related diseases was required to prevent and control the health problems that could endanger small-scale fishermen’s health and productivity.


INTRODUCTION
There are 90% of fishermen work in small-scale fishery industries, and 97% of small-scale fishermen found in less developed countries [1,2]. Likewise, small-scale fishermen still dominate the capture fishery business in Indonesia. Only 15% of fisheries in Indonesia were categorized as large-scale fisheries, while the rest about 85%, are included in small-scale fishing [3]. The protection of small-scale fisheries needs to be guaranteed by the state. The Food and Agriculture Organization (FAO) has established guidelines for protecting small-scale fisheries, especially in terms of occupational health aspects. Small-scale capture fisheries are among the most dangerous occupations, with high threat and danger [4]. Fishing activities can be exposed to two potential hazards: carried out to avoid the occurrence of work-related diseases. The definition of work-related diseases according to the Presidential Regulation of the Republic of Indonesia No.7 of 2019 concerning Occupational Diseases is a disease caused by work and/or the work environment. Work environmental factors can be distinguished into two types, i.e., natural factors and work factors that potentially cause a risk of death, accidents, injuries, health problems, and diseases for fishermen. Based on the 2018 Basic Health Research (Riskesdas), the highest infectious diseases suffered by fishermen, namely, acute respiratory infection (ARI), pneumonia, pulmonary TB, diarrhea, and malaria, while the highest non-communicable diseases are hypertension, joint pain, emotional disorders, stroke and chronic heart disease (CHD).
The work environment influences fishermen in fishing activities [12]. The work environment is a social, psychological, and physical life that affects work activities. Potential health hazards in the workplace and derived from the work environment are, among others, chemical factors, physical factors, biological factors, ergonomic factors, and psychological factors [13,14]. According to the Regulation of the Minister of Manpower of the Republic of Indonesia Number 5 of 2018 concerning Occupational Safety and Health of the Work Environment, the work environment is defined as an aspect of hygiene in the workplace that includes physical, chemical, biological, ergonomic and psychological factors in influencing the safety and health of workers. These factors are also found in the fishermans work environment. Fishermen use boats in the middle of the sea with wet and slippery floor conditions from sea water splashing on the boat. This condition can pose a risk of sprains or fractures due to a fall or slip. While on the ship, 62% of the crew reported declining health performance, for example, musculoskeletal disorders, respiratory diseases, digestive system diseases, and eye-and skin-related diseases [15]. Identification of work-related diseases needs to be carried out to prevent and control health problems that can endanger the health and productivity of fishermen.
Several previous studies have mentioned that the dangers that impact fishermens health include ergonomics, noise, dehydration, extreme pressure, and cold and hot temperatures [16 -18]. However, research on the complete identification of work-related diseases in small-scale fishery fishermen is still limited. This study aims to identify the incidence of workrelated diseases in small-scale fishermen based on the type of fishermans work environment consisting of physical, chemical, biological, ergonomic, and psychosocial factors.

Small-scale Fisheries
The small-scale fisheries sector is concerned with the role of communities, local traditions, and values. Small-scale fishermen are self-employed and usually provide caught fish for direct consumption by their families or communities. Thus, small-scale fisheries support coastal communities economic and social livelihoods by ensuring food and nutrition safety. Without fishermen as human components, fishery resources will not have value and benefits regarding social, cultural, economic, and biodiversity [16]. The definition of small-scale fisheries and their scope in several research results show the relationship between various aspects, namely, social, cultural, economic, ecological, health, and governance, as well as regulation, law, and policy [2, 17 -21].
Characteristics of small-scale fisheries include fisheries management at the household level, fishing without or with fish vessels measuring less than five (gross tonnages (GT), and fishing gear operated only by human labor. This definition combines the attributes of boat size, mechanization of fishing gear, decision-making business units (households), and directed government assistance to poor fishermen prone to social and economic shocks [18]. The term small-scale fisheries have been used to characterize a subsector of fisheries to distinguish it from medium-scale and large-scale fisheries. The Food and Agriculture Organization (FAO) defines smallscale fisheries as traditional fisheries involving fishing households (as opposed to commercial enterprises), using capital and relatively little power, relatively small vessels, short fishing trips, near the coast, and mainly for local consumption [22].

Fisherman's Work Environment
Risks to occupational safety and health are influenced by work environment factors, including the physical environment, work processes, human factors, and economic factors [23,24]. Occupational environment factors include potential workplace hazards, including aspects of the physical, chemical, ergonomic, biological, and psychosocial environment [13]. Influential factors in the work process are hazardous materials, working procedures, work skills, and the use of machinery [12].
Physical factors are associated with using machinery, equipment, materials, and environmental conditions around the workplace, such as work, climate, noise, vibration, radiation, air pressure, and lighting that cause disturbances and diseases in the workforce. Biological factors are caused by living things, including animals, plants, and their products, as well as microorganisms that can cause occupational diseases. Chemical factors are caused by using chemicals and their derivatives in the workplace, including chemical contaminants in the air, in the form of gases, vapors, and particulates. The ergonomic factor is caused by a mismatch between work facilities, including the working position, work tools, and the lifting load on the workforce. Psychological factors are caused by interpersonal relationships in the workplace, roles, and responsibilities at work. The psychosocial work environment is how the interrelation of the structure of society, the environment of exposure, and the psychological that have a potential impact in terms of well-being and discomfort, for example, job satisfaction, stress, and fatigue [25].

Occupational Diseases
A work-related or occupational disease is caused by work and/or work environment. Fishing fishermen are at risk of occupational diseases related to the work environment. The condition of the marine environment has an impact on health [26]. The fisherman's work environment, such as exposure to seawater, working posture, and noise from ship engines, can produce health problems such as dermatitis, indigestion, skeletal muscle disorders, hearing loss, dehydration, and acute respiratory distress infections (ARI) [27 -31]. In the work process, fishermen work outside the building and are directly exposed to sunlight, so fishermen are one of the jobs at risk of cataracts. Outdoor workers are at high risk of prolonged and high exposure to solar ultraviolet radiation, known to cause skin cancer [32,33]. Research by Laraqui et al. [29] found that skin disease prevalence among fishermen was 43%, 27.2%, 9.5%, and 2.5% for respondents who experienced one type, two types, three types, and four types of skin disease, respectively. Skin diseases include skin infections, scabies, and stings of marine life. Percin et al. [34] mentioned that humidity, cold weather, and harsh sea conditions could stimulate rheumatism in fishermen.

Study Area
The research was conducted on Batam Island, Riau Archipelago Province, Indonesia. Riau Archipelago Province is one of the provinces in Indonesia, with most of its area being an archipelago area, and 95% of the site is the ocean. Its area reaches 8,201.72 km 2, or about 0.43% of the area of Indonesia. Stretching from the Strait of Malacca to the Natuna Sea, Riau Archipelago Province is a strategic area because it borders Singapore, Vietnam, Malaysia, and Cambodia. The population of Riau Archipelago Province was 2,189,653 in 2019, and it is highly concentrated on Batam Island, with about 56.47% or around 1.1 million people.

Data Collection
This study applied both quantitative and qualitative methods. The quantitative research method is carried out by survey using questionnaires. The qualitative method was a case study method, including observation, in-depth interviews, and focus group discussion (FGD). The questionnaire contains questions including the socioeconomic and demographic data of fishermen: age, education level, ethnicity, income level, length of work, place of residence, employment status, smoking history, and marital status. The interview question list contains complaints of occupational diseases based on work environment factors: physics, chemistry, biology, ergonomics, and psychosocial. Data collection is carried out when fishermen are not at work. Questionnaire filling and interview activities are conducted at fishermen's homes or associations. Data collection was carried out from July to September 2022. The data source in this study was 119 fishermen selected by purposive sampling. A reliability test was carried out to strengthen the questionnaire as one of the instruments. From the test, the alpha is obtained as follows: The rule in determining the alpha value is if the alpha value > 0.90, then the reliability is perfect. The reliability is high if the alpha value is 0.70 < alpha < 0.90. The reliability is moderate if the alpha value is 0.70 < alpha < 0.5. If the alpha value is <0.5, then the reliability is low. The test results in Table 1 showed an alpha of 0.504, meaning the questionnaire has moderate reliability.

Data Analysis
The data collected from the questionnaire results were processed using descriptive statistics. In contrast, the data from the interview was summarized and coded. Then the results were displayed in the form of a table to provide an easy outlook of the types of occupational disease complaints based on the type of work environment. Concerning complaints of occupational diseases, interview data may show some similarities, even from different subdistrict locations, due to similar work environment characteristics, including socioeconomic and natural conditions.

Socioeconomy Characteristics
The socioeconomic characteristics of the fisherman's demographic consisted of age, education level, ethnicity, income level, length of employment, working status, smoking history, and marital status ( Table 2). Most fishermen, for about 32% of the population, are aged between 56 and 65. Most fishermen's education level is elementary school graduates, with a percentage of 60%. The most numerous fishing tribe is the Malay tribe, with about 92% indigenous tribes. 75% of fishermen have an average monthly income of between 96-160 USD. For about 34% of the population, most fishermen have worked for more than 20 years. 77% of fishermen work fulltime, and 23% work part-time. Employment as a fisherman is a hereditary occupation for parents, recognized by 86% of fishermen. Most fishermen, about 83% of the population, had a smoking habit. 90% of fishermen were in married relationships. 87% of fishermen lived near the coastline, and 13% were far from the coast.

Work-related Diseases based on the Work Environment
Complaints of diseases suffered by fishermen included fever, fatigue, soreness, back and waist pain, colds, flu, stinging, blistering from the spines of fish or marine animals, headaches, eye disorders/myopia, rheumatism, ulcers, skin allergies or hives, sprains and fractures ( Table 3). Complaints of diseases suffered by fishermen are the types of diseases that fishermen often experience when doing fisherman work, including being exposed to sea breezes, being exposed to fish spines, holding fish catches for too long or often pulling and lifting nets, exposed to ultraviolet light, and hungry from carrying little food. The most mentioned disease complaints by fishermen are colds, fever, stinging or blisters, skin allergies or hives, eye disorders, or myopia.

Ergonomic
The activity of pulling and lifting fishing nets

Ergonomic
The activity of pulling and lifting fishing nets

Skin allergies or hives
Biology, physic, chemical Holding fish too long or often (Biology); exposed to ultraviolet rays, exposed to seawater, exposed to sea breezes (Physic); exposed to fuel or oil (Chemical)

Ulcer or indigestion
Biology, psychological Not bringing enough food (Biology); Anxiety about the small amount of income and anxiety about disasters at sea result in stress (Psychological)

Rheumatism
Ergonomic, physic The activity of attracting and lifting fishing nets (Ergonomic); exposure to ultraviolet rays, sea breeze and seawater (Physic)

Headache
Physic, biology, chemical, psychological Hot or scorching weather (Physic); Dehydration due to lack of drinking (Biology); Smell of fuel (Chemical); Anxiety about the small amount of income and anxiety about disasters at sea result in stress (Psychological)

Stung or blistered from fish spines
Biology Fish barbs or stings Flu Physic Exposed to the sea breeze, seawater, cold weather Colds Physic Exposed to the sea breeze, seawater, cold weather

Back and waist pain Ergonomic
The activity of pulling and lifting fishing nets

Ergonomic
The activity of pulling and lifting fishing nets

Fatigue
Physics, biology, ergonomics, psychological Exposed to the sea breeze, seawater, hot and cold weather, and ultraviolet rays (Physic); Not bringing enough food (Biology); From the activity of pulling and lifting fishing nets (Ergonomic); Anxiety about the small amount of income and anxiety about disasters at sea result in stress (Psychological) Fever Physic Exposed to the sea breeze, seawater, hot and cold weather, ultraviolet rays (Physic) The type of work environment could be identified according to complaints of occupational diseases in fishermen ( Table 4). The working environment consisted of physical, chemical, biological, ergonomic, and psychological factors. Based on Fig. (1), the fisherman's work environment factors consisted of physical, biological, and ergonomic factors. Complaints of diseases related to chemical and psychological factors were not mentioned directly by fishermen. Factors of physics are a type of fisherman's work environment related to the natural or open environment. Fishermen complained about frequent colds and fevers due to sea breeze and seawater exposure. Biological factors were related to fishermen catching fish influenced by other living things, such as exposure to fish stings and spines. Fishermen also complained about skin allergies and itching. Ergonomic factors were associated with complaints of fatigue, soreness, sprains, and fractures due to pulling and lifting activities that required muscle strength and working posture corresponding to the workload.

DISCUSSION
Most fishermen's age was categorized as the elder/late senior, in the range of 56-65 years. Moreover, there were some fishermen with age over 60 years old. In contrast, the research by Zakaria et al. (2022) found that most fishermen age consists of the young age group between the ages of 20-30 years (44%). Most fishermen had more than 20 years of working experience, similar to earlier studies at the Tanji fishing site in West Africa [35]. Fishermen worked full-time and mostly lived near the coastline. The majority of fishermen were the indigenous Malays tribe. Most fishermen's education was an elementary school degree, almost the same as Bangladeshi fishermen's education [36], because fishermen's jobs did not require higher education. Work as a fisherman was considered traditionrelated work passed down through generations. However, there were children of fisherman's parents who did not become fishermen because they had upper educational levels at junior and high school and got non-fishermen jobs. Fishermen's educational level can be associated with the occurrence of occupational diseases. Higher education can increase knowledge and behavior of safety and health at work to reduce the risk of occupational diseases. The income level of fishermen was classified as middle to a lower level, which was only enough to meet daily needs. The average fisherman is married and has a family [37]. Amid low income, some fishermen were still addicted to smoking.
Fishermen working outdoors with occupational hazards risks related to ergonomics, physical, and environmental/ climate hazards. Muscle stress was a common danger felt by fishermen [35]. There was still a lack of understanding of fishermen's health problems, such as general physical health, mental health, lifestyle, and behavioral factors [38 -40]. Based on Case et al. (2018) research, 90% of small-scale fishermen wrought full-time even though they were no longer youth or had already senior [41].
Complaints of occupational diseases experienced by smallscale fishermen obtained in this study were based on the work environment conditions, including physical factors such as heat and UV exposure during the day [42], cold air during the night, seawater, and wind exposure in the entire day. Biological and ergonomic factors that caused soreness in the back and waist were also found in other studies [43 -45]. Chemical factors could be in the smell of fuel oil, while the physicological factors could be in the form of anxiety if there is a sea disaster. However, there was no complaint about those chemical and physiological factors due to the absence of respiratory and skin damage felt by small-scale fishermen; and the fishermen's work culture had been passed down through generations, respectively.
In addition to work-related diseases, age factors also influenced fishing performance. Due to the majority of fishermen being categorized as senior to late senior, they might share a similar age, over 40 years old. As they get older, their endurance and physical strength would declined. Smoking habits were unfavorable due to exacerbating fishermen's health problems. Fishermen would not go to sea if they were sick. If the illness continuously occurred, fishermen checked their health at the local community health center. Fishermen work every day because the income earned is daily. Personal protective equipment for small-scale fishermen still needs to be completed and followed by occupational safety and health standards, such as wearing protective clothing, gloves, head coverings, eyeglass, and shoes.

CONCLUSION
This research revealed that fishermen's occupational diseases were related to fishermen's work environment conditions, which included physical, biological, chemical, ergonomic, and physiological factors. Occupational diseases were back and waist pain, stings or blisters from fish spines, fatigue, eye problems or low vision, skin allergies or itching, sprains, broken bones, and other generic types of illness, including fever, flu, headaches, colds, rheumatism, and ulcers. A specific threat from the fishermen's work environment is the physical factor influenced by the natural marine environment. Efforts and strategies were needed to increase promotion and prevention to improve the occupational health status of fishermen to be more productive and prosperous through health promotion, occupational safety training, periodic health checks, and empowerment of fishermen groups.
Reducing the risk of occupational diseases in fishermen could be done by providing personal protective equipment in the form of head protection, proper clothing to cover the skin, eyeglasses to reduce UV exposure, and gloves to reduce allergies to itching and stinging by marine life. In addition, fishermen could also provide first aid boxes in their boats to handle the presence of work-related diseases such as dizziness, fever, and flu.

AUTHORS' CONTRIBUTIONS
Fitri Sari Dewi as a PhD student, has published articles about occupational health and safety issues in general and also working on occupational health and safety for her PhD Dissertation. Fitri Sari Dewi contribution are making the title and outline, guiding discussion, leading the interview, and writing the initial draft report; Haryoto Kusnoputranto contribution are providing critical comments, making the theoretical framework and reviewing the article; Rachmadhi Purwana and Tri Edhi Budhi Soesilo designed the research methods, supervised the research progress and reviewed the article.

LIST OF ABBREVIATIONS ARI
= Acute Respiratory Infections

ETHICAL STATEMENT
This research is part of a doctoral dissertation that is submitted to fulfill one of the requirements for obtaining a Doctorate at University of Indonesia. This study did not involve ethical issues, such as informed consent, permission needs, etc.

CONSENT FOR PUBLICATION
Not applicable.