SELF-PROTECTION BEHAVIORS TOWARDS COVID-19 AMONG WOMEN RELIGIOUS GROUP IN INDONESIA: A QUALITATIVE STUDY

Background : Optimizing the role of religious-based communities in preventing the transmission of COVID-19 through the application of self-protection to its facilitators and members is an important part of efforts to stop the pandemic. Objective : The purpose of this study was to determine the perceptions of facilitators and members of religious group in implementing self-protection behaviour. Method : A qualitative study was conducted from August to December 2021 using a purposive sampling approach to collect the data. In total, 6 individual interviews were conducted with facilitators of religious group and one focus group discussion (FGD) with 12 members of religious-based communities. Data analysis was performed using a conventional content analysis approach. Results : The results of this study indicate that both facilitators and members of religious-based communities have a favourable perception of self-protection in religious group. However, this perception is not enough to support readiness in implementing self-protection behaviour. Self-efficacy is still weak, this is indicated by weaknesses in mastery experiences, vicarious experiences, verbal persuasion, and emotional and physiological states variables. Conclusion : Increasing roles in religious-based communities and strengthening collaboration in the application of self-protection through increasing self-efficacy forming variables in religious group are urgent needs to be carried out in COVID-19 prevention programs.


INTRODUCTION
Global COVID-19 cases have been rising significantly since the end of 2020 due to new variants with higher virulence. 1 This has emphasized the importance of new preventive measures in society. Self-protective are implemented in public places to prevent new epicenters or clusters during the pandemic. Other than playing a role in COVID-19 prevention, these measures are also preventing other diseases. 2,3 Self-protective behaviors indirectly contribute towards common solutions for public health issues.
During the beginning of the pandemic, many socio-religious activities came to a halt due to government regulations that limited mobilization. 4,5 As time went on, parts of the community adapted to the pandemic conditions and encouraged the rest of the community to resume socioreligious activities, including holding majelis taklim (MT). 6,7 MT is a routine need for urban women in Indonesia. 6,8 Previous study showed MT is a medium to maintain the congregation's mental health and psychological state through spiritual consultation, especially for women. 9 Other than that, MT also functions to help members of the congregation that are economically impacted due to COVID-19. [6][7][8][9] MT is a religious study activity such as listening to Islamic teachings, reading the Qur'an, and reciting salawat (praises for the Prophet Muhammad). MT depicts both prophetic and celebration functions. 8,10 MT activities are held routinely, once or twice a week. These activities are usually attended by tens to hundreds of people. Due to the volume of attendees, self-protective behaviors are important to uphold. MT led by a facilitator that is appointed by the community. The head of the MT could be an ustazah (female Islamic teacher).
There are usually large numbers of MT members, yet the venue's conditions (mosques or the ustazah's house) are not capable of facilitating self-protective behaviors. Furthermore, MT is usually held in closed areas with a lack of sunlight and poor indoor air, limiting proper ventilation. According to the World Health organization (WHO), SARS-CoV-2 transmission happens through contact transmission, droplets, airborne transmission, and fomites. Airborne transmission is defined as transmission due to the spread of droplet nuclei (aerosol). 11 Crowds in enclosed areas 12 indicate the possibility of aerosol transmission accompanied by droplet transmission, for instance when having meals together, at religious venues, sports centers, or training centers. 2 The chance of aerosol transmission within short ranges, especially in crowded and enclosed areas with poor ventilation, increase by being within range of someone with COVID-19 for extended period. 13 Transmission may also occur from surfaces contaminated with fomites (respiratory secrete) or through droplets from someone with COVID-19. 13 Based on these conditions, increasing self-protective behaviors when attending MT is a key in successfully reducing COVID-19 transmission and other infectious diseases throughout communities.
Based on a preliminary observation conducted in May 2021, many MT members still wear masks incorrectly and are not physically distanced. There are even members that attend while feeling ill. This is contradictive to Fatwa Majelis Ulama Indonesia (MUI) or Indonesian Ulema Council No. 14 2020 about Holding Religious Activities during the COVID-19 Pandemic, stressing that it is prioritized to hold religious activities from home to protect one's self and others from COVID-19, even though this Fatwa does not specifically regulate MT and other religious study groups such as pengajian. 14 ___________________________ Jurnal Kesehatan Reproduksi, 13(1), 2022 When implementing self-protective behaviors, the WHO recommends religious figures and other religious or faith-based organizations to be leaders in engaging communities to participate in preventing COVID-19. 13 As leaders, religious figures or facilitators need strong motivation, which can be sourced from religious teachings. Self and communityprotective behaviors can be found in Islamic teachings, specifically in explanations (tafsir) of hadith. 15 Moreover, motivation for religious figures or religious-group facilitators in engaging the congregation to implement selfprotective behaviors is also influenced by the perception of behavioral control in an individual.
This study adopts Albert Bandura's selfefficacy belief. Self-efficacy is an individual's cognitive process that encourages them to behave based on their concepts of faith in managing various life situations, such as adapting to their roles during the pandemic. 16,17 This study aims to understand the perceptions of religious communities (facilitators and members) in implementing self-protection behaviors towards COVID-19 through the application of self-efficacy beliefs.

Design and Setting
We conducted a qualitative study throughout existing MT in Ciputat Timur in Banten from August until December 2021. Ciputat Timur was chosen because of its high number of COVID-19 cases in Banten. 22

Participants and Sample
The sample of this study were the facilitators of MT that were willing to participate. Purposive sampling was used to choose samples that have prior understanding and backgrounds related to the aim of this study. The informants in this study included 6 MT facilitators and 12 MT members that represented their own MT from 6 sub-districts (kelurahan) in Ciputat Timur.

Instrument, Data Collection, and Analysis
Two instruments were utilized in this study. Interview guides were used for in-depth interviews to ensure structured interviews results that are in line with the aim of this study. FGD guides were used to aid the facilitator in proposing relevant issues in the discussion as to not drift from the aim of this study.
The validity and reliability of the facilities and infrastructure needed to support self-protection behaviors at MT were checked by triangulation. Triangulation was conducted by collecting data from both in-depth interviews with MT facilitators and the FGD conducted with MT members. Self-protective behavior was defined as efforts exerted for the sake of self-protection before, during, and after religious activities during MT. Self-protective behaviors include 3M protocols (maskwearing, hand washing, and physical distancing).
MT facilitators are the team that organizes the MT, usually led by the founder of the group or an individual appointed by other members to organize MT activities. Self-efficacy was defined as an individual's cognitive process that encourages them to behave based on their concepts of faith in managing various life situations. 16 Data management in this study was done by manually transcribing in-depth interviews and the FGD. The transcript was coded and stored in a folder to ease the search. Content analysis was used to analyze the result.  The results of the in-depth interviews are divided into two categories. The first category is "The need to accompany MT facilitators in implementing self-protection at MT," stemming from two sub-categories. The second category is "the role of MT facilitators in implementing self-protection behaviors at MT," stemming from two sub-categories (Table 3). Jurnal Kesehatan Reproduksi, 13(1), 2022

Category
Sub Category Potential internal support in implementing self-protection at MT Advising fellow MT members and advice from the ustazah or MT Facilitator Beliefs in implementing self-protection Uncertainty in the preparedness of implementing self-protection protection Reasons for not implementing self-protection Wudhu (ablution) is believed to be a part of selfprotection FGD results (Table 4) revealed two categories, "Potential internal support in implementing self-protection at MT" and "Beliefs in implementing self-protection." The first category stems from one sub-category, while the second category stems from three subcategories.

The need to accompany MT facilitators in implementing self-protection at MT MT facilitators feel they are not yet consistent in implementing self-protection at MT
One of the MT facilitators feels that the previous implementation of 3M protocols has been successful, but not yet consistent. Other MT facilitators say that one of the protocols that haven't been implemented consistently is wearing masks. An MT facilitator mentioned that she doesn't know if her members are aware of how to correctly wear a mask. Yet, other MT facilitators perceive that the members already know how to wear their masks correctly and that they should use hand sanitizer. MT facilitators believe that MT members are already aware that they should stay at home if they're feeling unwell without having to be informed or prohibited by the MT facilitators, even though MT facilitators aren't aware of all of the members' health conditions. Moreover, MT facilitators also admit that some members don't implement health protocols.
All MT facilitators have stated that since the pandemic started until the time the in-depth interviews were conducted, there hasn't been any information or socialization about COVID-19 from the COVID-19 task force, public health centers, or the sub-district (kelurahan). Their source of COVID-19 information is either from television or family.
MT facilitators expect to receive complete socializations to not instill false perceptions, especially from social media. MT facilitators hope for intensive socialization so that they can comprehensively convey the message to their members and the ustazah can convey information about implementing selfprotection at MT.

Some MT facilitators believe that wudhu (Islamic procedure of cleansing parts of the body) is the same as hand-washing
The finding in this study is that MT facilitators believe hand washing is the same as wudhu.
They have the perception that during this pandemic, it is very important to increase the frequency of wudhu. "Amongst others are wearing masks, of course we wash our hands because after dzuhur (midday prayers) we wudhu again, but we sit far apart from each other…" (MT-D)

The role of MT facilitators in implementing self-protection behaviors at MT MT facilitators in providing self-protection equipment based on their ability
MT facilitators feel that they should play a role in providing self-protection equipment based on the MT's ability. They prepare masks and hand sanitizer for members that forget to wear Jurnal Kesehatan Reproduksi, 13(1), 2022 or bring them. One MT facilitator would seek solutions related to funding.
Other facilitators feel they have already provided equipment and infrastructure because the MT venue is spacious and has adequate ventilation. Their MT is held at a wide and open-aired hall. Other facilitators also mentioned that when they have the funds, they will provide sinks, hand sanitizer, and soap. However, MT facilitators stated that the funds for sinks and thermometer guns are scarce.

MT Facilitators in Observing Their Members
During MT, MT facilitators observe their members in implementing mask-wearing behaviors. According to the MT facilitators, mask-wearing has already been consistent.

Potential internal support in implementing self-protection at MT Advising fellow MT members and advice from the ustazah or MT Facilitator
MT members stated that they would remind their peers to wash their hands, stay physically distanced, and pay special attention to wash their hands after holding or changing their masks. MT members agree that they should always remind each other to implement selfprotection.
MT members stated that MT facilitators ask them to bring their hand sanitizer if they attend the MT. Other MT members stated that the ustazah will remind them to stay at home and not attend the MT if they are feeling unwell.

Uncertainty in the preparedness of implementing self-protection
Many MT members expressed that the equipment for health protocols at MT is still scarce. Hand washing facilities and soap are the main things that MT members identified as lacking. "At the MT, they don't provide handwashing facilities and soap, but they tell us to bring our hand sanitizer." (MT-5) Besides that, MT members also stated that thermometer guns aren't provided at their MT. MT members expect MT to provide them.
The majority of MT members are unsure about implementing 3M protocols (mask-wearing, hand washing, and physical distancing) because it's difficult to implement throughout all the members. Some MT members believe physical distancing is the hardest to implement. Even though some MT members feel unsure about the implementation of selfprotection, the members feel ready to start implementing self-protection, especially handwashing.

Reasons for not implementing self-protection
MT members believe that the reason they don't always wear masks is that many MT members are elderly and feel breathless wearing them. "It's hard for the elderly to wears masks, they say it makes them breathless." (MT-1) Members have also stated that they wear masks because it is obliged by the government. Besides that, one reason they don't wash their hands is that there is no soap and they didn't bring any hand sanitizer. Some also say it's because they frequently forget due to their age.

Wudhu is believed to be a part of selfprotection
A couple of MT members assume that if you have performed wudhu with running water, you won't need to wash your hands. "Yes ma'am, wudhu is enough. The important thing is that you use running water." (MT-10) Jurnal Kesehatan Reproduksi, 13(1), 2022 Although some members said when you have already performed wudhu, you still have to wash your hands for example there is still a chance that they have shaken hands with someone else. Therefore, they need to wash their hands again with soap or hand sanitizer.

DISCUSSION
Generally, this study found that all informants have the perception that self-protection at MT can be implemented. Both MT facilitators and members stated their readiness to implement self-protection behaviors. However, this readiness is still weak, indicated by MT facilitators' need to support in implementing self-protection in MT.
According to previous study, an individual that carries a heavy responsibility will need internal belief or faith in their abilities and efforts, known as self-efficacy. 18 In this study, MT facilitators are responsible for preventing their MT from becoming a COVID-19 cluster. This is a heavy responsibility that requires strong self-efficacy. The results of this study show that self-efficacy in both MT facilitators and members is still weak.
Self-efficacy refers to an individual's cognitive process that encourages their behavior. 16 Selfefficacy is an individual's cognitive process that encourages them to behave based on their concepts of faith in managing various life situations. An individual's faith in their ability to execute these tasks efficiently and effectively will influence: 1) actions and behaviors, 2) the choice to adapt to new situations and environments, 3) the execution of certain tasks. 19 Strong self-efficacy in MT facilitators result in robust efforts, strategy improvement, and problem and weakness identification that can guarantee the success of students' actions. 18 Our study found that SE in MT facilitators is still weak, which may potentially influence the actions and readiness of MT members that play the role of students.
This study indicates the importance of strengthening variables that shape self-efficacy. 16 The FGD results showed that MT members have the potential to implement satisfactory self-protection, despite the uncertainty about readiness in implementing self-protection.

Strengthening variables that shape selfefficacy
Mastery experiences are defined as successful experiences in personally implementing selfprotection. This study shows that a portion of the MTs have resumed MT activity after a 1 -2-year vacuum, which indicates some MT facilitators are inexperienced. MT facilitators require experience in implementing selfprotection and the confidence to do it well.
Intervention is required to improve their knowledge and motivation, which is a crucial point in consistent implementation of these behaviors. 16,19,20 It was observed that MT members implement weaker self-protection than MT facilitators. While MT members showed a lesser understanding of implementing selfprotection, they also showed a weaker selfefficacy. This is due to MT facilitators not yet being successful in implementing selfprotection in their everyday lives, including 3M protocols.
Increasing mastery experiences by improving performance outcomes is a process that helps individuals attain simple tasks that contribute towards a more complex goal. Bandura theorized that an individual's most influential source of information stems from the result of an interpretation of their past. 16 Past achievements may shape strong self-efficacy in the future. Creating a short guidebook to aid the implementation of self-protection before, during, and after MT activities may ease both MT facilitators and members. Implementation of self-protection may be divided into several parts and made into posters that can be seen around the MT venue.
This motivation may also be increased by the quality of self-protection implementation at MT. Developing well-executed MT criteria, socializing, and incentivizing MT that can Jurnal Kesehatan Reproduksi, 13(1), 2022 execute self-protection is necessary. The development of self-protection implementation specifically for MT may be done by regional health offices, public health centers, academics, The Indonesian Public Health Association (IPHA), district-level COVID-19 task forces, and MUI.
The MTs involved in this study are not yet categorized as having well-executed selfprotection. Increasing vicarious experience by social modeling may be done through an identifiable model that exhibits a process of accomplishing a behavior. The formation of an MT under the supervision of district-level COVID-19 task forces may become a prototype of an MT that implements selfprotection. Furthermore, socializing how the MT prototype can implement self-protection should be done to motivate other MT.
Verbal persuasion aims to motivate an individual to finish a task or attain a certain behavior. 16 Verbal persuasion is related to the verbal interaction that MT facilitators or members accept about their performance and achievements in the context of engaging other members to get vaccinated. In the verbal persuasion variable, this study highlights that the local government is lacking in disseminating information about COVID-19 and self-protection measures that must be implemented at MT. This is a cause of MT facilitators' weak self-efficacy in implementing self-protection measures, which also impacts MT members.
This study underlines that there have been Islamic lectures about self-protection implementation at MT from the ustazah, facilitators, and members. MT is a forum for empowering women in increasing knowledge both religiously and in general knowledge such as health. This is an opportunity that can be taken by the government or health-related institutions to optimize the role of ustazahs, facilitators and members as part of strengthening women in the social sphere. However, this is not accompanied by adequate information about self-protection implementation among ustazah and facilitators. MUI is a socio-religious actor that hopes Muslim Indonesians can be influenced by the fatwa or formal rulings on Islamic law they issued about worship protocols during the COVID-19 pandemic. 21 The implementation of self-protection at MT would be stronger if MUI played a role in giving recommendations. That way, it is expected that verbal persuasion as a shaping variable of SE will become stronger.
MT facilitators play a role in advising their members about implementing self-protection. However, this role should be further optimized with the right knowledge, attitude, and skills for better implementation of self-protection. Other than internal roles, collaboration with external roles such as health offices, public health centers, academics, IPHA, district-level COVID-19 task forces, and MUI will also strengthen self-protection implementation at MT.
Emotional or physiological states are also crucial for MT facilitators in increasing selfefficacy. Emotional or physiological states are strong emotional conditions, such as anxiousness, that could effectively change an individual's belief about their capability. 16 There is a necessity for religious study materials that can spike emotion. Spiritual Islamic study materials that are related to ideal conditions in facing the pandemic need to specifically be developed. Materials such as the concept of thaharah (purification) and wudhu may be developed while paying attention to religious standards that are relevant to self-protection. By doing so, MT facilitators can emotionally feel that engaging members to implement self-protection is also a part of worship due to the material being parallel to Islamic teachings. This will increase motivation and indirectly increase MT facilitator and member's self-efficacy.
The limitation of the study that this study focuses on MT facilitators and members and does not focus on ustazah also have strong influences on self-protection behavior implementation in religious groups. Despite of the limitation, this study contributes valuable insight on how women religious group shape their efficacy into self-protection behaviors