THE INCIDENCE OF DERMATITIS IN FISHERMEN IN BONTANG CITY, EAST KALIMANTAN, INDONESIA

Background: Occupational skin diseases are the most common occupational diseases in many countries. Dermatitis has become one of the top 10 occupational diseases (PAK) based on the potential incidence, severity, and prevention ability. Fishermen are one of the oldest occupations and have a high risk of occupational accidents or occupational diseases, which one of the risks is dermatitis due to the exposure to sea water containing salt which is high enough to absorb the water from the skin. Objective: This study aims to determine the incidence of dermatitis, working duration, duration of exposure, history of skin diseases, use of personal protective equipment, and personal hygiene in the fishing communities in North Bontang. Methods: This study is an analytic observational study with a cross sectional study design. The population in this study was the fishing community in Loktuan Urban-Village, North Bontang. The samples were taken with the purposive sampling and a sample of 154 fishermen was obtained. The data were collected with a questionnaire that has been tested for the validity. The statistical analysis was conducted by Chi Square test with a significance level of 0.05. Results: The results showed that the history of skin diseases, the duration of exposure are related to the incidence of dermatitis in fishermen. Conclusion: Further research is needed to find out other risk factors that can cause dermatitis in fishermen.


BACKGROUND
Occupational dermatitis is classified internationally as the second largest occupational disease group after musculoskeletal disorders (Frosch & John, 2011). Epidemiological data show that contact dermatitis comprises 90 to 95% of all occupational dermatitis. The National Institute of Occupational Safety Hazards (NIOSH) in its annual survey (1975) estimated the actual incidence of occupational dermatitis to be 20-50 times higher than the reported cases (Lestari & Utomo, 2007). Irritant and allergic contact dermatitis are inflammatory skin conditions caused by skin contact with exogenous agents, that occur with or without simultaneous exposure to the contributing physical agents. The largest number of cases of occupational dermatitis occur in the factory/company sector, but the highest incidence rates occur in agriculture/forestry/fisheries sector. Dermatitis in fishermen is likely caused by the seawater which due to its concentration draws water from the skin; in this case sea water is a cause of chronic skin dermatitis as the primary stimuli (Lestari & Utomo, 2007). Epidemiologic data show that contact dermatitis comprises 90 to 95% of all occupational skin diseases. Both irritant and allergic contact dermatitis are inflammatory skin conditions caused by skin contact with exogenous agents, with or without a concurrent exposure to a contributory physical agent (Levy, 2006). The greatest number of cases of occupational skin diseases is seen in manufacturing, but the highest incidence rate is seen in agriculture/forestry/ fishing.
Fungi or marine animals may also cause skin diseases in fishermen. Fishermen work in wet areas where fungal diseases are prevalent, such as moniliasis (Chew & Maibach, 2006;Kaukiainen et al., 2005). Dermatitis can cause allergies, skin irritation, skin hypersensitivity, and also eczema (Czarnobilska, Obtulowicz, Dyga, Wsolek-Wnek, & Spiewak, 2009). Fishermen are one of the oldest occupations and have a high risk of occupational accidents or occupational diseases, where one of the risks is dermatitis due to the exposure to sea water containing salt which is high enough to absorb water from the skin. Working fishermen do not have regular work hours and have a long working time duration with uncomfortable working environment conditions such as the influence of extreme weather. A long sailing is expected and there is a risk of skin damage due to the exposure to sun heat and sea water (El-Saadawy, Soliman, El-Tayeb, & Hammouda, 2014).
Loktuan Urban Village, North Bontang Subdistrict is one of the largest settlements in North Bontang Sub-district, Bontang City, adjacent to two large-scale SOE companies, the number of neighborhood associations is 51 Neighborhood, a narrow and dense residential area with the largest number of poor people in Bontang City, and most of the people work as fishermen (Lok Tuan, 2015).
With low economic and educational conditions, the people generally do not pay much attention to the personal hygiene nor use personal protective equipment while working, as a result, it will certainly increase the risk of dermatitis in fishermen. Based on the data from the top 10 diseases in the North Bontang Public Health Center, dermatitis ranks the 3rd as the most suffered disease. The massive incidence of dermatitis in fishermen has the potential to increase every year, therefore, the main focus of this study was to determine the factors associated with the incidence of dermatitis in fishermen in the City of North Bontang, East Kalimantan Province, Indonesia.

Study design
This study is an observational analytic study with a cross sectional study approach. Variables in this study are the incidence of dermatitis, working duration, length of contact, history of previous skin diseases, use of PPE (Personal Protective Equipment), personal hygiene, and the use of sea / river water for daily use by fishermen in North Bontang City, East Kalimantan in 2019.

Setting and sample
The study was conducted on April 2019. The population in this study was the people who work as fishermen in Loktuan Urban-Village, North Bontang. Samples were taken with a purposive sampling, with a total sample of 154 fishermen.

Instrument
The instrument was adopted and developed based on the book Occupational and Environmental Health, Recognizing and Preventing Disease Injury, regarding variables dermatitis, personal hygiene, duration of work, length of work, history of skin diseases, and the use of Personal Protective Equipment (Levy, 2006). The instrument was tested in advance to 32 fishermen living in the coastal area of Tanjung Laut Sub-District, South Bontang District before the study was conducted. The data were collected with a questionnaire that has been tested for the validity and reliability. 38 of 50 question items can be used in the research questionnaire with an ordinal scale. The validity results showed that, of 38 items questions, had Pearson correlation > 0.3494.
The reliability results showed Cronbach's alpha of 0.649. Based on the results of statistical tests showed 38 items are valid and reliable questions and can be used for research. Data were collected by 10 trained enumerators who mastered the local language.

Data analysis
The statistical analysis was conducted by Chi Square test with a significance level of 0.05.  (CIOMS 2016). Informed written consent was obtained from the participants prior to data collection. The informed consent stated the purpose of the study, data confidentiality, and the voluntary right of participation in the study, as well as provided the guarantee that no participant suffered any harm as a result of his/her participation in the study.

RESULTS
Most respondents in this study were males (85.1%) and the age group was above 35 years (66.9%). Out of the total respondents, only 2.6% who had dermatitis, with a working duration of more than one year (98.1%) and a length of work above 8 hours a day (57.8%). 28.6% had a history of previous skin disease, only 17.5% of respondents used PPE at work, and those who applied personal hygiene were 81.8%.
Chi Square test showed that the duration of contact with the sea water in which the length of work was more than 8 hours a day (p = 0.03) and a history of previous skin disease (p = 0.006) were significantly related to the incidence of dermatitis whereas the use of PPE and personal hygiene of the respondents did not affect the incidence of dermatitis in fishermen in Bontang City respectively (p >0.05).

DISCUSSIONS
The results of this study indicate that most fishermen in North Bontang City did not use gloves and shoes as personal protective equipment (PPE) at work (82.5%) of which 3 people (4.7%) had dermatitis. After statistical tests, it was found that there was no relationship between the use of PPE and the incidence of dermatitis in fishermen (p = 0.54). This is not in line with the research conducted in Rembang Regency by Norma et al where the results of the study shows a significant relationship between the use of PPE and the incidence of irritant contact dermatitis in salt farmers (p = 0.042) (Suryani, 2017). This research is also not in line with Retnoningsih's research in 2017, which shows a p value of 0.000 which means there is a relationship between the incidences of dermatitis in fishermen with the use of PPE (Retnoningsih, 2017).
In the personal hygiene variable, it was found that fishermen who applied personal hygiene by washing their hands using soap and did not use sea / river water for bathing, washing and other daily needs were more (81.8%) than fishermen with less personal hygiene (18.2% ) although in fact fishermen with good personal hygiene experienced as much dermatitis (2.4%). This finding is also not in line with a research in Kolaka Regency Southeast Sulawesi who found a close relationship between personal hygiene in fishermen with the incidence of irritant contact dermatitis (p = 0.0012) (Zania, 2018).
Similarly, the results of a research conducted on fishermen in Tonyaman Village, Binuang District, Polewali Mandar Regency, stated that there is a relationship between personal hygiene of fishermen with skin disorders (Andan, 2018). This study is also not in line with previous research revealed that personal hygiene is related to the incidence of dermatitis in Lamanggau Village, Wakatobi Regency (Sarfiah, 2016). One cause of skin disorders is good work and personal hygiene while using PPE at work (Andan, 2018).
To maintain skin hygiene, healthy habits must always be considered (Potter, 2005). Efforts to prevent skin disorders that can be done is to maintain personal hygiene. Personal hygiene is an effort of individuals or groups in maintaining health through individual hygiene by controlling environmental conditions and disorders of the skin (Ministry of Health of the Republic of Indonesia, 2015). Retnoningsih (2017) also supports that there is a significant relationship between the incidence of dermatitis in fishermen and the personal hygiene.
Working in a damp place as happen in the fishermen can be a major factor in the occurrence of dermatitis since the concentration of sea water can draw the water from the skin (Iswara Wijaya, 2016). Dermatitis can also occur due to the presence of bacteria such as Mycobacterium marinum, fungi or sea animals which can cause dermatitis (Cahyawati & Budiono, 2011). In theory, prolonged contact with sea water is supposed to cause dermatitis. However, in contrast with what was found in this study, fishermen who worked less than 8 hours a day actually experience dermatitis (6.2%). This could be due to the history of previous skin disease suffered by the fishermen. The results of this study are not in line with what was found in a research which shows that there was a relationship between the work duration and skin disorder in fishermen in Kalinaun Village, Likupang Timur Sub-District, North Minasaha Regency (Langi, Kawatu, & Langi, 2019).
The study by Ambarsari and Mulasari (2018) found exactly the same thing as the results of this study. There was no significant relationship between contact duration and the incidence of dermatitis in garbage collectors in the city of Yogyakarta. Research conducted by Retnoningsih (2017) shows the same results as this study that there is no correlation between the incidence of dermatitis with work period.
The results of the analysis test show a significant relationship between the history of the previous skin disease and the incidence of dermatitis in fishermen in North Bontang City (p = 0.006). The disease history is used as a basis for determining whether a disease occurs due to a previous disease, as a result the history of the disease is very important in the healing process of a person. Someone who has previously suffered from dermatitis will be more susceptible to irritants, because the skin's defense will decrease (Kennedy C, 2010), and that previous disease history was not related to the incidence of dermatitis in fishermen in Wakatobi Regency (Sarfiah, 2016).
Workers such as fishermen, who have a history of skin diseases, will more easily experience dermatitis due to work because the protective function of the skin has declined because of the previous skin disorders. A previous study revealed that to have a history of allergies is the dominant factor associated with dermatitis (each OR: 6.74) (Hendra, Nirwana, & Isahak, 2018), and it is in accordance with what happened to fishermen in North Bontang City in which most of the respondents did not experience dermatitis because they did not possess the history of previous skin diseases.

CONCLUSION
The incidence of dermatitis in fishermen is related to the history of the previous skin diseases and the duration of contact. Further research is needed to find out other factors that are suspected as risk factors for dermatitis in fishermen.

Declaration of Conflicting Interest
No competing interests were disclosed.