Health Lecturers a nd Students Views’ a bout Healthcare Workers’ as Healthy Lifestye Role Models: a Qualitative Study

Background : Health education institutions as producers of healthcare workers have a duty to demonstrate healthy lifestyles to the students as the future healthy role models. Objective : This research aimed to describe the views of health lecturers and students about their role and the effect of healthcare workers’ behavior as healthy lifestye role models. Method : An exploratory qualitative study with in-depth interviews was conducted in 2017. Six lecturers and five studentss were chosen as key informants, who were selected from the medicine, nursing, and health nutrition departments. We analyzed the data manually, by identifying categories then created into themes. Result : Healthcare workers were judged as a representative figure to demonstrate healthy lifestyles. Unhealthy lifestyle practice by healthcare workers was considered a violation of their responsibility. Furthermore, it will decrease the image and respect of healthcare workers which will cause people to trust less in the treatment process and health counseling, and finally, the society will imitate unhealthy lifestyles. Furthermore, in medical education, this influences lecturers’ self -efficacy in health counseling, causing guilty feelings and shame for not implementing a healthy lifestyle although they had already learned health science. Moreover, the students sometimes feel sadness and disappointment, since not all lecturers can become healthy lifestyle role models. Conclusion: Healthcare workers are role models of healthy lifestyles in society and expected to be in any setting. Therefore, they should appropriately respond to becoming someone who qualifies to be imitated and be a good example of a healthy lifestyle


INTRODUCTION
A healthy lifestyle has been believed for a long time to be the main strategy for prevention of disease and the indicators are maintaining dietary habits by increasing the consumption of fruits and vegetables, doing physical activity, and avoiding smoking (AlAteeq & AlArawi, 2014;Özçakar, Kartal, Mert, & Güldal, 2015). Unfortunately, some healthcare workers have an unhealthy behavior, eighty-two percent of healthcare workers have a very low physical activity, and only 13% of doctors do physical activity >30 minutes 5 times a week (Barros, Lucas, & Ferrari, 2012;Borgan, Jassim, Marhoon, & Ibrahim, 2015). Furthermore, only 26.2% consume fruits and vegetables >5 portions per day and maintain healthy habits significantly related to physical activity (Florindo et al., 2015). In Indonesia, 32% of health office workers of South Sulawesi have low physical activity and 62% have low fruit and vegetable intake (Nadimin, 2011). Other research showed 38% of doctors do physical activity once per week and mostly consume only two portions of fruits and vegetables daily (31.6%) (Prabandari, 2013).
Being a healthy role model is an unwritten contract between patients and healthcare workers so that implementing a healthy lifestyle is a personal commitment and responsibility of healthcare workers toward their patients (Hoare, Mills, & Francis, 2013). Research shows becoming a positive role model in the society will increase trust in medical practice (Birden et al., 2014), compliance of treatment plan and satisfaction of the service (Mold & Forbes, 2013). Oppositely, unhealthy lifestyle practices by healthcare workers will affect society's judgment toward them, making people uncomfortable if they consult with healthcare workers who have similar unhealthy behavior with them. As a result, they will consider healthcare workers have no right to give healthy lifestyle suggestions to them (Pistikou et al., 2014). Moreover, this negative perception will affect healthcare workers' self-confidence and desire to give counseling about physical activity or healthy lifestyle to society (Bleich, Bennett, Gudzune, & Cooper, 2012;Florindo et al., 2015;Zhu, Norman, & While, 2013).
Medical education institutions have a role in developing professionalism, professional identity, career path, and students' ethical character as a role model (Benbassat, 2014;Passi & Johnson, 2015). Teachers have become the first-seen image of healthcare workers, therefore students give a deep attention, judging and imitating their teachers' behavior, and this role modeling also applies to the educational staff (Haider, Snead, & Bari, 2016). Eventually, it will affect the students' self-image and professional perceptions in the future (Felstead, 2013). However, the lecturers and educational staff often ignore their responsibility to be positive role models (Jochemsen-van der Leeuw, van Dijk, van Etten-Jamaludin, & Wieringa-de Waard, 2013;Vinales, 2015), although many actually understand they should become healthy role models (Passi & Johnson, 2016). Unfortunately, the practice of lecturers as healthy lifestyle role models in the health education institutions is still uncommon, and as a result, the impact on the students and their perceptions of becoming healthy role models are not well understood yet. This study aimed to determine the perceptions and experiences from the perspectives of the lecturers and health students about the role of healthcare workers as healthy lifestyle role models.

METHOD
The exploratory qualitative methods with in-depth interviews was conducted from May until June 2017. The interviewer served as the principal investigator, in addition to a lecturer in the Faculty of Medicine, Tanjungpura University and an alumnus from the Department of Nutrition Science Health Polytechnic of Pontianak.
The informants were lecturers and students from an undergraduate program of Medicine and Nursing, Faculty of Medicine, Tanjungpura University, and diploma program of Nutrition Science, Health Polytechnic of Pontianak. At the beginning of the study, we selected informants by a personal approach, explaining the aim of the study, and asking about their willingness to participate in the research. Criterion sampling method was used to choose the informants, where the chosen lecturers had working period for more than three years because of his/her experience and closeness to the students, and students were year-end students (sixth semester) who also had longer exposure to their lecturers and were soon to start their clinical rotation in various communities.
There were 6 lecturers and 10 students who agreed to participate, however for the data analysis we only selected some of the informants as subjects from each study program and finally had 11 key informants. Selection of key informants was completed after conducting all interviews and rereading the transcripts from all 16 informants. Eventualy, 6 lecturers (3 doctors, 2 nurses and 1 nutritionist) and 5 students (3 medical students and one student each from nursing and nutrition department). The number of informants was not picked from the beginning, but determined by the amount of information given by the informants and saturations (Malterud, Siersma, & Guassora, 2016).
Each interview was conducted at an agreed time and location between the informants and investigator, so we could not ideally set the interview room. The informant sat beside the interviewer so to maintain eye contact and have clear voice during the interview. Before starting, the informants had NURSING PRACTICES already received a clear explanation of the interview process, which involved using a voice recorder and taking notes. Each informant's privacy was maintained and their identity kept anonymous and all knew they had the rights to not answer any question or refuse to continue to participate in the study.
Each interview ran for 45 minutes and started with an opening question: 'What do you understand about the concept of a role model?'. There were 2 main questions as response triggers: 'From your opinion, is it necessary for healthcare workers to become healthy lifestyle role models?' and 'From your opinion, what is the influence of healthcare workers' behavior as a healthy lifestyle role model?' We inserted probing questions to collect additional data and also clarify the meaning of informant's answer. The interviewer did not limit the informants from answering with relevant experiences about healthy lifestyles and role models. Replaying the voice recording was done after interviewing and reading the transcript were completed, to ensure all questions were answered, clarified, and written down.
We conducted manual descriptive analysis by reading the transcripts line by line and then organizing the data manually. Data categorization was performed by giving highlights in a unique sentence or giving a categorical meaning from informants' answers. That process was done two times until the investigators clearly understood the meaning of the answers and the categories were also already appropriately saturated, i.e. no new codes were emerging. In the next step, we categorized similar categories into several subthemes and from sub-themes into an organizational framework. There were some categories that needed to be separated because they had no similarity with other categories and did not provide themes but were not deleted, since they will enrich the content of the study. After completing the process, all investigators re-read the categories and themes to better establish the correct themes that match with the study aims and finally applied simple coding to designate data sources (Sutton & Austin, 2015). Member-checking with one qualitative expert was conducted to ensure the trustworthiness. We gave the code to each of the informants who were lecturers (L1-L6) and students (S1-S5). This study was approved by the Medical and Health Research Ethics Committee Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, number KE/FK/0528/EC/2017.

Informants characteristic
Informants with a variety of ages was chosen, which for lecturers were between 30-53 years old and for the students were between 19-20 years old. According to sex, lecturer informants were predominately males (4 from 6) while there were more female student informants (4 from 5). We selected only qualified informants, where one of the informants was a former head of a study program and another was currently head of a study program.
We selected year-end students, who were currently doing their final thesis, and the background of their participation in an organization was also a consideration, where one of them was the head of the students' organization.

What is a healthy role model?
Healthcare workers are considered as 'vanguard' people, since their behavior is seen as a role model, even if it is a 'bad one'. From the view of society, the healthcare workers must be a 'representative' as a healthy person, since they are seen as 'a leader', so being healthy is a must, especially for a doctor. Becoming a healthy role model is not a compulsory act, but it is a 'mindset' that all healthcare workers must have. One informant explained the following: "From my opinion, a role model is a reference or an example ... We as a doctor act to serve the society, it means we become a role model or reference for the society in daily life, especially in health. If we are a lecturer, it means we become references for the students in attitude, something like that" (L1) The previous statement explained that a role model in healthcare workers was someone who is being 'an example to others', while others stated it as someone who 'exemplifys' healthy lifestyle. On the other hand, some informants emphasized a role model was someone who is 'eligible' to be followed from the scientific and ethics-norm viewpoints. The society also described healthy healthcare workers from their 'appearance' and 'healthy lifestyle'. Most highlighted the 'bad' lifestyle was the 'smoking' habit in healthcare workers.

'No Action Talk Only' healthcare workers as an unhealthy role model
Healthcare workers who do not implement healthy lifestyle are considered as someone who only knows the theory or 'no action talk only'. They can only 'advise' other people to implement a healthy lifestyle but they do not do that, and are considered as 'irresponsible' and 'opposite' from the ideal that should be performed by healthcare workers. This unhealthy behavior will reduce the important 'image' and 'respect' of healthcare workers as a competent person in health matters.
In addition, all informants stated that it will negatively affect the 'trust' of patients so they will 'refuse' to do healthy lifestyles because they reflect on the lack of an appropriate role model in healthcare workers' behavior. The informants stated that society will 'question' the result of the given treatment and not 'trust' in him/herself to practice a healthy lifestyle. Moreover, unhealthy behavior conducted by healthcare workers will be 'followed'. In the end, it will severely affect the health promotion programs in society: "...Healthcare workers conduct unhealthy behavior... so we (society) also followed them (healthcare workers)... if it is contradictive, they won't follow us anymore... they do not want to follow what we advise to them" (L3).
One of the adverse effects of the unhealthy behavior conducted by healthcare workers in him/herself is the lack of 'self-confidence' of giving consultation for patients. They will self-reflect while doing education, feeling what they said is not yet done and that they had not enough 'experience' in giving education about healthy lifestyle. They felt they 'lied to' the patients and the patients felt 'cheated' if the healthcare workers giving the instruction about health recommendations that had never been conducted by him/her.
The worst impact may create the image of the healthcare workers as a 'contagious patient' and the real patient feels worried if he/she got infected by some disease while they get treatment. One informant stated that: "...The doctor is prone to catch a disease... it would shape people's mind that if doctor or paramedics often ill 'how could they treat sick people, if they often got sick too" (L4).

Other informant stated:
"We told them, 'Please watch your diet, ma'am' meanwhile I am obese'.... thus, patient will respond with 'Heh' [cynical face while looking at me from head to toe].... yes, negative look from patient like she wants to tell me, 'Ah you're just like me doc' that's what I felt'... "Oh doctor also got the flu", oh yeah right. So, we are afraid of bringing our children which have no flu before, will catch the flu after visiting doctor" (L1).

Feel guilty as a professional healthcare worker
As someone who receives higher education in the health field, it is a must for a healthcare worker to apply healthy lifestyle behavior. It is a responsibility of healthcare workers towards themselves and the community as stated by one student: "... Healthcare workers act as people who know more about health, people who understand about health have the responsibility to give model ... we could not order other people to do healthy lifestyle if we do not start it ourselves" (S4).
Healthcare workers who do not apply healthy lifestyle according to what it is said by the people in the communities would be presumed guilty due to the assumption of being irresponsible towards their obtained knowledge and health messages about what they said to their patient. This 'guilty' feeling is felt by healthcare workers appearing either from themselves or direct reprimands from community. Some informants stated that: "... We did not avoid those so there is a feeling of talking only and not accompanied by actions, this triggers a guilty feeling of doing nothing but still lecturing about the topic." (L1).
"...We educate something which is not done by ourselves, sometimes it hits us ... you have not done that but why you are still brave enough to tell people to do so', it becomes a reflection for us." (S4).
Furthermore, it is stated that healthcare workers are "part of the community" so that the practice of

NURSING PRACTICES
healthy lifestyle behavior is a form of social responsibility by being amidst a community. Considering the role as part of the community might sometimes raise the issue that the practice of healthy lifestyle behavior is caused by 'shame' feelings due to not showing and practicing a healthy lifestyle.
What comes up as interesting is that the feeling of shame is caused by not yet obtaining the ideal 'physical appearance'. Obtaining good physical appearance is presumed as proper body image for healthcare workers in the community's view and success in applying a healthy lifestyle is assessed from clothing size.
" .... smoking, like it or not, is due to habit... would feel ashamed if seen by people, trying to change little by little.' ... We try to keep our weight in the ideal state, would be a disgrace if healthcare workers are fat." (L6).
Besides, there is a 'demand' from communities that healthcare workers demonstrate a healthy lifestyle, since if there is unhealthy behavior acted by even one healthcare worker, it will reflect on all healthcare workers and health messages. As a result, sometimes behavior which is not shown by healthcare workers would be as a boomerang to them. Eventually, negative lifestyle behavior done by healthcare workers would affect community behavior.
"Just said by proverb 'a speck of indigo would damage the entire milk' (Nila setitik rusak susu sebelanga) ... even though others try perfectly, yet if there is even one who does wrong, sometimes people would defend themselves that they want to smoke (be unhealthy)" (S4).
One of the lecturers stated that practicing a healthy lifestyle is part of applying religious teaching, believing that: "God would be angry if we talk something that we do not do ourselves" (L3).
While the healthy lifestyle is a 'fortress' towards healthcare workers' behavior so that they are in accordance to obtain knowledge, and 'awareness' as role models of practicing healthy lifestyle which has been known by healthcare workers as their: "morale and personal responsibility towards knowledge, God, and themselves" (L2).
Although they understood this, some of the informants stated that being a role model is a 'personal entitlement' and depends on 'awareness'.

'Ironic'-Lecturers as students' bad role models
In health education institutions students see lecturers as their role models. Lecturers are viewed as 'health educators' so that they are presumed to perform the 'ideal' behavior as a model, which students will later imitate during their study period. Therefore, becoming a role model is a joint responsibility, not only by lecturers as healthcare workers but also all of the people who exist in the campus environment and relate to the college image as a field of health education.
Lecturers who do not perform healthy lifestyle behavior lead students to be 'confused' because they are considered to practice improper behavior that is not in accordance with their knowledge as a health educator. Besides, other feelings were expressed by students such as 'sadness' and 'disappointment', since lecturers are considered 'useless' as healthcare workers. Also, it is 'unfortunate' regarding the obtained knowledge because of being unable to perform healthy lifestyle behavior for themselves, and eventually it is considered as 'ironic'. "hmm.. maybe only disappointment in the community, he/she should be able to perform what he/she has known, it feels like 'unfortunate', his/her knowledge becomes useless" (S3).

Other supporting statement:
"Yes, become role model, because they teach about health, would be an irony if healthcare workers teach about health yet still smoking, do not obtain the culture of a healthy lifestyle, eating without hand washing, still love to stay up all night, etc... So, it would be an irony, even less as a lecturer (we) should be a role model too" (L3).
Teaching about the application of healthy lifestyle behavior should be done as early as possible even though not all of the healthcare workers could be a role model of a healthy lifestyle. Making someone into a role model needs 'acquaintanceship' (S1) and a 'learning process' (L2,L3) over a long time period, and this statement also was affirmed by the lecturers. The behavior shown by lecturers inside or outside campus becomes an 'attention-getter' for students. One of the students said that: "there are some lecturers bringing unhealthy lifestyle to campus who want to transmit their behavior to students" (L1).
Students would see, and assess the behavior even to the extreme state to seek for lecturers' behavior outside the campus. Students clearly consider the goodness and badness shown by lecturers such as healthy lifestyle behavior habits including smoking habit, sports habit, hand washing, and selection of food.
Responsibility as a role model of healthy lifestyle behavior for students is actually very important. For example, there was a lecturer teaching about obesity who received reprimands from students for being obese: "Sir...why is it fat, sir? The student reprimanded me.....so we are ashamed basically if the healthcare workers are fat, it's a shamed" (L6).
Although based on some students' statements (S2,S3), the practice of healthy lifestyle does not have to be applied to lecturer due to their position as an indirect healthcare worker in the communities.
There is sometimes a contradiction in knowledge between what has been taught and lecturer's appearance, such as in the experience where the lecturer was reprimanded by a patient due to having an obese appearance, so that the patient disbelieved the solicitation of doing healthy lifestyle behavior (L1) and was doubting the behavior was also done by healthcare workers (L5). Interestingly, those reprimands also were felt by students (S1,S3), where the status of being health science students forms the image that students have practiced healthy lifestyle behavior so that they are appropriate enough to be role models for the community. This fact represents the learning community's perspective that being role models of a healthy lifestyle should be performed since becoming a student.

Healthcare workers are also human
Although performing healthy lifestyle behavior is an obligation for healthcare workers towards the community and themselves, there are several constraints faced. As a worker assigned to working hours, constraints appear from time limitations to do physical activities since they have to divide their time for family and work. Another interesting reason to justify not being healthy is frequent 'meetings' serving unhealthy meals. Even though they have the status as a healthcare worker, selection of food still depends on indulgence so that healthcare workers' behavior is similar to the patient. Obstacles in applying healthy lifestyle in daily life are presumed part of being human, thus if healthcare workers could not perform healthy lifestyle behavior or become ill, those outcomes are considered reasonable.
"I could say sometimes I do it, other times I do not, yet I frequently do it. Because I know the effect so I still do it anyway, but as a human, we may feel tired, bored, so sometimes we just forget and seek for other eating patterns" (L5).
Until recently, all of the lecturer informants stated that they have done changes in lifestyle behavior, while some informants changed due to gaining negative impacts of unhealthy lifestyle behavior such as increasing weights, hypercholesterol, feeling unproductive while working and feeling ashamed about their overweight bodies. Other factors that served as backgrounds were getting older, afraid of the risk of degenerative diseases and feeling older than they should be.
This state is inversely proportional to the students, where all of the student informants have not performed healthy lifestyle behavior yet, and this is due to time limitations. The density of campus activities caused all of the students to not have more time to do physical activities, and besides, they are also involved in organizational activities, and thus the rest of the time is used for resting. Another reason for not applying healthy eating lifestyle is 'economic limitations', because the limited amount of money affected their desire and the daily needs

NURSING PRACTICES
for buying and eating fruits and vegetables are seldom fulfilled. Therefore, they feel that: "being role models for performing healthy lifestyle is very strenuous" (S2,S5) .

DISCUSSION
In this study, we analyzed perspectives from lecturers and students about the role of healthcare workers as healthy lifestyle behavior role models, whereas most of the studies about role models are usually related to the medical education field, and as a consequence, there is a lack of sources of information concerning this discussion. However, as healthcare workers who also obtain the role of medical educator, it may be felt that the discussion of healthcare workers' role as an educator would be similar to a clinical practitioner in the community.
As a person being imitated and serving as a model about health to the community, healthcare workers are urged to be role models for good healthy lifestyle behavior. According to Kelly, Wills, Jester, and Speller (2016), several factors influence the eagerness from healthcare workers to be role models of a healthy lifestyle including credibility, responsibility, the impact of health behavior, professional duties and social norms. Compared to the result of the study, that statement is especially true because unhealthy lifestyle behaviors which are done by healthcare workers are presumed irresponsible according to the point of view of the community, thus it would give impact on patients' trust toward healthcare workers. Furthermore, it would influence healthcare workers' confidence to give counseling about health and their health condition would eventually lead to the community perspective that healthcare workers have lied and are not to be trusted if they are not modeling the healthy lifestyle.
Teaching methods by role modeling is judged to be strongly effective for teaching and achieving changes in students (Jochemsen-van der Leeuw, van Dijk, van Etten-Jamaludin, & Wieringa-de Waard, 2013). Students can more easily form selfidentity by seeing, analyzing and imitating actions, skills, and behaviors from their lecturers (Haider, Snead, & Bari, 2016). The role modeling process could happen unconsciously, inadvertently, dynamically and continuously during the learning process (Benbassat, 2014;Nouri, Ebadi, Alhani, & Rejeh, 2015). Research has showed that there is a unique relation between modeling and the image of the role model, where being a model is not always something that can be taught and obtained through education. Character qualities such as being enthusiastic, compassionate, open-minded, and having integrity and good relations with a patient should be known consciously by medical educators because their behavior would serve as an example for students beyond the learning process in the class (Paice, 2002).
According to this research, health education lecturers are sometimes not representing appropriate behavior towards health in a campus environment. This problem could be caused by a lack of attention toward the important aspects of being role models to shape the identity of students or community views toward their profession, although they are aware and understand about the responsibility of being a healthy role model (Passi & Johnson, 2016). Being a negative role model would have a poor effect on students, causing confusion toward the difference between correct clinical management and actions showed by role models, which eventually might lead to students' desperation in finding the truth between theory and practice. As a consequence, they would be constrained by ashamed feelings of not having enough experience and afraid of questioning lecturers (Mileder, Schmidt, & Dimai, 2014).
Therefore, students' identity formation through role modeling should be taught correctly by lecturers, by encourage the self-awareness to practice healthy behavior and self-confidence to be a good role model. On the other side, the health education institution also need to provide the health facilities for support healthy behavior.

CONCLUSION
Role model in healthcare workers is defined as a person who is recognized by society for exemplifying healthy lifestyle, so their behavior is considered worthy to be followed. This study shows only lecturers' and students' perspectives toward the role of healthcare workers as role models in the healthy lifestyle, therefore further studies are still needed to compare the perceptions of service users toward the role of healthcare workers mainly in the profession of lecturers as healthy role models. These future studies are aimed to increase awareness of all health professions in any field to perform healthy behaviors.