INTRODUCTION
As of December 2024, there were 28,731 Korean seafarers, of whom 10,106 worked on oceangoing merchant ships. These workers represent a particularly health-vulnerable group because they spend prolonged periods at sea with limited access to onshore health services [1]. A recent study reported that 34.0% of seafarers experienced illness during voyages and that 29.1% had chronic diseases [2], indicating a considerable burden of both acute and chronic health problems in this occupational group. These health problems have been associated with demanding working conditions, irregular sleep patterns, and unhealthy lifestyles characteristic of maritime labor [3]. Given that oceangoing seafarers continuously work under such conditions, attention to their lifestyles and health-promoting behaviors is essential for preventing chronic diseases.
Lifestyle behaviors play a key role in health promotion and are closely related to the prevention of major chronic diseases, including cardiovascular disease [4,5]. However, maintaining healthy lifestyles can be challenging for oceangoing seafarers because they work in physically and psychologically demanding environments characterized by constant ship movement, noise, vibration, irregular work schedules, and prolonged separation from family and society [6,7]. These occupational conditions may contribute to sleep deprivation, physical fatigue, and psychological stress, which can negatively influence health-promoting behaviors.
Previous studies on Korean seafarers have largely been conducted within the field of maritime studies and have primarily focused on working environments, occupational diseases, or institutional and policy-related issues [2,8,9]. Since 2003, few studies have specifically examined health-promoting behaviors among seafarers, and research from a nursing perspective remains particularly limited [10]. International studies conducted among Iranian and Danish seafarers have examined certain health-related behaviors, such as dietary habits, physical activity, smoking, and alcohol consumption [11,12]. However, these studies often focused on fragmented health behaviors or used assessment tools that did not adequately reflect the distinctive working environment of maritime occupations. Consequently, they provide only a limited understanding of the factors influencing seafarers’ health-promoting behaviors and the challenges involved in maintaining them during long voyages.
Health-promoting behaviors are a central concern in fundamental nursing because they are closely related to disease prevention, health education, and nursing assessment in various populations. Pender's Health Promotion Model (HPM) provides a useful theoretical framework for understanding such behaviors. According to the HPM, health-promoting behaviors are influenced by individual characteristics and experiences as well as behavior-specific cognitions and interpersonal influences [13]. Psychological attributes such as hardiness and self-efficacy may enhance individuals’ motivation and ability to engage in health-promoting behaviors, while social support functions as an important interpersonal resource that facilitates behavioral change. In the demanding and isolated environment of maritime work, these factors may play a particularly important role in shaping seafarers’ health behaviors.
Therefore, this study aimed to examine health-promoting behaviors among South Korean oceangoing seafarers from a nursing perspective and to identify factors associated with these behaviors using a quantitative approach based on Pender's Health Promotion Model while considering the sociocultural context and unique occupational environment of maritime labor. In addition, focus group interviews were conducted to qualitatively explore seafarers’ firsthand experiences with health-promoting behaviors, thereby providing a more comprehensive understanding of this phenomenon.
More specifically, it aimed to achieve the following research objectives:
• To describe seafarers’ general and health-related characteristics.
• To analyze seafarers’ hardiness, self-efficacy, social support, and health-promoting behaviors.
• To examine the differences in seafarers’ health-promoting behaviors based on their general and health-related characteristics.
• To identify correlations between seafarers’ hardiness, self-efficacy, social support, and health-promoting behaviors.
• To determine the factors associated with seafarers’ health-promoting behaviors.
• To understand seafarers’ experiences related to health-promoting behaviors through qualitative inquiry.
• Using a mixed-methods approach, this study aimed to provide a comprehensive understanding of the health-promoting behaviors of South Korean oceangoing seafarers and to offer evidence that may inform nursing interventions and health promotion strategies for this occupational population.
METHODS
1. Study Design
This study adopted a convergent (QUAN + qual) mixed-methods design. The quantitative component used a cross-sectional descriptive design to identify factors associated with South Korean oceangoing seafarers’ health-promoting behaviors, and the qualitative component used focus group interviews to explore their experiences related to these behaviors. The quantitative and qualitative findings were then compared and integrated to provide a comprehensive understanding of health-promoting behaviors in this occupational group. This study was theoretically grounded in Pender's Health Promotion Model, in which individual characteristics and experiences influence behavior-specific cognitions and affect, ultimately leading to health-promoting behaviors. In our conceptual framework (Figure 1), demographic, health-related, and work-related factors and hardiness are conceptualized as personal factors, while self-efficacy and social support represent behavior-specific cognitions that are expected to interact with each other and contribute to health-promoting behaviors among seafarers.
2. Participants
For the quantitative component, participants were eligible if they were male seafarers enrolled in training at a seafarer retraining center in Busan, had served on oceangoing merchant ships for more than five years, had worked on an oceangoing merchant ship within the past year, and understood the purpose of the study and provided written informed consent. The required sample size was calculated using G*Power. Based on a previous study on health-promoting behaviors [10], an effect size (f2) of .16, a significance level of .05, a statistical power of .95, and three key predictors were applied for multiple regression analysis. The minimum required sample size was 112. Considering a 25% dropout rate, 140 questionnaires were distributed. After excluding eight incomplete responses, data from 132 participants were analyzed, yielding a response rate of 94.3%. Only male seafarers were included because almost all trainees at the retraining center during the data collection period were men, so caution is needed when generalizing the findings to female seafarers.
For the qualitative component, participants who expressed willingness to participate after completing the survey were invited, and additional participants were recruited through referral sampling. A total of eight participants were selected and allocated to two focus groups, each consisting of four interviewees.
Participants were seafarers working on oceangoing merchant ships, including dry cargo ships, liquid cargo ships, and container ships. Dry cargo ships transport large quantities of non-liquid bulk commodities in multiple cargo holds, whereas liquid cargo ships carry crude oil and other liquid products in segregated tanks with specialized pumping and safety systems. Container ships mainly carry standardized containers on fixed international routes, where schedule reliability and rapid cargo handling are essential. Across these ship types, seafarers undertake long voyages lasting several weeks to months, are exposed to various physical hazards, and often work under rotating shift systems which contribute to irregular daily routines. They live with multinational crew members in confined spaces, and shortened port stays combined with rapid cargo operations limit opportunities to use shore-based medical and recreational facilities.
3. Instruments
1) Health-promoting behaviors
Health-promoting behaviors were measured using the Korean version of the Health-Promoting Lifestyle Profile II (HPLP-II). The HPLP-II was developed by Walker et al. [14], and Yoon and Kim [15] translated it into Korean. The 52-item scale comprises six subscales: interpersonal relationships (9 items), nutrition (9 items), health responsibility (9 items), physical activity (8 items), stress management (8 items), and spiritual growth (9 items). Each item is rated on a 4-point Likert scale from 1 (never) to 4 (routinely), and higher scores indicate greater commitment to health-promoting behaviors. In Yoon and Kim's study [15], Cronbach's ⍺ for the total scale was .91, and the subscale coefficients were .74, .46, .75, .79, .64, and .80 for interpersonal relationships, nutrition, health responsibility, physical activity, stress management, and spiritual growth, respectively. In this study, Cronbach's ⍺ for the total scale was .95, and the subscale coefficients were .78, .73, .86, .88, .75, and .89, respectively.
Although the HPLP-II was originally developed for general adult populations, it has been widely used to assess health-promoting behaviors in diverse occupational groups. The multidimensional structure of the scale allows comprehensive assessment of lifestyle-related health behaviors, making it appropriate for evaluating health-promoting behaviors among seafarers working in unique occupational environments.
2) Hardiness
Hardiness was measured using the Korean version of the Dispositional Resilience Scale (DRS-15). The DRS-15 was developed by Bartone [16], and Cho et al.[17] translated it into Korean. It comprises 15 items measuring three subscales: commitment (5 items), control (5 items), and challenge (5 items). Items numbered 3, 4, 8, 11, 13, and 14 are reverse-scored. Each item is rated on a 4-point Likert scale, ranging from 0 (not at all true) to 3 (completely true), and the total score ranges from 0 to 45. Total scores of 39 or higher, 34 to 38, 28 to 33, 22 to 27, and 21 or lower denote very high, high, average, low, and very low levels of hardiness. In Cho et al.'s study [17], Cronbach's ⍺ was .72 for the total scale and .80, .79, and .78 for the commitment, control, and challenge subscales, respectively. In this study, Cronbach's ⍺ for the total scale was .74.
3) Self-efficacy
Self-efficacy was measured using the Korean version of the General Self-efficacy Scale. Its internal reliability was validated by Schwarzer et al.[18]. Moreover, it comprises 10 items rated on a 4-point Likert scale ranging from 1 (not at all true) to 4 (exactly true). Higher scores indicate higher levels of self-efficacy. The Cronbach's ⍺ of the original scale was .88, and .84 in this study.
4) Social support
Social support was measured using the Korean version of the Multidimensional Scale of Perceived Social Support (MSPSS). The MSPSS was developed by Zimet et al. [19], and Shin and Lee [20] translated it into Korean. The scale comprises 12 items measuring three subscales: family (4 items), friends (4 items), and significant others (4 items). All items are scored on a 4-point Likert scale ranging from 1 (not at all true) to 4 (exactly true), and higher scores indicate greater levels of perceived social support. The Cronbach's ⍺ of the scale at the time of its development was .85. The Cronbach's ⍺ of the subscales family, friends, and significant others was .85, .75, and .72, respectively. In this study, the Cronbach's ⍺ for the total scale was .91, and the subscale coefficients were .73, .92, and .88, respectively.
4. Data Collection
Participants were recruited using convenience sampling from oceangoing seafarers attending a seafarer retraining program in Korea. The retraining program is periodically attended by seafarers from various ships and ranks to maintain their professional qualifications, which provides access to seafarers with diverse occupational backgrounds. After obtaining permission from the staff member in charge, the researcher visited the retraining center, explained the purpose and procedures of the study, and invited seafarers who voluntarily agreed to participate.
For the quantitative component, data were collected between April 13 and June 19, 2019. Questionnaires were distributed to eligible participants who agreed to participate, and the completed questionnaires were collected immediately after completion.
For the qualitative component, focus group interviews were conducted between January and March 2020. Participants were recruited from among seafarers who expressed willingness to participate in the interviews. Prior to the interviews, participants received the interview questions via text message to allow them time to reflect on their experiences. Two focus group interviews were conducted with four participants in each group. Smaller group sizes were used to encourage open discussion and allow participants to share their experiences in depth. The first interview was conducted in a meeting room at the participants’ affiliated company where interruptions could be minimized, and the second interview was held at a quiet cafe selected according to the participants’ preference and convenience. Immediately before each interview, participants were informed about the purpose and procedures of the study and were given an opportunity to ask questions. The interviews were guided by semi-structured questions exploring seafarers’ health-promoting behaviors during long voyages and the factors that facilitated or hindered such behaviors. During the interviews, the researcher summarized participants’ responses and invited them to add further comments before moving to the next question. At the end of each interview, participants were given the opportunity to review their responses and clarify or supplement any statements. Each interview lasted approximately 60 minutes and was audio-recorded. The recordings were transcribed verbatim by the researcher on the same day. To clarify ambiguous statements and supplement incomplete information, follow-up telephone interviews were conducted with two participants (one from each group) on March 14 and 15.
5. Data Analysis
1) Quantitative data analysis
The data collected were analyzed using SPSS version 30.0. Descriptive statistics, including frequencies, percentages, means, and standard deviations, were used to examine participants’ general and health-related characteristics. Health-promoting behaviors, hardiness, self-efficacy, and social support were analyzed using means and standard deviations. Differences in participants’ health-promoting behaviors according to their general and health-related characteristics were assessed using independent t-tests and one-way ANOVA. Post-hoc analyses were conducted using Scheffé's method. Correlations among health-promoting behaviors, hardiness, self-efficacy, and social support were analyzed using Pearson's correlation coefficients. Finally, hierarchical multiple regression analysis was performed to identify the factors associated with participants’ health-promoting behaviors. Prior to the regression analysis, the assumptions of normality, linearity, homoscedasticity, independence of residuals, and multicollinearity were examined and met.
2) Qualitative data analysis
Elo and Kyngas's inductive content analysis was used to analyze the qualitative data obtained from the focus group interviews [21]. In the preparation phase, the transcripts were read repeatedly to achieve immersion and gain an overall understanding of the data. Meaningful units relevant to the research aim were identified and extracted. During the organizing phase, open coding was conducted and similar codes were grouped into subcategories and categories based on their similarities and differences. In the abstraction phase, the categories were integrated and interpreted to derive the final themes.
6. Ethical Consideration
This study was conducted after receiving approval from the Institutional Review Board of P University for both the quantitative and qualitative phases of the study (IRB No.: 2017_97_HR; IRB No.: 2019_74_HR). To ensure the ethical protection of participants, the study purpose, procedures, anonymity, confidentiality, voluntary participation, and the right to withdraw at any time without penalty were explained to all participants. Only those who agreed to participate voluntarily signed the informed consent form and participated in the survey or interviews.
RESULTS
1. Results of Quantitative Data Analysis
1) Participants’ general and health-related characteristics
The mean age of participants was 48.44 years, and most were married (68.2%). Nearly half had university-level education or higher (45.5%), and 47.0% worked as engineering or deck officers. Participants had an average of 17.7 years of job experience, with 46.2% reporting more than 20 years of experience. More than half of the participants were smokers (52.3%), and 76.5% reported poor or very poor sleep quality. Overall, participants perceived their health status as good. Job stress levels were low in 31.8%, moderate in 40.9%, and high in 27.3% of participants (Table 1).
Table 1.
Health-Promoting Behaviors of the Subjects According to General Characteristics and Health-related Characteristics (N=132)
| Characteristics | Categories | n (%) | M±SD | Health-promoting behaviors | |
|---|---|---|---|---|---|
| M±SD | t or F (p) | ||||
| Age (year) | ≤29 | 18 (13.6) | 48.44±14.69 | 2.46±0.48 | 2.60 |
| 30∼39 | 30 (22.7) | 2.21±0.36 | (.039) | ||
| 40∼49 | 15 (11.4) | 2.11±0.39 | a＞c, d | ||
| 50∼59 | 27 (20.5) | 2.08±0.45 | |||
| ≥60 | 42 (31.8) | 2.28±0.46 | |||
| Marital status | Single | 30 (22.7) | 2.37±0.47 | 2.74 | |
| Married | 90 (68.2) | 2.21±0.44 | (.068) | ||
| Others | 12 (9.1) | 2.03±0.33 | |||
| Education | ≤High school | 52 (39.4) | 2.16±0.44 | 6.09 | |
| College | 20 (15.1) | 2.02±0.45 | (.003) | ||
| ≥University | 60 (45.5) | 2.36±0.41 | b＜c | ||
| Job position | Captain and chief engineer | 56 (42.4) | 2.22±0.44 | 0.09 | |
| Officer and engineer | 62 (47.0) | 2.25±0.47 | (.916) | ||
| Crew | 14 (10.6) | 2.21±0.35 | |||
| Ship type | Liquid cargo ship | 46 (34.8) | 2.21±0.46 | 0.60 | |
| Dry cargo ship | 25 (18.9) | 2.17±0.44 | (.617) | ||
| Container ship | 8 (6.1) | 2.14±0.31 | |||
| Others | 53 (40.2) | 2.29±0.44 | |||
| Career experience (year) | 5∼9 | 51 (38.6) | 17.69±13.14 | 2.29±0.40 | 1.37 |
| 10∼19 | 20 (15.2) | 2.10±0.47 | (.258) | ||
| ≥20 | 61 (46.2) | 2.22±0.46 | |||
| Disease | Yes† | 51 (38.6) | 2.13±0.42 | 2.07 | |
| No | 81 (61.4) | 2.29±0.45 | (.041) | ||
| Smoking | Yes | 69 (52.3) | 2.12±0.40 | 2.73 | |
| No | 63 (47.7) | 2.33±0.46 | (.007) | ||
| Drinking | Yes | 92 (69.7) | 2.21±0.48 | -0.37 | |
| No | 40 (30.3) | 2.24±0.43 | (.710) | ||
| Exercise (min/session) | Yes ＜60 | 85 (64.4) | 2.21±0.43 | 11.99 | |
| ≥60 | 19 (14.4) | 2.61±0.38 | (＜.001) | ||
| No | 28 (21.2) | 2.03±0.37 | a, c＜b | ||
| Sleep quality | Very bad | 28 (21.2) | 2.21±0.48 | 0.19 | |
| Bad | 73 (55.3) | 2.22±0.43 | (.829) | ||
| Good | 31 (23.5) | 2.27±0.45 | |||
| Perceived health status | Poor | 27 (20.5) | 2.28±0.36 | -2.05 | |
| Good | 105 (79.5) | 2.27±0.45 | (.043) | ||
| Health checkup (within 2 years) | Yes | 113 (85.6) | 2.25±0.44 | 1.47 | |
| No | 19 (14.4) | 2.09±0.45 | (.145) | ||
| Job stress | Slightly stressful | 42 (31.8) | 2.38±0.48 | 5.52 | |
| Moderate | 54 (40.9) | 2.22±0.39 | (.005) | ||
| Stressful | 36 (27.3) | 2.06±0.42 | a＞c | ||
2) Participants’ health-promoting behaviors, hardiness, self-efficacy, and social support
The mean score for participants’ health-promoting behaviors was 2.23±0.44. Among the subdomains, the highest score was for interpersonal relationships (2.47±0.47), followed by spiritual growth (2.43±0.63), stress management (2.27±0.47), and physical activity (2.04±0.66). Health responsibility showed the lowest score (1.91±0.53). The mean score for hardiness was 25.77±6.33. Hardiness scores were most frequently distributed in the 22∼27 point range (36.4%), followed by 28∼33 points (22.7%) and 21 points or less (27.3%) (Supplementary Table S1). The mean score for self-efficacy was 2.89±0.39. The mean score for social support was 2.97±0.52. Among the social support subscales, the highest score was for family (3.20±0.54), followed by significant others (2.93±0.63) and friends (2.77± 0.70) (Supplementary Table S1).
3) Differences in participants’ health-promoting behaviors based on their general and health-related characteristics
Participants in their 20s demonstrated greater adherence to health-promoting behaviors than those in their 40s and 50s (F=2.60, p=.039). Those with college-level education showed greater adherence than those with university-level education or higher (F=6.09, p =.003). Furthermore, significantly higher levels of adherence were found among those who did not have a health condition compared with those who had a health condition (t=2.07, p=.041), nonsmokers compared with smokers (F=2.73, p= .007), those who exercised for ≥60 min/session compared with those who exercised for <60 min/session and those who did not exercise (F=11.99, p<.001), those who perceived their health as good compared with those who perceived it as poor (t=-2.05, p =.043), and those with low stress compared with those with high stress (F=5.52, p= .005) (Table 1).
4) Correlations between participants’ health-promoting behaviors, hardiness, self-efficacy, and social support
Participants’ health-promoting behaviors was significantly correlated with their hardiness (r=.66, p<.001), self-efficacy (r=.41, p<.001), and social support (r=.36, p< .001). Hardiness was significantly and positively correlated with self-efficacy (r=.44, p<.001) and social support (r=.43, p<.001). Self-efficacy and social support were significantly and positively correlated (r=.30, p<.001). Higher scores for hardiness, self-efficacy, and social support indicated greater adherence to health-promoting behaviors (Table 2).
Table 2.
Correlations between Health-Promoting Behaviors, Hardiness, Self-Efficacy, and Social Support (N=132)
| Variables | Hardiness | Self-efficacy | Social support |
|---|---|---|---|
| r (p) | r (p) | r (p) | |
| Health-promoting behaviors | .66 (＜.001) | .41 (＜.001) | .36 (＜.001) |
| Hardiness | .44 (＜.001) | .43 (＜.001) | |
| Self-efficacy | .30 (＜.001) |
5) Factors affecting the health-promoting behaviors of the participants
In the first step, Model 1 was constructed by entering the general and health-related characteristics based on which participants’ health-promoting behaviors differed significantly: age, education level, existing health condition, smoking practice, exercise participation, perceived health status, and job stress. Models 2, 3, and 4 were constructed by successively adding hardiness, self-efficacy, and social support. The Durbin-Watson value was 1.87, close to the standard value of 2 and indicating no autocorrelation. The variance inflation factor (VIF) ranged from 1.21 to 3.74, indicating no multicollinearity issues with the independent variables. Scatterplots of standardized residuals showed that the residuals were randomly dispersed around zero, supporting the assumptions of linearity and homoscedasticity. In addition, the normal probability (P-P) plot of standardized residuals indicated that the residuals were approximately normally distributed, supporting the assumption of normality. These findings confirmed that the assumptions for hierarchical multiple regression analysis were satisfied.
In Model 1, the first hierarchical model, having high school-level education or lower (β=-.28, p=.005), having college-level education (β=-.30, p=.001), and exercising for ≥60 min/session (β=.36, p<.001) were found to influence health-promoting behaviors. They explained 29.2% of the variance (F=5.16, p<.001). In Model 2, having high school-level education or lower (β=-.17, p=.031), having college-level education (β=-.18, p=.012), exercising for ≥60 min/session (β=.28, p<.001), having low job stress (β=.15, p=.029), and hardiness (β=.54, p<.001) were found to influence health-promoting behaviors. The addition of hardiness resulted in an additional explanation of 22.9% of variance (F=12.12, p<.001). In Model 3, having college-level education (β=-.19, p=.008), exercising for ≥60 min/session (β=.30, p<.001), having low job stress (β=.17, p= .012), hardiness (β=.45, p<.001), and self-efficacy (β=.18, p=.009) were found to influence health-promoting behaviors. The inclusion of self-efficacy explained an additional 2.4% of variance, resulting in a total explanatory power of 56.6%(F=12.38, p<.001).
In Model 4, the final step of hierarchical regression analysis, having college-level education (β=-.19, p=.007), exercising for ≥60 min/session (β=.29, p<.001), having low job stress (β=.16, p=.022), hardiness (β=.44, p<.001), and self-efficacy (β=.17, p=.020) were found to influence health-promoting behaviors. The coefficient of social support was not statistically significant. Higher levels of adherence to health-promoting behaviors were observed among participants with a university-level education or higher (vs. those with a college-level education), those who exercised for ≥60 min/session (vs. those who did not exercise), those with low job stress (vs. those with neutral job stress), those with greater self-efficacy and hardiness. The model explained 56.5% of the variance (F=11.65, p<.001) (Table 3).
Table 3.
Factors affecting Health-Promoting Behaviors (N=132)
2. Results of Qualitative Data Analysis
The general characteristics of the eight interviewees were as follows. The average age was 41.25±4.99. Most (75%) were married. Six had college-level education, and two had university-level education or higher. Six were engineering officers, and two were deck officers. The interviewees mainly boarded bulk carriers and container ships. Two had more than 10 years of experience, while the remaining had lesser experience.
A total of 17 subcategories, 7 categories, and 3 main themes were derived from the content analysis (Table 4).
Table 4.
Experience of Health-Promoting Behaviors
1) Theme 1: Difficulty in maintaining health on board
Theme 1 describes the difficulties seafarers experience in maintaining their health within the shipboard environment, which was characterized by restricted autonomy and substantial physical and psychological burdens.
Under the category of a controlled boarding life, participants reported that health-related behaviors were strongly influenced by a captain-centered hierarchical culture. The captain's leadership style affected daily life on board and limited crew members’ autonomy. In addition, participants described limited dietary options and restricted leisure activities due to confined spaces and lack of choice, as well as disruption of social and family life caused by prolonged separation from home and frequent crew rotation. Access to medical services was also described as inadequate, particularly during long voyages, as onboard infirmaries lacked professional medical staff and specialized treatment.
The second category, physical and mental burden, reflected the cumulative strain resulting from irregular work schedules, overtime during port operations, and exposure to extreme environmental conditions. Participants described persistent fatigue related to long working hours, time zone changes, and seasonal transitions. In addition, interpersonal conflicts and negative emotions were commonly suppressed rather than expressed, contributing to psychological distress and emotional exhaustion.
The captain is like the president. If the captain is good, everything is good; if the captain is not good, everything is not good. (Participant 7)
On land, there are places to go after work, but on the ship, there is neither time nor place. (Participant 3)
On container ships, we hit about 20 ports in just two months. When we dock, we're always on standby, day and night. It's a real physical toll. When we cross the equator, the engine room temperature can rise up to 50°C, causing us to sweat a lot, lose minerals, and get totally drained and exhausted. (Participant 2)
2) Theme 2: Administration for health protection of seafarers
Theme 2 reflects administrative and institutional efforts to protect seafarers’ health through onboard welfare facilities and safety management systems.
Participants reported that, despite spatial limitations, ships were equipped with basic exercise and recreational facilities that supported physical activity and rest. Improved communication infrastructure, such as onboard wireless internet, enabled regular contact with family and friends and contributed to psychological well-being.
In addition, seafarers described structured safety management systems regulated by international conventions and national laws, which helped prevent excessive overtime and ensured timely emergency responses. Strict quarantine and hygiene procedures during port operations were also perceived as essential measures for protecting both seafarers and public health.
There's a space we call the sunken deck… There is a table tennis court and a gym for us to exercise… In the recreation room, we have a TV, karaoke, and books. (Participant 7)
In the past, we only had satellite phones. Now, some companies have equipped ships with Wi‑Fi devices for welfare purposes. On such ships, it's easier to keep in touch with family and friends. (Participant 2)
Thanks to the International Labour Organization, there's a time limit to overtime work. If one is caught forcing overtime, there are consequences. (Participant 1)
3) Theme 3: Habituation of health behaviors
Theme 3 describes the process by which seafarers gradually internalized and habituated health-promoting behaviors through personal responsibility, self-regulation, and everyday practice.
Participants expressed a strong will to adopt healthy behaviors, which was rooted in pride in their professional identity and an awareness of personal responsibility for health management. Recognizing physical changes and health risks associated with long-term seafaring, they emphasized the need for proactive lifestyle modification.
In addition, seafarers described controlling deviant health behaviors by complying with onboard safety regulations and exercising self-restraint regarding unhealthy behaviors. Health-promoting behaviors were practiced through regular physical and leisure activities adapted to limited shipboard environments, reflection on and adjustment of dietary habits, and efforts to build harmonious relationships with colleagues. These practices were perceived as contributing not only to individual well-being but also to positive social interactions and a healthier onboard culture.
We are professionals, and we have to take care of ourselves. Nobody looks after us. If I fall ill, I believe it's because I neglected my health. (Participant 5)
If you're careful enough, you can stay healthy. We have safety regulations, and I'm confident that there's no risk of exposure to diseases if we abide by them. (Participant 6)
We can jog on the deck, but mostly we use treadmills or indoor cycles. (Participant 2)
After turning 30, however, I felt my body wasn't the same as before, and that's when I started controlling my diet. (Participant 6)
I often encourage younger officers to exercise with me. If they request training, I ensure they commit to exercising for at least a month. (Participant 7)
DISCUSSION
This study yielded several important findings regarding health-promoting behaviors among Korean oceangoing seafarers. The participants perceived their health status as high, attributed to the "healthy worker effect." Although their mean job stress score was slightly lower than that found in a previous study [10], difficulties stemming from the uncontrollable work environment and interpersonal conflicts were chronic sources of stress, as found in the focus group interviews.
The mean score for health-promoting behaviors was 2.23, lower than those reported in previous studies [10,11,22], with particularly low scores in the subdomains of physical activity and health responsibility. Qualitative findings indicated that, although some oceangoing ships were equipped with onboard sports facilities, both endogenous and exogenous factors—such as strenuous working conditions, physical decline, fatigue, and rigid shift and meal schedules—limited opportunities for exercise and other self-directed health-promoting activities. Limited peer support due to unfamiliarity with colleagues and hierarchical onboard culture further contributed to the low engagement in health-promoting behaviors and physical activity.
The relatively low score in the health responsibility domain may also reflect limited access to healthcare resources in maritime settings. Although onboard medical managers provide basic assistance during voyages, they are usually not trained healthcare professionals. In addition, remote maritime medical services may not fully compensate for the absence of onboard healthcare providers. These structural limitations may restrict seafarers’ ability to actively manage their health despite their awareness of its importance. From a fundamental nursing perspective, this finding highlights the need for system-level strategies to improve access to health information, counseling, and preventive services for seafarers working in isolated environments.
Significant differences in health-promoting behaviors were observed according to age, education, disease, smoking, exercise, perceived health status, and job stress. These findings are consistent with previous studies reporting that health-promoting behaviors vary according to sociodemographic and health-related characteristics [23-26]. In maritime settings, younger or less experienced seafarers may have fewer resources or coping strategies to manage job stress and maintain healthy lifestyles, whereas older or more educated seafarers may have developed more adaptive coping mechanisms and health-related knowledge over time.
Health-promoting behaviors were significantly and positively associated with hardiness, self-efficacy, and social support. In the regression analysis, hardiness, self-efficacy, education, exercise, and job stress together explained 56.5% of the variance in health-promoting behaviors, with hardiness showing the strongest association. This finding supports previous research identifying hardiness as a key correlate of health-promoting behaviors and is in line with Pender's Health Promotion Model, which emphasizes the importance of personal psychological resources and behavior-specific cognitions in shaping health behaviors. The positive association between self-efficacy and health-promoting behaviors in this study is also consistent with findings from studies involving various occupational groups [23,25,29], suggesting that individuals who believe in their ability to manage their health are more likely to maintain health-promoting behaviors even under stressful or irregular working conditions.
The qualitative findings further support this interpretation. Although health management systems and fitness facilities were available onboard, engagement in health-promoting behaviors varied considerably among individuals. This finding indicates that similar environmental conditions may lead to different behavioral outcomes depending on personal psychological resources such as hardiness and self-efficacy, highlighting the importance of strengthening these resources in nursing interventions for seafarers.
Pender's Health Promotion Model emphasizes the role of interpersonal influences, such as social support, in shaping health-promoting behaviors, and previous studies have similarly identified social support as an important factor associated with health-promoting behaviors. However, in the present study, social support was not identified as a significant factor in health-promoting behaviors in the regression model, despite its positive correlation with health-promoting behaviors. This divergence from the HPM and prior findings suggests that, in the context of oceangoing seafaring, the influence of social support on health-promoting behaviors may be attenuated or altered by structural characteristics of the work environment.
Qualitative findings provide further insight into this discrepancy. Participants described that shipboard environments are characterized by clear task division and relatively narrow interpersonal networks, which often lead to passive and formal relationships among crew members. Because crew members are typically replaced every 6∼12 months, the continuity of communication and interpersonal relationships may be limited, making it difficult to establish stable and long-term support systems. These conditions may partly explain the relatively low level of social support observed in this study and may weaken the direct influence of social support on health-promoting behaviors, even when individuals perceive some degree of interpersonal support. Nevertheless, the interviews indicated that a captain's interest in health and supportive leadership can increase opportunities for exercise and encourage health behaviors among crew members. As seafarers advance in rank, they also reported improved social skills and more harmonious peer relationships, which may foster informal support for health-promoting behaviors. From a theoretical perspective, this finding does not contradict the HPM but rather highlights the importance of considering how occupational contexts can constrain or mediate the role of interpersonal influences. Taken together, the findings of this study have several implications for nursing assessment, intervention, and education. Nursing assessments for seafarers should include psychological resources such as hardiness and self-efficacy, as well as individual characteristics such as age, health status, and lifestyle risk factors. These assessments may be relevant not only in community or occupational health settings but also in clinical settings when seafarers seek medical care during port calls or hospital visits. In addition, health promotion interventions should incorporate strategies to strengthen hardiness and self-efficacy, including stress-management techniques and feasible health goals adapted to irregular work schedules. Health education programs should also be tailored to shipboard environments using modular education sessions, digital materials, or peer-led activities.
From a fundamental nursing standpoint, this study expands the conceptual understanding of health-promoting behaviors by applying Pender's Health Promotion Model to an understudied occupational group and by demonstrating how individual psychological resources and occupational characteristics interact to shape lifestyle behaviors. The results can also be used in nursing education as case-based material to illustrate the application of theory-based health promotion in complex work environments and to enhance students’ competence in occupational and community health nursing.
This study has several limitations. Participants were recruited through convenience sampling from seafarers attending retraining programs, which may limit the generalizability of the findings. In addition, the study did not include seafarers from other ship types whose working conditions may differ. Furthermore, the cross-sectional design precludes causal inference, and self-reported measures may be subject to recall or social desirability bias.
Despite these limitations, this mixed-methods study provides a comprehensive understanding of health-promoting behaviors among Korean oceangoing seafarers. The data were collected prior to the widespread outbreak of the COVID-19 pandemic, allowing the findings to reflect seafarers’ health-promoting lifestyle practices in a pre-pandemic occupational context. These results offer valuable baseline data for post-pandemic comparative research and contribute nursing-specific evidence for the development of tailored health promotion strategies and occupational health nursing interventions for seafarers.
CONCLUSION
The level of health-promoting behaviors among Korean oceangoing seafarers was relatively low. Although many seafarers perceived their health status as good, limited engagement in health-promoting behaviors within the challenging shipboard environment may increase their risk of chronic diseases. These findings indicate that enhancing hardiness and self-efficacy, which were identified as key determinants of health-promoting behaviors, is essential.
In addition, raising health awareness among ship managers, including captains, strengthening peer support systems among seafarers, and promoting collaborative efforts among shipping companies, government agencies, and related organizations may contribute to improving seafarers’ health-promoting behaviors. The findings also suggest the need for accessible health education and counseling support on board.
Based on these findings, future research should focus on: (1) developing and evaluating intervention programs designed to enhance hardiness and self-efficacy among seafarers; (2) extending research to include seafarers working on domestic ships, distant-water fishing ships, and nearshore fishing ships under diverse working conditions; and (3) exploring strategies to improve health leadership among captains and to establish supportive onboard health environments.
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