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Advocate Program for Healthy Traditional Houses, UmeKbubu, in a Timor Community: Preserving TraditionalBehavior and Promoting Improved Health OutcomesRachmalina Prasodjoa, D. Anwar Musadada, Salut Muhidinb, Jerico Pardosia & Maria Silalahica National Institute of Health Research and Development, Ministry of Health, Indonesia,Jakarta, Indonesiab Department of Business, Faculty of Business and Economics, Macquarie University, Sydney,Australiac Nusa Tenggara Timur Provincial Health Office, Kupang, IndonesiaPublished online: 03 Apr 2015.

To cite this article: Rachmalina Prasodjo, D. Anwar Musadad, Salut Muhidin, Jerico Pardosi & Maria Silalahi (2015)Advocate Program for Healthy Traditional Houses, Ume Kbubu, in a Timor Community: Preserving Traditional Behavior andPromoting Improved Health Outcomes, Journal of Health Communication: International Perspectives, 20:sup1, 10-19, DOI:10.1080/10810730.2015.1013390

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Advocate Program for Healthy Traditional Houses,Ume Kbubu, in a Timor Community: Preserving TraditionalBehavior and Promoting Improved Health Outcomes

RACHMALINA PRASODJO1, D. ANWAR MUSADAD1, SALUT MUHIDIN2, JERICO PARDOSI1, andMARIA SILALAHI3

1National Institute of Health Research and Development, Ministry of Health, Indonesia, Jakarta, Indonesia2Department of Business, Faculty of Business and Economics, Macquarie University, Sydney, Australia3Nusa Tenggara Timur Provincial Health Office, Kupang, Indonesia

Families in the Timor society of Indonesia have customarily used traditional houses, called Ume Kbubu, for confinement practicesof a newborn baby and the mother during the first 40 days after birth. The practice, known as Sei (smoke) tradition, involves retain-ing heat, which is believed to foster healing, inside the house by continuously burning a wood burning stove. Exacerbated by inad-equate ventilation in the traditional house, this practice results in poor indoor air quality and negatively affects the health of themother and baby. Preliminary findings from a baseline study conducted in 2009 identified high levels of indoor air pollution in UmeKbubu where mothers practiced the Sei tradition. Many respondents expressed that they suffered from respiratory health problemsduring the practice. On the basis of those results, a follow-up study was conducted in 2011 to develop and test acommunication-focused behavior change intervention that would foster conversion of traditional houses into healthy Ume Kbubuand promote changes to traditional practices for better health outcomes. The study suggests that redesigning an Ume Kbubu housecould promote better air quality inside the house and involving the community in the health intervention program led to positivechanges in the Sei practice (i.e., decreasing the Sei period’s length from 40 days to 4 days on average and attempting to reducehousehold air pollution). The study resulted in several recommendations in relation to sustained transformation to improve healthbehaviors.

Traditional beliefs and practices are common in variouscultures around the world, including Indonesia. Out of1,331 ethnic groups currently living in Indonesia, around370 ethnicities are still practicing their local traditions (Agus,Horiuchi, & Porter, 2012; Swasono, 1998; Wulandari &Klinken, 2011). As early as 1961, anthropological studiesdescribed how a wide range of cultural ceremonies and tradi-tions were performed by Javanese families in connectionwith weddings, pregnancy, and childbirth (Geertz, 1961).

In the Timor communities of Indonesia, one commonpostpartum tradition is the Sei or smoke tradition, in whichnew mothers and their newborn babies sit or lie aboveembers from biomass fuel (e.g., wood and agricultural cropresidue) for up to 40 days (Prasodjo 2009, 2012). The com-munity believes that childbirth causes a state of excess coldthat depletes the mother’s heat and blood, leaving hervulnerable to cold, wind, bad spirits, and disease. The Sei

tradition is performed to restore the mother to a state of equi-librium. While participating in the Sei tradition, mothers arealso encouraged to consume hot food and drinks, and areforbidden from eating particular foods such as seafood thatmay cause salty breast milk and stomachache. This practiceof new mothers restoring their equilibrium and warmth dur-ing the postnatal period is similarly found in other Easternand Southern Asian cultures and countries (e.g., Hoekmanet al., 2008; Raven et al., 2007; Yamashita et al., 2014).

Sei, Household Air Pollution, and Health

The Sei tradition in the Timor community frequently takesplace inside a traditional house, Ume Kbubu, which meansa ‘‘rounded house’’ as reflected by its physical shape (seeFigure 1). In the past, the Ume Kbubu served as the maindwelling place for people to sleep, cook, store food, and saveseeds for the planting season. Today, most people havemoved to permanent houses, and the Ume Kbubu is nowusually used for domestic activities (e.g., cooking, familygatherings, other social interactions), as a nurturing spacefor mothers, and for food storage (McWilliam, 2002; Windi& Whittaker, 2012).

The house is generally made of rattan frames that arebent into a beehive-shape and covered with long, thick dried

Address correspondence to Salut Muhidin, Department of Busi-ness, Faculty of Business and Economics, Macquarie Univer-sity, Sydney, NSW 2109, Australia. E-mail: salut.muhidin@mq.edu.au

Color versions of one or more of the figures in the articlecan be found online at www.tandfonline.com/uhcm.

Journal of Health Communication, 20:10–19, 2015

Copyright # Taylor & Francis Group, LLC

ISSN: 1081-0730 print/1087-0415 online

DOI: 10.1080/10810730.2015.1013390

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grasses, which extend to the ground. There is a small, lowentrance door through which most people must bend toenter. It has an earthen-based floor, no windows or venti-lation, and a central fireplace (Dima, Antariksa, & Nugroho,2013). Owing to these characteristics, the house effectivelytraps heat from the burning of firewood that is used to pro-vide warmth during cold weather and to protect food stocks(e.g., dry and preserve corns and grains). However, theseconditions also lead to high levels of exposure to householdair pollution for the mother and newborn baby during theSei (Prasodjo, 2009).

Studies indicate that housing conditions have a significantinfluence on the health of the occupants (see, for example,Armstrong & Campbell, 1991; Bruce et al., 2014; Bruce,Perez-Padilla & Albalak, 2000; Krieger & Higgins, 2002;Lim et al., 2012). Furthermore, the effect of high levels ofhousehold air pollution on health is much higher amongthose who spend more time indoors than outdoors. Thus,mothers and young children who are confined indoors afterchildbirth in dwellings with high levels of household air pol-lution are a particularly vulnerable group (Smith et al., 2011;Warwick & Doig, 2004).

Globally, household air pollution is attributed to 3.5 to4.3 million deaths annually (Bruce et al., 2014; Lim et al.,2012; World Health Organization, 2014) and accounts for4% to 6% of the global burden of disease (Smith et al.,2011). The levels of household air pollution are usuallyhigher among poor households in developing countries(Martin et al., 2013), particularly in rural areas as many ofthose families still rely on unprocessed biomass fuels forcooking and heating purposes (Smith et al., 2011). There isnow strong evidence to link an increased risk of diseasessuch as acute lower respiratory infections in children,chronic obstructive pulmonary disease and cardiovascular

disease in adults to exposure to high levels of householdair pollution (Barnes, 2014; Smith et al., 2011).

The high exposure of women and children during post-partum traditions (e.g., Sei tradition in Timor) is likely toresult in similar poor health outcomes as those linked tocooking related smoke. Yet, very little is known about theeffectiveness and feasibility of programs to reduce householdair pollution caused by the Sei. Even less is known about thepotential for behavioral change to reduce household air pol-lution exposure (Barnes, 2014). According to Buntoro(2006), the Ume Kbubu design may have contributed tothe recent increases in acute lower respiratory infectionsreported by the Timor Tengah Selatan District Health Office(i.e., acute lower respiratory infections increased from 17.1%in 2002 to 26.1% in 2004). However, the study did not collectany robust evidence on the household air pollution levelsinside the traditional house or on the health outcomes ofmothers and newborns that performed the Sei practice.

In response to this knowledge gap, the aim of this studywas to provide insight into a behavior change communi-cation intervention designed to promote the constructionand use of healthy adapted-traditional houses among Timorwomen in Indonesia following childbirth. The objectives ofthe study were as follows:

. To qualitatively understand knowledge, attitudes andpractices about the Sei tradition.

. To describe the possible effect of the intervention on levelsof household air pollution.

. To describe the development of the behavior change com-munication intervention.

Theoretical Perspective

The Diffusion of Innovation theory (Rogers, 2003) providesa theoretical orientation for this study. The Diffusion ofInnovation theory focuses on behaviors in terms ofinnovation rather than the individual as an agent ofbehavior change. The innovation here can be defined as anidea, practice or object perceived as new. It theorizes fourmain elements of behavior change, namely innovation,communication channels, time and social system (Rogers,2003).

This study focused on promoting innovative healthyadapted-traditional houses through behavior change com-munication with the community. In this study, consultationswith local institutions (e.g., policymakers, medical staff,community-based leaders, and other stakeholders who havebeen directly involved in the traditional behavior) were con-ducted for promotion, socialization, and advocacy. The sta-keholders were facilitated and encouraged to discuss the Seitradition and its implications for health issues. By involvingthe wider community in such a participatory action pro-gram, the prototype of a redesigned traditional house wasexpected to transform traditional houses into healthy UmeKbubu, which have more adequate ventilation that will leadto better health.

In line with the Diffusion of Innovation theory, this inter-vention focused on relationships between people, theirenvironment, and the technology that surrounds them to

Fig. 1. Ume Kbubu traditional house in Timor community, oftencalled rumah bulat or ‘‘round house,’’ as reflected by its physicalshape.

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change behavior. The innovations were designed to be com-patible with existing values, experiences and needs of poten-tial adopters; easy to understand; testable by communities;and to have observable results. Rogers (2003) argued thatsuch innovations are evaluated ‘‘through the subjectivevaluations of near peers’’ (p. 36). Therefore, interpersonalcommunications played a key role in the intervention. Thisidea is especially relevant in the context of Timor societyand in Indonesia in general, where social networks and acommunal environment are particularly strong. Therefore,consultations with different stakeholders who influence andapprove changes to cultural practices were necessary for dif-fusion of innovation to occur.

Method

Study Site

The Timor community is one of the indigenous groups in theeastern part of Indonesia. They are largely situated in thewestern part of Timor Island in the province of Nusa Teng-gara Timur, covering four districts (Belu, Kupang, TimorTengah Selatan, and Timor Tengah Utara) and one capitalcity (Kupang). The province of Nusa Tenggara Timur hasrelatively high poverty, child malnutrition, and maternaland child mortality rates. In 2010, the poverty level was23% and the maternal mortality rate was 271 per 100,000 livebirths (Dinas Kesehatan Timor Tengah Selatan, 2010).

The Atoni, also known as the Dawan, make up themajority of the Timorese population, which was estimatedat about 61% of the West Timor population (Windi &Whittaker, 2012). Many ethnic groups in Timor, especiallyamong rural populations, are still following traditional prac-tices to satisfy cultural patterning. The Sei tradition is largelypracticed by rural communities in Timor Tengah SelatanandTimor Tengah Utara districts. The Boti tribe from theDawan in Timor Tengah Selatan district is one of the groups

who continue to routinely practice Sei tradition; familiesin major urban cities are less likely to participate in thispractice.

Using purposive sampling, the district of Timor TengahSelatan where the proportion of women practicing Sei tra-dition is high (more than 40%, based on the 2009 healthreport from Dinkes Nusa Tenggara Timur) was selected asthe main study site. On the basis of the availability of timeand resources, the subdistricts of Amanuban (Nulle) andKie (where more than 40% of families had practiced theSei tradition) were selected.

Study Design

This study was part of a larger research project focused onmorbidity and mortality among mothers who practice theSei tradition. It was conducted in two stages: a baselinestudy in 2009 and a follow-up study in 2011–2012 (Prasodjo,2009, 2012). The baseline study focused on the identificationof health issues related to the Sei practice, while thefollow-up study focused on evaluating the feasibility andpossible effect of the behavior change intervention. Asummary of study frameworks applied in the two stages ispresented in Figure 2.

Baseline Study

During the baseline study, a mixed methods approach(Creswell, 2003) was used to identify the issues related toSei tradition. Quantitative structured questionnaires wereconducted with 358 mothers who had practiced Sei traditionin the past year. The qualitative in-depth interviews andobservation were carried out with 10 randomly selectedmothers, of whom 5 were still practicing the Sei traditionat the time of the interview and the other 5 had completedthe practice.

Fig. 2. Study framework in Stage 1 (baseline study) and Stage 2 (follow-up study).

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Household Air Pollution Monitoring

Household air pollution was monitored in the houses of the 5mothers still practicing the Sei tradition, by measuring para-meters of temperature, humidity, ventilation speed, naturallight, dust particle matter (i.e., particulate matter less than 10microns in aerodynamic diameter [PM10]), sulfur dioxideand nitrogen dioxide levels, and formaldehyde. The levels ofPM10, sulfur dioxide, and nitrogen dioxide were measuredaccording to the principals of national standard. For example,gravimetric analysis was used to measure suspended particulatematter (SPM) levels (Badan Standardisasi Nasional, 2005).Over 24 hours, the dust from indoor air was sucked on apreweighed filter with the aid of vacuum pump. The trappeddust in the filter was then analyzed to assess the elemental

composition of the dust and the microbial composition. Detailmeasure principles for sulfur dioxide and nitrogen dioxidelevels were evaluated by using pararosaniline and GriessSaltzman methods, respectively (Prasodjo, 2009, 2012). Allcollected data on household air pollution were compared withthe limit levels as recommended in the national regulation (i.e.,829=Menkes=SK=VII=1999) that was adapted from the WorldHealth Organization’s guidelines on the requirements for ahealthy house.

Follow-Up Study

The follow-up study included a behavioral change communi-cation campaign through advocate programs in 2011,followed by an evaluation study in 2012.

Fig. 3. A media communication to community about the Sei tradition and its consequences to health-related issues for mothers andchildren, in the Bahasa Indonesian language: the front (top panel) and back (bottom panel) sides of the brochure.

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Advocate Program

The advocate programs were developed by considering find-ings and recommendations obtained from the baseline study,particularly on the identification of health related issuescaused by the Sei traditional practices among the communityand the importance of social and cultural factors to the tra-dition. As reported in Prasodjo (2009), respiratory healthissues, household air pollution, and a reluctance to changeSei practices were all identified in the baseline study.

Behavior Change Communication Interventions

On the basis of findings from the baseline study, thefollow-up study developed promotional and educationalmaterials to improve community awareness on maternalhealth and the consequences of Sei traditional practice. Par-ticipatory action research was used to develop these beha-vior change communication materials and approaches.Participatory action research assists researchers and researchparticipants (e.g., the community) to work together duringthe project to improve or change the condition or situation(Cohen, Greenwood & Harkavay, 1992). In this study,

community stakeholders were gathered to discuss theirunderstanding about traditional practices (including Sei tra-dition) and to find strategies for adopting healthier behavior.This involved interpersonal communication, intersectoralmeetings, and coordination with local health departments,nongovernmental organizations, and community members(including families). Support was received from Nusa Teng-gara Timur provincial health office, Timor Tengah Selatandistrict health office, women’s society club (Sanggar SuaraPerempuan), Puskesmas Kie and Puskesmas Nulle, villageleaders, traditional births attendances, elders, and familiesin the study sites.

Consultations with local health staff identified healthissues related to the Sei tradition, as well as potential solu-tions. Families and wider communities were also instrumen-tal in designing the behavior change communicationmessages and channels, including designing the contentand wording of media materials, such as brochures (seeFigure 3; an English translation is provided in Figure 4).The information provided in the brochure aimed to encour-age the community to be aware of health issues in relation to

Fig. 4. Media communication to community about the Sei tradition and its consequences to health-related issues for mothers andchildren, translated from Bahasa Indonesian to English: the front (top panel) and back (bottom panel) sides of the brochure.

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Sei tradition, particularly on the issues of respiratory infection,burns and mortality of mothers and newborns, and to promoteconstruction of healthy traditional houses. The brochure con-tains three parts: (a) general information on short- andlong-term effects of Sei (smoke) tradition on health, (b) specificinformation on the effects of Sei tradition on newborn babies’health, and (c) specific information on the effects of Sei tra-dition on mother’s health. A culturally appropriate representa-tive picture and short messages in the local language wereincluded to facilitate understanding. The messages includedthe following content [English translation]:

‘‘Don’t Sei your mum, and neither your baby.’’‘‘Ume Kbubu should be used to keep foods, not to Sei

(smoke) yourself.’’‘‘Don’t Sei me; what I really need is a good care.’’‘‘Sei is not helping your body to rejuvenate, instead it

may cause you heat stroke.’’

After developing the promotional=educational materials,the next step was to identify the optimal channel to deliverthe message. In-depth interviews and roundtable discussionswith stakeholders revealed that fathers and grandmothershave the most influence over the mother and newborn withinthe family. Moreover, at the wider level the Timor communi-ties have traditionally high levels of respect and trust for thepriests, community leaders and health volunteers. Therefore,those stakeholders were chosen as the most effectivechannels for communication as a result of their ability toinfluence and approve changes to cultural practices in thecommunity.

The second phase of the behavior change communicationinterventions aimed to promote the adoption of a healthyUme Kbubu house in order to reduce the levels of householdair pollution experienced in the traditional Ume Kbubu. Thecommunities also helped design a healthy Ume Kbubu proto-type (see Figure 5). During a roundtable discussion, the localcommunity decided to redesign the traditional house by build-ing a new house rather than modifying an existing one. Thiswas due to most families being initially reluctant to offer theirtraditional house to be redesigned. The community activelyparticipated in redesigning this healthy house by taking intoaccount earlier findings and recommendations obtained fromthe baseline study. In terms of its construction, this redesignedhealthy Ume Kbubu has some differences with the old tra-ditional house while at the same time retained several key ele-ments. For example, the redesigned house has a betterventilation system with a proper high entrance door and win-dows. Yet, the redesigned house retains its main function as aplace to protect or preserve food stocks. Families wereencouraged to voluntarily accept a healthy Ume Kbubu andafter being informed about the household air pollution levelsinside their traditional house and the potential detrimentalhealth impacts among mothers and newborns.

Evaluation Study

The evaluation was conducted 1 year after implementationin 2012 to assess the effectiveness of the behavior changecommunication interventions. As with the baseline, a mixed

methods approach was used. Structured quantitative surveyswere conducted with 202 women who had given birth in thelast year. Of these, 81% (n¼ 163) had practiced Sei traditionand 19% (n¼ 39) had not. Information was collected onsocioeconomic background, knowledge, and public healthimplications related to the traditional behaviors. For thequalitative study, in-depth interviews were conducted with10 randomly selected mothers, of whom 5 were still practi-cing the Sei tradition at the time of interview and the other5 had completed the practice (Prasodjo, 2012).

Similar with the baseline study, the follow-up study alsocollected information on household air pollution from fourtraditional houses and one prototype of a redesigned healthyUme Kbubu for comparison purposes. In this case, the samemethods as used in the baseline survey were applied. Allhouses belonged to mothers who were doing Sei traditionat the time of observation in 2012.

Data Analysis

A descriptive analysis was applied for quantitative data. For thequalitative analysis, this study applied a triangulation approachby using thematic analysis. The data were transcribed and thenanalyzed using a matrix system (Hansen, 2006)

Results

Knowledge, Attitudes, and Practice: Healthy TraditionalUme Kbubu

During the follow-up study, the in-depth interviews conduc-ted with mothers and families showed that the majority of

Fig. 5. Process of building a healthy Ume Kbubu in TimorTengah Selatan District, Indonesia.

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the participants perceived Sei tradition as an importantelement in Timorese traditional practice. It has been prac-ticed for many generations by mothers after giving birth,and has continued due to the influence of parents and grand-parents, and sometimes fear of consequences for not partici-pating such as social stigma. Most participants believed thatthere are fundamental values attached to this tradition,which form a group symbol and kinship among family.

From the structured quantitative survey, there were somewomen (19%, n¼ 39) who had given birth in the past yearbut did not practice Sei tradition. These women indicatedthat marriage with other ethnic groups, medical conditions,or perceptions that the Sei tradition had no significant effectwere their main reasons for not practicing the behavior.

All respondents who practiced Sei tradition stated that itis believed to speed up the recovery process after giving birthby shrinking swollen tissues, drying up the blood and pre-venting bleeding. This practice was also recognized as oneway to achieve birth spacing, as it involves a separation per-iod between mother and her partner. Moreover, the infor-mants considered childbirth as a state of excess cold thatrequired special treatments such as Sei or smoke andtatobi—hot water massage on the belly—as stated by fourrespondents:

. . . a mother who just gave a birth has cold condition, thusshe has to do Sei tradition in order to keep her warm,besides the weather here is so cold, so it should be Sei.(Husband of FM1)

. . . doing Sei will make your body rejuvenate, whiletatobi or taking hot water bath will make you feel fresh . . .(Mother FM2)

Yes Sei tradition is still carried out here, so here mostof the hot water bath, the term is tatobi, use hot waterthat is placed in a large bowl, so that mothers get strongerfaster and prevent the white blood not to rise. (MotherFM3)

After my wife giving a birth, I will keep her warm andprepare burning firewood. Here, if we didn’t do Sei andtatobi then it will harm a mother’s life. She could notuse cold water for bathing because it could also harmher and even death, therefore Sei tradition should bedone. We believe that cold condition could increase thewhite blood levels for a mother. (Husband of FM4)

Some health related consequences were reported bymothers who practiced the Sei tradition. Respondents whohad practiced the tradition in the last year reported thatmothers and their babies suffered from health respiratoryproblems (i.e., coughing and wheezing) during the practice.

. . . indeed I often had coughing during Sei practice, andmy baby did too. However this is our tradition, so wehad to do it anyway. (Mother FM5)

The majority of the interviewed mothers stayed in thetraditional house Ume Kbubu for the Sei process. The main

reason reported for this was the constant warmth from thefire pit inside the house that created a comfortable placefor recovery. Another reason was the significant traditionalfunction of the house in Timorese culture. A few mothersreported using alternative locations and procedures. Alter-native locations included the Lopo (another Timorese tra-ditional house) and the main regular house known asrumah besar. The differences between Ume Kbubu and Lopohouses are in their physical structures and functions. TheUme Kbubu has a roof with sides that touch the groundand is the main place where people cook, store food, andsave seeds for the planting season. The Lopo has more openspace with short walls, and mainly functions as a living roomespecially to greet and receive guests.

In the follow-up study, there was tentative evidence tosuggest that behavior change communication in terms of dif-fusion of innovation of healthy traditional houses led tobehavior change. More mothers practiced the Sei traditionin an alternative place such as rumah besar or Lopo in thefollow-up compared to baseline. On average, the practicingmothers had done the Sei tradition for the duration of 21days compared with 26 days at baseline. A small proportionof mothers (15%, n¼ 24) have started to do Sei tradition foronly 4 days or less.

. . .since I heard about the dangers of Sei tradition to mybaby’s health, I did Sei tradition for my second child onlyfor 4 days; I also understand what village midwife hadalready told me about the danger. (Mother FM5)

. . .I follow my priest who told us in church about theeffect of 40 days Sei=smoke tradition to my baby’s health,so for my 3rd child I only did 3 days Sei tradition.(Mother FM1)

. . . since I live in my healthy traditional house, I feel thedifference, my house much brighter, we already have 2windows, it’s not humid anymore, due to this cementfloor. (Mother FM4)

In terms of the heat source used inside the traditionalhouse, some families had started to use charcoal embersunder the bed instead of burning firewood. As many familiesnow perceived that the main health concern related withtheir Sei tradition was due to the smoke inside the house,they have attempted to reduce the smoke levels by changingthe firewood pit inside the house with charcoal because it isbelieved to emit less smoke. There was also evidence that theduration of using a hot furnace or burning coal was alsoreduced. Based on the interviews, instead of a full 24hoursper day, the warm condition was only introduced by lightingthe fire pits=stoves during the night when the outsideweather was cold. The husband usually prepared firewoodin the afternoon, and then placed it inside the house beforethe night came. Such practices may have been associatedwith a reduction in air pollution as indicated from measuredindicators presented in Prasodjo (2012).

The results also show that the wider community benefitedfrom this intervention. For example, the staff from theDistrict Health Office and puskesmas indicated that they

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have more comprehensive knowledge about the effect of Seitradition on the health of mothers and babies, as well as itspossible effect on indoor air quality.

Household Air Pollution

At baseline, recorded household air pollution levels in tra-ditional houses did not comply with the standard of healthyindoor air quality. The range of concentration levels ofPM10 was very variable and was between 155 mg=m3 and1,370 mg=m3, which was higher than the limited standardlevel recommended by the Ministry of Health (i.e., 150 mg=m3). Significant variations in factors that contribute to levelsof household air pollution were seen at baseline—forexample, differences in how long the Sei had been in practicefor (i.e., early days or toward the end of 40th day), the size ofburning firewood (i.e., small or big), ventilation, floor type,and composition of households.

At follow-up, results indicated that concentration levelsof PM10, sulfur dioxide, nitrogen dioxide, and formalde-hyde were also variable but with lower median levels as com-pared with the medians at baseline. For example, the medianconcentration of PM10 was 122 mg=m3 at follow-up and315 mg=m3 at baseline. Overall, the concentration levels atfollow-up were lower in the prototype healthy-redesignedhouse as compared with the four traditional houses (Pra-sodjo, 2012). These results are from a very small sampleand the large variation in values suggests that the resultsare indicative only and should be interpreted with caution.

Development of Behavior Change CommunicationIntervention: Healthy Improved Ume Kbubu

The study originally aimed to introduce five prototypes ofhealthy-improved Ume Kbubu to the community. Becauseof some limitations in technical tools, budgetary aspects aswell as the number of volunteers, only one healthy UmeKbubu was introduced. Constructing the new healthy UmeKbubu cost 5 million Indonesian rupiah (around US$500).This amount is very expensive for the communities, whichhave an annual provincial gross domestic product of aboutUS$262 (Biro Pusat Statistik, 2010). Despite those chal-lenges, one community supported the process by contribu-ting their time and manual skills. They expressed that theprocess helped them to understand the community empow-erment program, the process of community empowerment,and the advantages of a healthy Ume Kbubu.

Despite evidence of behavior change with regard to lengthand location of Sei practices, some families were still reluctantto support these interventions. Many families said they werewilling to adopt it, yet poor education and low socioeconomiclevels were barriers to adoption of a healthy improved house.The families also expressed concern that the new Ume Kbubuwould no longer provide warmth during the cold weather, norprotect their crops and food stock.

Feedback from the local communities provided tworecommendations for future practice. Many families wouldlike to have more information written in the local languagein addition to Indonesian, which is currently used in the

brochure. The use of Indonesian language was initially doneto ensure understanding by the community leaders whocame from different cultural backgrounds. For the healthyUme Kbubu, the house structure should be redesigned in away that maintains its original structure and compositionbecause of its significant traditional function as indicatedin McWilliam (2002) and Windi and Whittaker (2012). Moreimportant, the house should be used to protect the family aswell as to preserve their harvests.

Discussion

Preliminary findings from this study identify a range ofhealth concerns relating to high levels of indoor air pollutionin the traditional house Ume Kbubu, where mothers prac-ticed the Sei tradition. At the same time, this tradition is stillperceived as an important element in Timorese traditionalpractice. Therefore, a communication-focused behaviorchange intervention was introduced to foster conversion oftraditional houses into healthy Ume Kbubu, and promotechanges to traditional practices for better health outcomes.

For many Timorese, leaving Ume Kbubu is considered toomit the essence of the past. Promoting behavior changes inrelation to maternal, child and newborn health behavior inrelation to entrenched traditional practices is a complex pro-cess that requires an awareness and respect of the signifi-cance of these practices in the community as well as anunderstanding of the realities, sociocultural variables andenvironmental factors. Strategies need to accommodate theexisting behavior practiced and acknowledged by the com-munities. From the baseline study in 2009, we identifiedand understood the behaviors which were having negativehealth impacts. Accordingly, the behavior change communi-cation plans were designed by considering the observed riskfactors related to the health of the mother and newborn.

Among the Timor population, the Sei tradition wastraditionally done for up to 40 days. Because of that, manyhealth services for postnatal mothers and babies, such aschildhood immunization, could not be provided effectively.This tradition is still difficult to eliminate in some villages,such as Boti (Timor Tengah Selatan district) and Hauteas(Timor Tengah Utara district) where the communities haveretained monarchy and traditional systems in which theheads of village are their leaders. Many mothers from Botitribe, who prefer to have care from traditional healers, haveinsisted on following the Sei tradition even though it wasdiscouraged by the village midwives.

The assessments of household air pollution in the existingtraditional houses Ume Kbubu suggest that levels of severalpollutants are far above the recommendations for a healthyhouse as stated by the Indonesian Ministry of Health (1999)or the World Health Organization (2014). This is due to thefire pit inside the house that produces unhealthy gases andsmoke, as well as poor ventilation. Nevertheless, theextremely variable results were from a very small sample sizeand so can only be interpreted as indicative and notconclusive evidence of the household air pollution in thesetraditional houses. These preliminary findings were

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presented to and discussed with involved stakeholders in thecommunity. It has therefore increased their understandingabout traditional practices (i.e., Sei tradition). At the sametime, some families started to use an alternative practice ofthe Sei tradition by using a charcoal ember instead of burn-ing firewood. Such practice requires further investigation toensure that it is not exposing the mothers and babies todangerously high levels of carbon monoxide. Further studiesare needed to conduct personal exposure monitoring for thewoman and child during the Sei tradition, to get robust dataon their exposure at baseline and postintervention (whichmight include shortening the duration, increasing ventilationand making other affordable culturally appropriate changesto the traditional Ume Kbubu).

The participatory action research, which involved thewider community to develop a brochure on the healthimpacts of Sei tradition and to introduce a prototype of ahealthy traditional house Ume Kbubu, demonstrated severalimportant findings. The behavior change strategy success-fully engaged the Timorese community, through consul-tation and involvement, as indicated by their willingness tosupport and adopt the interventions. Some families havealready used healthy traditional houses Ume Kbubu thathave more ventilation to help reduce levels of householdair pollution, and there has been a shift toward reducingthe length of the Sei tradition from the first 40 days afterthe baby was born to an average of 21 days (Prasodjo, 2012).

Some challenges were also identified in this study. Thehealthy redesigned Ume Kbubu is considered expensive formany rural communities that are dominated by poor famil-ies. It is not surprising that some families are still reluctant toadopt this approach. Therefore, a more cost efficient alterna-tive is needed. The study found that some families used alter-native places such as rumah besar or Lopo for doing theirSei tradition. Other alternatives would be using simplelocally available materials that can be easily found for build-ing the healthy Ume Kbubu, rather than using modernmaterials such as bricks and cement as was done for theprototype house. As a result, the cost could be reduced whilemaintaining its traditional function.

Conclusion

This study has shown that traditional behaviors can be chan-ged by using participatory approaches. At the level of pre-vention, behavior change has been identified as a possibleintervention strategy to reduce the effect of household airpollution on the health of mothers and children. In this case,introduction of a healthy traditional house was communi-cated to the wider community, and early adopters whostarted to change their traditional practices were identified.The strategy showed preliminary evidence of reducing theduration of Sei tradition from 40 days to only 4 days witha postintervention average of 21 days. It is hoped with con-tinued behavior change communication intervention suchchanges in practices become more accepted and durationof exposure to high levels of household air pollution arereduced to improve the health status of communities, parti-cularly mothers and newborn babies.

In summary, this current study has implications forfurther research. The preliminary study highlighted thatTimorese women practiced Sei in the traditional house,which has many negative consequences. Some preliminarychanges in Sei practice, including shorting the period’slength and attempting to reduce household air pollution,have been seen after the behavior change communicationintervention. To determine the current extent of traditionalSei practices among women, as well as the effect on house-hold air pollution levels and health, a larger study with morerobust household air pollution monitoring is required. Thiswill provide further evidence on the relationship betweentraditional practices and maternal=children’s health andmorbidity among the Timorese population. It is also recom-mended that more collaboration between the government,the community and all related stakeholders is needed tocommunicate and socialize the implementation of thehealthy house.

Acknowledgments

The authors acknowledge the support received fromIndonesian Ministry of Health, particularly the Center forPublic Health Intervention Technology from the NationalInstitute of Health Research and Development, and the NusaTenggara Timur Provincial Health Office as well as theTimor Tengah Selatan District Health Office in conductingthe study. Special thanks are also given to the research team,mothers, families, and all stakeholders who participated inand contributed to this study.

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