formative study: health communication program...

Formative Study: Health Communication Program Development

For Aceh – North Sumatera Relief/Rehabilitation

Center for Communication Programs (CCP) Johns Hopkins Bloomberg School of Public Health

INDONESIA

Collaboration with Universitas Muhammadiyah, Banda Aceh

February – March 2005

Center for Communication Programs-Johns Hopkins Bloomberg School of Public Health - 1

Formative Research For Health Communication Program Development

For Aceh – North Sumatera Relief / Rehabilitation February – March 2005

I. Introduction In responding to the Aceh/Sumut emergency, the January MOH/WHO Reproductive Health/Nutrition/Child Health donors’ coordination meeting requested Johns Hopkins University to develop a communication strategy to orchestrate the delivery of effective health message for the people in the affected areas. The messages will include reproductive health, nutrition, child health, hygiene improvement, sanitation and other priority issues as identified for medium and long term communication activities. II. Problem Statement The Tsunami has resulted in around 400,000 people living in refugee camps. Now they still live in very simple tents, which do not fulfill the healthy standards of living. The lack of clean water, healthy waste and sewage disposal aggravate their health.

The common diseases are diarrhea, acute respiratory infection, dengue, malaria, tuberculosis, scabies etc. Bad sanitation and hygiene would worsen the incidence of these diseases. Other problem might also happen such as poor food intake, especially among pregnant mothers and under-fives. It is predicted that the distribution of food is not well planned and also most people are poor because they lost everything during the tsunami, including their belongings and also their jobs. The stock of drugs, vaccines and contraception also decreased, because some of the puskesmas, hospital and storerooms were swept away by the tsunami. The temporary IDP camps maybe far from the existing health facilities and the transportation system still needs to be improved. It seems that providing simple health facilities in the refugee camps are needed and effective health messages are needed to improve access and use. With the uncertain environment and situation, it is imperative that people receive accurate, understandable, and consistent messages, and not be confused by crossed messages or misinformation. With so many organizations working in the area, it would be very easy to send mixed messages and confusing information. To address this demand issue, there is a need to develop an integrated and comprehensive communication program to increase the availability of information concerning health among the population in the affected areas of Aceh and North Sumatra. With such an strategic communication plan that could orchestrate the messages around health, correct and relevant information can be provided to the affected population on matters of public health, prevention of diseases, and other relief oriented information through one outlet of information for the efforts being implemented in the medium and long term. JHU and its team will collaborate with the organizations working on the ground such as WHO, UNICEF, UNFA, Care International, USAID, Local NGOs, Dinas Kesehatan and BKKBN


to help standardized messages and materials. This will include a communication strategy to provide communication support for all of the programs working in the health area. III. Objectives The objective of this planning process activity is to develop an integrated and comprehensive communication program to provide critical health information to the affected population and also the health providers in those areas. The strategic communication plan: (1) Will provide correct and relevant information on public health, prevention and other

relief-oriented information; (2) Will serve as a coordinated source of messages and information for relief and

rehabilitation efforts being implemented in the medium and long term; (3) Will be the complementary with the ongoing health promotion in those areas, and (4) Should build capacity among local government and NGO partners. IV. Communication Program Development Approach To address the need of health messages to be disseminated to the target population, a strategic communication plan will be developed using the P-Process framework which follow the 5 steps as follows:

1. Analysis: Situation and audience/communication analysis.

2. Strategic design: Communication objectives, program approach and positioning, channel identification, implementation plan and monitoring & evaluation plan.

3. Development and Testing

4. Implementation and Monitoring

5. Evaluation and Re-planning

The process will emphasize participation and fully engage multiple partners and consider ways to build capacity strengthening at the institutional and community level. One of the initial stages of the overall activities is to conduct formative study to understand audiences’ needs and priorities as a base information and foundation for developing the communication program and messages. Formative research includes reviews existing research studies, pre-testing concept and messages, or trying out a program on a small scale before full implementation. The specific objectives of the study are to look at the health problems of the target population, the health services available, and source of health information. The details of these study areas are: A. Health Problem Aspect

• To identify health problems faced before and after the disaster • To identify health problems perceived as the most important and need the

most priority


B. Population in refugee camps

• To identify health problems faced by refugee (before and after the disaster) • To identify health seeking behavior of the refugee • To identify health services, facilities and providers utilized by the refugee • Picture of day to day activities of the refugee

C. Health Services Aspect

1. Actual Services To identify: • Existing health services, facilities and providers • The capacity of the services (equipment, products) • Type of the services available (FP; immunization; pregnancy, etc) • Type of utilization by the client (most used before and after)

2. Potential Services

To identify: • Potential/alternative health services, facilities and providers • The potential capacity of the services • Type of the potential services • Type of potential utilization • Support needed:

o Product o Type of Training, etc.

D. Source of Health Information Aspect

1. Actual Sources To identify: • Existing source of health information • The capacity of the sources (meaning geographic coverage) • Type of content • Type of the medium • Type of utilization by client and provider

2. Potential Sources

To identify: • Potential/alternative source of health information (including existing actual

information channel which has not been utilized for disseminating health information and promotion)

• The potential capacity • Type of content that can be disseminated • Type of utilization • Support needed:


o Materials o Production means o Trainings, etc.

All these information should provide:

• Mapping of the major health issues

• Mapping of health services available and needed o Type of health services o Actors involved

• Mapping of information sources available and needed o Type of information o actors involved

• Mapping of the potential health services (to close the gap with needs identified)

• Mapping of the potential information sources (to close the gap with needs identified)

With these maps, a strategic communication plan will be developed that includes:

• Formulation of the key messages and the priority • Identification of the communication channel and format • Identification of the actors and their function • Formulation of the media distribution model • Formulation of the monitoring and evaluation activities

V.1. The Data Collection Methods

The study will be conducted by using several data collection methods as follows:

1. Compilation of existing health data for Aceh To collect statistical data, report and documents related to the subjects of the study (current diseases; availability of services, service use, quality of services, etc).

2. Focus Group Discussion The FGD will be carried out with the informant in the locations with different characteristic:

a. Refugee in the camp b. People who live outside the camp

3. In-depth Interview

A. Agents and actor in the field: a. Government Health Offices b. Health providers c. Volunteers and NGO with activities related to health issues d. Informal leaders


B. One informant from each FGD will be interviewed individually to elaborate the information and issues raised from the FGD

V.2. Location of Study and respondent/Informants

The study will be conducted in two locations: 1. Banda Aceh, to represent urban area 2. Meulaboh, to represent rural and remote area

Within these locations, two major groups of respondent will be selected:

• Refugees in the camps • People who live outside the camps

The following table describes the complete list of the respondents/informants. Tabel # 1. Location, target, Lokasi, sasaran, collection method and total sample. Formative study, Aceh, 2005. Location, target and collection method

Banda Aceh Aceh Barat

Penampungan Penampungan Kecamatan Ule Kareng

Penampungan Kompi C, Kota Meulaboh

FGD group of men 5 5

FGD group of women 5 5

Indepth interview for each group FGD

2 2

Interview with Government health office

1 1

Interview with Volunteer 2 2

Interview with Health provider

1 1

Interview with Informal leader

1 1

Pemukiman Kecamatan Blower Kecamatan Meureuboh

FGD group of men 5 5

FGD group of women 5 5

Indepth interview for each group FGD

2 2

Interview with Health provider

1 1

Interview with Informal leader

1 1


VI. Main Findings VI.1. Washing Hands VI.1.1 Behavior Washing hands before or after a particular action that can cause contamination has not become a habit of the community. Even those who have practiced the habit of washing hands do not always practice it in their daily activities. Activities that involve washing hands are:

• After working • Before eating • Before cooking and preparing a meal • Before feeding children • Before taking care of children

Activities followed by washing hands, such as washing a baby’s or child’s bottom after defecating or urinating did not show up in the FGD. Excerpts from several FGDs are:

“...well, of course always...(wash hands)...well, after working.”(Men FGD Banda Aceh Housing)

“Sometimes...after gotong royong (collaborative community work), when our hands are full of dirt, when we want to eat.”(Men FGD Banda Aceh shelters)

“Every time after holding dirty objects, then we wash our hands.”(In-depth Interview of Banda Aceh Community Leader)

“So it’s clean before we eat. When our hands are dirty, we wash them. When we want to feed the children, when we want to hold them.”(Women FGD Banda Aceh Housing)

“...for instance, when we want to bake a cake.” (In-depth Interview of woman in Meulaboh Housing) “...when we want to eat, wash rice, when our hands are dirty, ...when we are going to handle food (cooking).”(Women FGD Banda Aceh shelters) “...When we are going to cook rice, eat, eat bread, want to get some food.”(Women FGD Meulaboh shelters)

The men do not seem to care much on washing their hands. They tend to wash their hands for working activities. Even those who do wash their hands do not feel the need to do it perfectly.


“...well, we use the available water. There is no specific place for washing hands. Don’t need to bother. Use what is available...”(Men FGD Banda Aceh shelters) The place for washing hands...is unavailable, there is no place anywhere (for washing hands) it’s like at our own home, when we want to wash our hands we have to fetch the water.”(Men FGD Meulaboh shelters)

People of the community do not always use soap for washing their hands.

“We do use soap...sometimes.”(Women FGD Meulaboh shelters) “Sometimes (use soap).”(In-depth Interview of woman in Meulaboh Housing) “We have none (place for washing hands), we use tap water in our own house. The tap could be anywhere, it doesn’t have to be inside the house.” (Women FGD Banda Aceh Housing) “Always use soap...for washing hands...use bath soap. We buy the bath soap.” (Women FGD Banda Aceh Housing)

The activity of washing hands using soap is usually done when they are taking a bath.

“...we use soap when we take a bath...currently there are no (private) open well...we have to queue. This is somebody’s well it’s their property. They are very nice indeed, letting us to use it.” (Women FGD Banda Aceh Housing)

In places other than these shelters, besides queuing usually the quality of the water to use for bathing (or washing hands) is frequently bad (has an odor).

“… the location is far, the water smells bad.” (Women FGD Banda Aceh Housing)

VI. 1.2 Barriers It seems that washing hands is only related to cleanliness, not to the possibility of contamination that can cause diseases transmitted through food, drinks, or direct contact. This is shown by FGD results which does not show their concern about being infected by diseases when discussing the issue of washing hands (see the aforementioned excerpts on washing hands). It seems that the use of soap has not been considered as beneficial for most people. They do not specifically provide soap for washing their hands. If they have soap they will use it but if they don’t, they will try to find some.

“...Sometimes we don’t use soap, just wash it clean.” (Women FGD Banda Aceh shelters)


“...yes, we use soap when we have some, if we don’t have any we don’t use soap. Well, just naturally.” (Men FGD Banda Aceh shelters)

“...Sometimes we use soap, sometimes we don’t, there’s no soap for washing our hands, we even don’t have soap for washing our clothes.” (Men FGD Meulaboh shelters)

Soap is not always available in the shelter’s bathrooms. The people must bring their own soap. Sometimes soap is distributed in the shelters, but findings from the FGDs showed that people in the shelters often do not have soap.

“...of course not...there is no soap. We have to bring it ourselves...there’s only a well (available), we have to fetch the water ourselves.” (Women FGD Banda Aceh shelters)

“None is available in the (public) bathrooms, we bring our own soap. Only water is available. (Women FGD Meulaboh shelters)

The people who are used to wash their hands using soap still depends on the supply of distributed soaps, which are not always available.

“...yes, there is...(soap), it’s specially supplied. The supply is from Mata’I (name of a large shelter)...yes. Currently it’s available. But they said within a week it would no longer be available. (Men FGD Banda Aceh Housing)

The people do not have any specific place for washing hands. The place for washing hands that are mentioned most frequently are public bathrooms, or open wells that can still be used, or where people wash themselves before praying in a mosque. Most people wash their hands using distributed waters stored in water containers.

“...in mosques, mosque’s water taps, from water taps.”(Men FGD Banda Aceh Housing) “...none. We find it ourselves. In the past, it was better at home we had soap and soap holders.” (Women FGD Banda Aceh shelters) “...None, we provide our own (water) when we want to eat.” (Women FGD Meulaboh shelters)

VI.2. Clean Water VI.2.1. Behavior Clean water for drinking is acquired by people in the shelters and housings from various sources such as distribution from water tank trucks, or bottled water supplied from aid or purchased by the people themselves.


“...now there is no more. At first there were many bottled water...Some from Australia, but most came from Turkey.” (Women FGD Banda Aceh shelters) “...well, we buy a bottle if we have the money. If not then we don’t drink. Then we try to find water to fulfill our needs during living in the tent.” (Men FGD Banda Aceh shelters)

Usually, the people boil clean water for drinking, although the water is ready-to-drink but it is still boiled. They do this because they consider boiled water is best.

“...I believe water must be boiled first. Although it’s already bottled, we still have to boil it. This will kill the germs...” (Women FGD Banda Aceh shelters)

The victims who live in housings are also provided with drinking water from PDAM (Local Drinking Water Company), or they buy bottled water themselves.

“The source is...PDAM. But it’s not clean, we must buy water ourselves.”(Women FGD Banda Aceh Housing)

Usually water is stored inside water jugs or a covered bucket.

“To prevent it from flies we cover it. To prevent it from dust. But we don’t keep it for days. Usually we keep one bucket a day.” (Women FGD Banda Aceh Housing) “...we receive water and then put it inside jugs, bottles, and buckets.” (Men FGD Banda Aceh shelters)

Besides water supply distributed through tank trucks, the people also receive water-purifying substances in form of chlorine dispersed into the water used for drinking. But the people do not like this chlorinated water, because of its medicated odor and causes the water to become cloudy. Activities that usually require clean water are cooking and drinking. While activities that do not require clean water are washing clothes, washing cooking appliances, bathing, and washing private parts.

(Q)What are the activities performed using clean water? (A) Cooking, drinking (Q) Can turbid water be used for washing? (A) Yes...for washing, but it causes itches if used for

bathing. The water used for washing flows down there.” (Women FGD Banda Aceh shelters)

“(Water that is not so clean) is used for our needs in the bathroom, for washing clothes, for bathing.” (Men FGD Meulaboh shelters)


VI. 2.2 Barriers A number of people does not have sufficient knowledge on the significance of boiling water prior for drinking water, because they believe that they have already maintained the cleanliness of the water source. On the contrary, some do not understand that bottled water does not need to be boiled.

“Before the tsunami we had our own well, we maintained it. We can drink water directly from the well without boiling the water first, it didn’t cause diarrhea, but now it instantly causes diarrhea.” (Women FGD Banda Aceh shelters) “To my opinion water should be boiled first. Although it’s bottled water, we still have to boil it. In order to kill the germs...” (Women FGD Banda Aceh shelters)

Water from PDAM and wells are usually turbid and cannot be consumed as drinking water, it even causes itches when used for bathing. People usually use it for washing clothes.

“The source...PDAM. It’s not clean, we must buy water ourselves.”(Women FGD Banda Aceh Housing)

“The water from PDAM is turbid and smells.” (In-depth interview of woman in Meulaboh Housing) “The water from water taps is turbid, the water from a well cannot be used any longer, and it’s very dirty. Contains lots of mud.” (Men FGD Banda Aceh Housing) “...tap water. Sometimes bottled water is available. The well has not yet functioned. On average, it’s very dirty.” (Men FGD Banda Aceh Housing) “Water from the well...tastes salty and the color is yellow.” (Women FGD Meulaboh Housing)

Compared to the water availability in shelters, there is less water in housing areas. The water truck only comes twice a week, and the people cannot carry water in sufficient amount due to the distance from where they reside. They hope for the availability of clean water in a sufficient amount.

“The water tank truck comes twice a week from the Posko (Command Post)”(Women FGD Meulaboh Shelters) “...clean water, water is critically needed. Water for drinking.” (Men FGD Banda Aceh Housing) “The issue of clean water has to be considered soon, because clean water is highly needed by the people now, for drinking


we buy bottled water.” (In-depth Interview of woman in Banda Aceh Housing) “We are willing to fetch more water, but there are no containers available...one family has only two jugs, that’s not enough, it’s not enough for drinking or bathing.” (Women FGD Meulaboh Housing) “Yes, we made a well then we built a filter and we boiled the water, but there are risks because the water in areas hit by the tsunami cannot be used”. (Men FGD Meulaboh Shelters) “...Please PDAM, provide water as it used to be.” (Women FGD Banda Aceh Housing)

Dissemination of information on the usage of chlorine as a water-purifying agent does not seem to run well. The people who are already aware of purifying water by using chlorine consider the water has a medicated odor and is cloudy. Meanwhile, the parties who distribute the agent to the people say that the complaint on turbidity is caused by the people’s lack of skill in dispersing the agent correctly.

“The water has medicated odor and is cloudy.”(Women FGD Meulaboh Shelters) “ The people from CARE said that it isn’t sterile yet. The water is turbid. So now CARE helps by adding agents. After this we don’t know what’s it like. After 25 minutes of treatment, the water becomes clear.” (Men FGD Banda Aceh Shelters - Pretest) “According to me clean water is not cloudy, odorless, and clear.” (In-depth Interview of woman in Banda Aceh Housing)

VI.3. Sanitation VI.3.1 Disposal of Human Waste (Feces) VI.3.1.1. Habits Related to Feces Disposal The tsunami survivors at the shelters relieve themselves in toilets, canals, ditches, and streams or on the ground of open fields.

“The (WC)...is available and good.” (Men FGD Banda Aceh Shelters) “The children relieve themselves in ditches or on open ground.” (Women FGD Banda Aceh Shelters) (Q) what if the children do not have the chance to relieve

themselves in the toilets?


(A) They do it in the ditches. (Q) Is it removed, or left there? (A) It is left there, in canals or ditches. It will then be

swept away by itself.(Women FGD Banda Aceh Shelters)

In housing locations, they do not relieve themselves in toilets, but in open fields, canals or “Floating Toilets”.

“We relieve ourselves in the bushes and in lueng (canals).” (Women FGD Meulaboh Housing) Q : Are there facilities available here for urinating or

defecating? A : No Q : So, how do people relieve themselves every day? A : Anywhere, if a WC is not available we use the ‘floating

toilets’. Q : What about at your own house, is there a toilet? A : It depends if we can afford it we can make a toilet, if

we have money, if not we go out to relieve ourselves. (Men FGD Meulaboh Housing)

Q : Where do you go for defecating and urinating? A : To the canals (lueng) Q : No toilets available? A : None, everyone relieves themselves in the canals. Q : Is there a bathroom in this house? A : Yes, one is built at the back Q : Inside or outside the house? A : There used to be one inside the house, we cannot build

one now there are no wood planks available. (In-depth Interview of woman in Meulaboh Housing) “The people living by the river have some difficulty to relieve themselves at an appropriate place”. (Interview with Meulaboh health worker) “The toilet is clogged. We defecate using ‘floating toilets’.” (Women FGD Banda Aceh Housing)

In this area infants below the age of five years old seldom wear disposable diapers. They usually use diapers made out of cloth that is washed in the place used for washing clothes. The activity of washing diapers is usually done at a well, public bathrooms or where people wash themselves before praying at mosques.

“...water from the well.” (Women FGD Banda Aceh Housing) If disposable diapers are used then it is usually disposed in a garbage bin, a ditch, or burned immediately.


(Q) “Where are the baby’s diapers usually disposed?” (A) ”...into a garbage can, then it is burned”. (Women FGD Banda Aceh Housing) “Usually it’s put inside a plastic bag then thrown into the river.” (Men FGD Banda Aceh Housing)

(Q) “Where are the baby’s diapers usually disposed?” (A) ”...into a garbage can, then it is burned”. (Men FGD Meulaboh Housing)

VI.3.1.2 Barriers on Behavior Related to Disposal of Feces The issues on defecating and urinating are significant at both shelters and housing. At the shelters, this issue is related to the disproportional ratio of toilets to the total of people located. Thus, when the urge to defecate is unbearable, they relieve themselves on an open or empty field (particularly at night).

“It’s crowded during the day...we must queue. Sometimes we defecate while waiting. This is worse when we get diarrhea if it’s normal then it’s OK to wait for up to two hours. When we have diarrhea, sometimes we defecate while waiting.” (Women FGD Banda Aceh Shelters) “Well, we must queue. We even don’t have time to do our afternoon prayers.”(Women FGD Meulaboh Shelters)

“There are always people anytime, it is never vacant. This time is the most crowded time, in the afternoon. In the morning and afternoon, it’s full from 3 to 6. Even at 10 o’clock in the evening, people still queue.” (Women FGD Meulaboh Shelters)

“Well, we used to bathe 3 times a day then we were clean, now we cannot bathe cleanly. There’s only one bathroom for the men, and one for the women. Every time we go there, it’s always full. How can we have a clean bath? For instance when we want to take a morning bath, we have to postpone it because the bathrooms are always full, so in this tent we can only take a bath once, and our body becomes dirtier. We must even queue for defecating. Usually at home, we can have a clean bath. We can have a bath in the morning another bath at noon, then put on some facial powder, sit down and relax, isn’t that pleasant. Now we can’t do that here.” (In-depth Interview with woman at Meulaboh Shelters)

The hygiene of the toilets in the shelters is not guaranteed. Several toilets are not clean, which are considered unhealthy for children.


“The toilets are rather unsuitable for children, because there are many germs.” (Women FGD Banda Aceh Shelters)

At urban residential areas, bathrooms are usually located inside the house. After the tsunami, the bathroom is used for bathing and washing because the water disposal can seep into the ground, but it cannot be used for defecating/urinating, because the disposal line is still clogged with mud. This problem becomes more complex because the disposal does not only involve existing defecation/urination facility at homes, but also the disposal line outside the houses (ditches/canals/streams). So even though their house’s defecation/urination facility has been cleaned, they still cannot use it because the disposal line outside the house is clogged by mud.

“There is none, because bathrooms are destroyed and many toilets are clogged.”(Women FGD Banda Aceh Housing) “The wells of mosques are used. We bring our own soap and water bucket.” (Women FGD Banda Aceh Housing) “Well, here’s an example, when defecating no water is available. People relieve themselves everywhere. So toilets must be provided and water must be available everyday.” (Women FGD Banda Aceh Housing)

VI. 3.2. Garbage Disposal VI. 3.2.1. Behavior Related to Garbage Disposal At urban shelters (in Banda Aceh) garbage is usually collected in plastic bags and transported regularly, while in rural shelters (in Meulaboh), garbage is usually disposed into a hole dugout in the ground then burned.

“The garbage from each tent? Plastic bags are given then collected gradually, wet garbage such as vegetables is buried, and dry garbage such as paper and noodle packages is burned. (Women FGD Meulaboh Shelters) “...it’s collected, later someone picks it up to be disposed to a place we don’t know.” (Women FGD Banda Aceh Shelters)

At urban housing, prior to the tsunami there was a garbage disposal system just like any other cities. Each house has a garbage collection bin that is transported regularly by a garbage truck and collected to the garbage disposal locations. But now after the tsunami the garbage collection bins are damaged. Now, to prevent garbage from piling up the people usually burn it.

“It’s collected nearby the house, then burned.”(In-depth Interview of woman at Meulaboh Housing) (Q) “where is the garbage disposed?”


(A) “into the garbage bin of course. We used to dispose the garbage into the river. Now we are no longer allowed to do that...(Now) it’s burned.”

(Women FGD Banda Aceh Housing) “...formerly there was (routinely) garbage transporter. After the tsunami, there’s no more.” (Women FGD Banda Aceh Housing) (Q) how is it transported? (A) by motorbike (Q) when? In how many days is it taken? (A) There’s no routine when it’s already full, once in several days, when the garbage is piled up and collected, it’s burned (Women FGD Banda Aceh Shelters)

“No proper garbage disposal is available yet, there are many mosquitoes. There was once a Japanese team who performed fogging.” (Men FGD Banda Aceh Housing)

The efforts they do among themselves to prevent the family from becoming sick and to keep them in healthy condition are maintaining the quality of food and preserve the environment.

“Food is kept safe by covering it so it’s prevented from flies.” (Men FGD Banda Aceh Shelters) “As I just mentioned, a clean environment is automatically healthy then obtain nutritious food. Here’s an example, if we eat chicken and vegetables but there are flies then that indicates it’s dirty. See this woman, she used to be healthy and plump but now she’s skinny.” (Women FGD Banda Aceh Housing) “In this case, the worst affected are children, pregnant women and breastfeeding mothers. Actions to take are to maintain cleanliness of the environment and obtain nutritious food.” (In-depth Interview of woman in Meulaboh Shelters)

“Maintain a clean environment and provide supplementary food for breastfeeding women. Especially the environment if it’s clean then it will automatically bring in clean air, especially for the children.” (Women FGD Banda Aceh Housing) “Currently, we cannot say it’s good or bad, why? Because of the condition after the tsunami. Before the tsunami, head of villages actively controls their areas for example if a dirty area needs to be cleaned the people will have to clean it. The village of Pasi for example, needed water channels so the water can flow smoothly, the people of the village were gathered, if they are incapable they will inform the head of


their village to contact the head of other villages, in order to obtain their goals.” (In-depth Interview of a man in the Meulaboh Housing)

VI. 3.2.2. Barriers related to the Behavior of Garbage Disposal After the tsunami, garbage bins in urban residential areas were also one of the facilities that was ruined. The disaster locations that were cleaned only touched areas of the main roads. Meanwhile small roads, alleys, also ditches were not taken care of. According to the public it can cause various diseases.

“... what we need now are not just clean main roads, but the ditches also need to be cleaned too because it causes many mosquitoes and flies. During the evening, we burn the garbage to reduce mosquitoes. Now we see that the roads can be used. But the alleys, are like this.” (In-depth Interview of Banda Aceh Community Leader)

The people also experience areas with bad sanitation, due to the piling of garbage that is a threat to children’s health. And becomes worse because the children frequently play near garbage bins.

(A) There are many (diseases) such as diarrhea, malaria (Q) How does it happen? (A) Children often play near the garbage bins. (Men FGD Meulaboh Housing)

Some people still consider the habit of disposing garbage as a personal responsibility, so they only dispose garbage from their own house. Other people even commercialize the activity of cleaning up the garbage.

“Temporarily, we have done it. But why should we clean up other people’s houses?” (Men FGD Banda Aceh Housing) “If we ask someone to clean a house...we have lifted it from inside to outside the house...He asked for twenty thousand rupiahs for one house.” (In-depth Interview of Banda Aceh Community Leader)

This becomes more complicated due to the fact that the community has not adapted maintaining cleanliness to become an attitude and behavior. So the effort performed by particular parties sometimes has no meaning because other parties do not participate in maintaining cleanliness.

“It’s difficult, I want it to be clean (by disposing garbage) ... but my neighbor doesn’t do so.” (Women FGD Meulaboh Shelters)

“For the time being, as at the front of my house, I clean it myself, but if the neighbors do not do so, it will have no


effect, for instance many of our neighbors have evacuated, so there should be a special team to do the cleaning.” (In-depth Interview of woman in Banda Aceh Housing) “So...we clean up the front of our house...to prevent diseases. There should also be (preferably) collaborative community work (gotong royong) too.” (In-depth Interview of Banda Aceh Community Leader) (Q) “Can you mention what kind of collaborations are there?” (A) “Collaborative community work, disposing, burning, planting garbage, overall the disposal of dirty objects is disposed far away from us in order to prevent diseases. The wells should not leave a puddle. Previously each tent had a well, but now it has to be covered up because no more wells are allowed. If there is a well and we do our washing there the water forms a puddle and the water can’t flow.” (Women FGD Meulaboh Shelters)

To maintain family health, informants stated the need of action to collectively clean the area. But they also complained that not everyone were aware of this issue. For example, sometimes it’s difficult to maintain cleanliness in the shelters, because their neighbors might not do the same, so the environment stays dirty and unhealthy.

“For the time being, as at the front of my house, I clean it myself, but if the neighbors don’t do so, it will have no effect, for instance, many of our neighbors have evacuated, so there should be a special team to do the cleaning.” (In-depth Interview of woman in Banda Aceh Housing)

Even those who are aware and are willing to clean the environment collectively still face problems such as lack of tools and sufficient garbage transporter.

“There’s no hoe, but we are given a shovel, a cart, an axe, a saw, a hammer, and 5 (five) kilos of nails, but that’s not enough and it’s not distributed evenly. The most important part is a wheeled cart to transport goods, from Pasi alley we have nothing left, we don’t even have an axe to cut down trees.” (Men FGD Meulaboh Shelters)

VI.4. Maternal and Child Health VI. 4. 1. Behavior Based on observations at Meureuboh, a village in Meulaboh, the awareness on maternal and child health is still low. Babies are born attended by village midwives and are not vaccinated. The babies are then bathed using dirty water from a well. The cloth to wrap the baby is also dirty. The mother and baby sleep on a thin cloth spread on concrete floor.


The most common and mostly found maternal and child health issue is malnutrition. Breastfeeding mothers with malnutrition cannot provide breast milk with good quality while many children suffer from diarrhea due to food with low quality.

(Q) Are there any breastfeeding mothers? (A) Yes, it’s a big problem because they lack food. (Men FGD Meulaboh Shelters) “But here we are only given instant noodles, we eat that everyday, it damages our stomach...It causes diarrhea.” (Men FGD Meulaboh Shelters) “Lack of nutrition reduces breast milk.” (Women FGD Banda Aceh Housing) “nutrition...Well, if aid is available then we’ll distribute it to the people. If there is no aid, then we use what’s available.” (In-depth Interview of Meulaboh health worker) “The need of staple food is also important because there are mothers who breastfeed their child and highly needs it for the development of her child.” (In-depth Woman Interview of Meulaboh Housing) “...often has pain in my waist, anemia, it’s because I sleep in a place like this, and in a condition like this (pregnant).” (Women FGD Meulaboh Shelters)

Due to health facilities that are destroyed and the missing staff (including health services for pregnant mothers), the activity of pregnancy examination becomes difficult. In the shelters, services for pregnant women are not always at hand because it is mostly for general health services. At places where health services still operate, pregnant women living nearby still use them.

(Q) During your pregnancy, have you had any health problems? (A) diarrhea (Q) ...how do you maintain your health? (A) if I have a health problem then I go to a hospital or a

community health center (Women FGD Banda Aceh Shelters)

But at these places the equipment and medicine to attend pregnant women are still limited.

“for maternal and child health, at this moment there are no special equipment for pregnant women at the community health centers. But in this case we advice the women to visit community health centers and if they are not willing to go there, they can still be examined at a midwife’s house.” (In-depth Interview of Meulaboh Health Worker)


(Q) Where do you usually go for pregnancy examination? (A) At the Community Health Centers (Puskesmas) also...Now

there are no more Puskesmas. (Q) Are the Puskesmas destroyed? (A) No. Only the medicine is not available. (Women FGD Meulaboh Shelters)

Generally, pregnant women prefer to give birth at home, the referral system still works and is practiced by health workers, in cases of diarrhea, bleeding, and pregnant women in Banda Aceh and Meulaboh.

“The communities here prefer giving birth at home they don’t want to give birth at hospitals. So they are referred to a hospital only when emergency cases occur. (In-depth Interview of Meulaboh Health Workers) “… if there is a serious case such as diarrhea, we do observation at the Puskesmas, as we collaborate with the Ule Kareng Puskesmas. For the diarrhea case as an example where special supervision is needed, we make a referral. Or when pregnant women hemorrhage we refer her to the hospital. We collaborate with the Puskesmas (In-depth Interview of Health Volunteers at the Banda Aceh Shelters)

Although medicine is available at shelters, many refugees buy their own medicine at pharmacies that are still open.

“We buy our own medicine at a pharmacy, Puskesmas or other places. Sometimes a person has diarrhea until he bleeds that should not happen, right? So we buy medicine at the pharmacy.” (Women FGD Banda Aceh Shelters)

Besides that the custom of helping neighbors is still practiced, for example by helping buying medicine or bringing a pregnant woman to the hospital in a car.

(Q) If such problem occurs, do the people help? (A) Oh, yes they do. (Q) For example, like what? (A) It varies, some give help in providing medicine. (Men FGD Meulaboh Housing) “There is support from the community, for example if someone is sick, they will find a car to bring him/her immediately to a hospital.” (In-depth Interview of a woman in Meulaboh Shelters) “Help a pregnant woman deliver her child who is in a difficult situation, carry and bring her to the hospital. Because when giving birth a life is in stake. We help bring her to the midwife.” (Men FGD Banda Aceh Shelters)


VI. 4. 2. Barriers An informant from a village said that a baby is not vaccinated because all four of its siblings were not vaccinated either. Based on observations at Meureuboh, a village in Meulaboh, the awareness on maternal and child health is still low. Babies are born attended by village midwives and are not vaccinated. The babies are then bathed using dirty water from wells. The cloth to wrap the baby is also dirty. The mother and baby sleep on a thin cloth spread on concrete floor. They often purchase medicine at a pharmacy because the medicine they receive is considered not effective to cure the disease they suffer from. And there is also the issue of the circulation of unknown medicine received from donor countries. They are not sure on the effectiveness of the medicine, because they have never used it, or do not understand how to use it because the instruction uses the language of the donor country.

“Well, the condition is like this, currently there was medicine that we have never seen before. For example, cough medicine for children, is it guaranteed to work the same as the cough medicine we are familiar with? We don’t know, so please provide information...” (Men FGD Banda Aceh shelters) “Here is an example; this is medicine from Turkey a Turkish brand. We don’t know how to use it we can’t even read the instructions. But they said that this is cough medicine.”(Men FGD Banda Aceh shelters) “Health treatment there (at Command Post) is not effective. No oral medication is given, only medication for itches.” (Women FGD Meulaboh Housing) “They give good services, they lack nothing, only the medicine is not effective, like I mentioned, after taking the medicine we are healed for only 2 hours, the pain is gone but then it returns. It’s because they’re not specialists. We are used to take medicine sold at the stalls. OKB (medicine brand) is actually strong, but is less effective because the disease has become severe.” (Men FGD Meulaboh shelters)

The requirement for children specialist arises in the disaster areas because the people consider that general practitioners are insufficient to help children’s health issues.

“We need doctors who are specialists for the babies, at least once a week, that’s what I think. Once a week a doctor should visit to know the condition of the children here.” (Men FGD Banda Aceh Shelters)

They also complain about health aid that frequently arrives late, especially for those in need, such as pregnant and breastfeeding mothers also the children. Many medical teams come only to collect data, yet the aid of medicine does not meet their expectations.


“There are medical teams from the Indonesian Red Cross (PMI) and from the committee who asks about our illness, but then our medicine arrives 6 days later. Sometimes, when we are washing at the back of the house they call on us just to collect data. The medicine arrives later but data collection is collected first and is considered more important. Finally our illness heals by itself without taking any medication.” (Women FGD Banda Aceh Shelters) “Actually, the current barrier is the health team doesn’t immediately give us instructions, they only provide us medicine. All of the sick people are taken care of but they do not come immediately to cure our illness. For example, if we come with a cough, breathing difficulty, irregular heartbeat, only cough medicine is given, heart medication is not dispensed. At the best, only our blood pressure is measured.” (Men FGD Meulaboh Shelters)

VI. 5. Family Planning VI. 5. 1. Behavior The mostly used family planning methods are pills and injection. The main reasons for using these two methods are because it’s suitable, maintenance is easy and is considered cheap. Besides that they also believe that these methods are practical, for instance the injection is only needed once in three months.

(Q) What family planning method are you using? (A) Pill (Q) Why do you use the pill? (A) Because I can’t use traditional medicine. (Q) Why not use the injection? (A) It’s available, yet it’s not suitable for me, it makes me

dizzy. The pill is suitable for me. (Women FGD Meulaboh Shelters)

“the injection is for every 3 months, it’s practical and inexpensive.” (In-depth Interview of woman in Banda Aceh Housing) (Q) Where do you obtain information on Family Planning? (A) The midwife. She asked what method I wanted to use. (Women FGD Banda Aceh Housing) “Formerly we used the injection method.” (Women FGD Banda Aceh Shelters)

“...including my wife. Many use the injection.” (Men FGD Banda Aceh Housing)


“We can maintain the injection easily.” (Women FGD Banda Aceh Shelters)

“The injection is good, only once in 3 months.” (In-depth Interview of woman in Meulaboh Shelters)

“The injection...is suitable, it has no effects.” (Women FGD Banda Aceh Shelters)

Most women do not use family planning methods; some of them use the traditional family planning method by taking turmeric and tamarind juice to prevent pregnancy.

“There are no reasons, I just don’t want to use family planning, after menstruation I take turmeric and tamarind juice for 7 days to prevent pregnancy. My mother told me to do so. So I never use any family planning methods.” (Women FGD Meulaboh Shelters)

Some of them say that it there is no need for them to use Family Planning methods because their spouses have passed away.

“What do I need for now...my wife has died.” (Men FGD Banda Aceh Shelters)

“For people like us, until we are provided with a house of our own, Family Planning is not required. Some of us have wives but has no children or there are women without husbands, so for the time being it isn’t needed.” (Men FGD Meulaboh Shelters)

The condition caused by the tsunami is made as an excuse by some parties to avoid using Family Planning. Loss of children as disaster victims makes them consider that they want children as replacement. Nevertheless, they also realize that they are in an unfavorable condition to raise more children.

“Family Planning isn’t necessary; at this situation it isn’t needed. To prevent having children is a sin. From the economic point of view children are needed. If we’re rich, we may have many children, but if we’re poor we don’t need to have many children. From another viewpoint, having many children but unable to take care of them is a sin.” (Men FGD Banda Aceh Housing)

VI. 5. 2. Barriers The men are not too much aware on Family Planning, because they consider that it is their wife’s affair. It is predicted that their knowledge of contraception is also far from sufficient, there even is a man that blames the usage of Family Planning pills for a long period caused his wife to be paralyzed.


(Q) What Family Planning method are you using? (A) I don’t know (Men FGD Meulaboh Housing) “My wife became paralyzed because she took Family Planning pills for such a long time.” (Men FGD Banda Aceh Housing) “Family Planning, I don’t know...currently I...” (Men FGD Banda Aceh Shelters)

The reason of people who are not using the existing Family Planning methods is because they consider it unsuitable. Cost factor is also one of the reasons that cause people not to continue using Family Planning.

(Q) Why don’t you use any method? (A) None is suitable, because I have varicose. Traditional family planning is not available I cannot use the injection because of varicose. Family Planning doesn’t suit me. (Woman FGD of Meulaboh Shelters)

(Q) Do you use Family Planning? (A) Yes, I used Family Planning after having my first child then I stopped. (Q) Any problems? (A) Financial problem. Whereas at the moment the Family Planning government program provides it free of charge. (Man FGD of Meulaboh SHELTERS)

After the disaster, many complained about the high cost of Family Planning. The cost for injection and pills increased and is a burden for them.

”It’s a burden. For what used to cost 1,500 now is 2,500. The injection was 10,000 now costs 12,000.” (Women FGD Meulaboh Shelters) “The program was organized and wasn’t too expensive.” (Women FGD Banda Aceh Housing) “It’s available but scarce, therefore if available it’s expensive and the access is too far.” (In-depth Interview of woman in Banda Aceh Housing) “The Family Planning devices are difficult to obtain...Currently it costs expensive, the service locations no longer exist.” (Women FGD Meulaboh Housing)

Other than expensive, due to the disaster the Family Planning service location they usually visit no longer exists. Many people do not know the locations of available Family Planning services. Several women understand the available service yet they complain that the distance is too far.


“Some of us here must have an injection once a month or once in three months, now we cannot go to the Puskesmas because it no longer exists, so we don’t know where else to go for our injection.”(In-depth Interview of woman in Banda Aceh Housing) “Oh, now it’s difficult to obtain services. Now the locations of services are very far and scattered.” (Men FGD Banda Aceh Housing) “The difference is that there used to be a Puskesmas.” (Men FGD Banda Aceh Shelters) “Now we don’t even know where to buy medicine (injection). Currently it’s available. (Women FGD Banda Aceh Shelters)

Even the staff in the Puskesmas complained about unavailability of equipment the women need. They can only suggest to the women requiring services to find other places to obtain services.

“All the Puskesmas were flooded, the equipment and medicine are all immersed. So the Puskesmas has to start from zero, there is no equipment at all.”(In-depth Interview of Meulaboh health worker)

The existing Family Planning service centers still have a problem because there are no midwives, either they became victims of the disaster or have moved to another place.

“Ah yes. We usually search for medication from a mantri (health worker) in the village, but now he’s gone.” (Men FGD Banda Aceh Shelters) It’s inappropriate; a mantri usually does not provide Family Planning. This is an expression given by a source the term mantri is his own term for any available health workers nearby his house. “Now it’s not available, once a week there used to be a Posyandu (integrated health services).”(Men FGD Banda Aceh Shelters)

For women who are using the injection as a Family Planning method, during the research was carried out, there was no problem because most were still in the injection period. And they happened to use the 3 months interval injection period, so they did not need to be injected yet.

“A time period is given, for example 3 months. We must return after the 3 months period. (Women FGD Meulaboh Shelters)

“Prior to the disaster, I went to the midwife for family planning. Now it’s not time yet.”(Women FGD Banda Aceh Shelters)


“It’s rather safe because it’s once in three months. I’m afraid if we use IUD and have intercourse it may cause a leak. There is no risk of leakage when using the injection method.” (Women FGD Banda Aceh Housing)

For those living in the shelters it is not possible to perform sexual intercourse. So although they do not use family planning specifically, they actually “perform family planning” due to the situation.

“No one is using Family Planning, but in general they are practicing Family Planning (that means everybody is practicing family planning together). Inside here, it’s impossible to do ‘something’ (sexual intercourse). So temporarily, in general family planning is natural abstinence. Natural family planning, it’s impossible for people to have intercourse in a place as crowded as this. We respect each other.”(Men FGD Banda Aceh Shelters)

VI. 6. Nutrition VI. 6.1. Behavior The nutrition issues that arose are those related to the quality of food. The quantity is not a problem at all. Those who live in housing areas will not experience hunger, although sometimes they buy food themselves. This food quality issue has become a main attention of the survivors. They believe that their children are becoming thinner. The children that previously were plump are now thin. This applies both to the survivors at the shelters also those who have returned to their original houses. According to the survivors living at the shelters, these children suffer from diarrhea because everyday they only eat cooked rice and instant noodles. This is the menu they eat everyday, breastfeeding mothers become thin and their breast milk decreases.

“It causes changes...our body becomes thinner, our skin becomes dry and breast milk decreases.”(In-depth Interview of woman in Banda Aceh Housing) (Q) It means if we talk about nutrition does it have any

impact to the children? (A) ...Their body becomes thinner...It is a pity that our

children currently cannot eat regularly. (Women FGD Banda Aceh Housing) “There is no variation, for example, vegetables. The instant noodle contains lots of calories...At best, we get canned fish twice.” (Men FGD Meulaboh Shelters)


“Instant noodles...salted fish, white bait.” (Women FGD Ulee Kareng Shelters) “The children are willing to eat although only with instant noodles, but the nutrition is insufficient.” (In-depth Interview of woman in Meulaboh) “Many diseases come from current food, sometimes the instant noodles causes illness. If we eat instant noodles we immediately get Diarrhea. Now we are given eggs or noodles.” (Women FGD Meulaboh Shelters)

The survivors in the shelters or housing areas are all provided with food aid. Thus the menus are relatively similar. The difference is only the access to the food. Food centers are usually located inside or nearby the shelters to ease the survivors obtaining their food. Meanwhile the survivors living nearby the housing areas has to wait for the distribution or at their own initiative fetch it or buy food of their own. They even try to collect money to buy nutritious food. With the collective purchase, the cost will feel lighter.

“There is nothing we can do, we cook and we eat what is available.” (Women FGD Meulaboh Shelters)

“But if we are willing to collect money, then we can buy nutritious food only if we all agree on that. So we collect five thousand per person to buy meat for nutrition.” (Men FGD Banda Aceh Housing)

VI. 6. 2. Barriers Informants in the shelters complain about the food that lack nutrition (instant noodles) and vegetables are also scarce. Meanwhile, informants at housings say that it is more difficult to obtain food aid because of distribution issues, but if they want to buy their own food they have no money. This is particularly experienced by those who are not government employees, because not only did they lose their possessions but also their jobs, while informants who are government employees still receive salary from the institution where they work.

“I want to buy food but I have no money.”(In-depth Interview of woman in Meulaboh Housing) “Once a week we used to have green pulses but now we only eat salted fish and noodles.” (Women FGD Meulaboh Housing) “Almost 90% of the people here are government employees. For them, this incident doesn’t worry them too much because they still receive their salary, not like me. It seems that they don’t need aid, because they still receive money every month.” (Men FGD Banda Aceh Housing) So, the solution is to increase the economy, if the condition becomes better then we won’t become weak. Because we will


have money to buy food.” (Interview of Banda Aceh Community Leader)

There is an issue that instant noodles is a dangerous food and can cause diarrhea

“We remind our family not to eat this or that. For example: Instant noodle is dangerous. That’s all we can do.”(Men FGD Banda Aceh Housing) If instant noodles causes diarrhea stop eating noodles and eat something else. (Men FGD Banda Aceh Housing)

The government has to act immediately in order to provide various kind of food.

“The food is adequate, but distribution must be even, for example: if today noodle is given, tomorrow the food should be different.” (Men FGD Meulaboh Shelters)

“For the time being they lack nutrition, because the aids are in the form of noodles, rice, whilst they prefer green pulses and chicken but it’s not available. It seems that eggs from Australia are not distributed to the refugees. They have no money to buy eggs so they automatically lack nutrition. As for milk, they received it only for three days, and then there was no more. Well, they do lack nutrition...” (In-depth Interview of Meulaboh health worker)

They need money, because they have lost their jobs, economic life is relatively devastated, the survivors need time and funding to build it.

“Don’t only provide money and help which are not too urgent such as feminine napkins, soap and brushes. But give us money to buy food.”(Men FGD Meulaboh Shelters)

The effort they performed to solve the nutrition problem is individualistic. They do not know what to expect on the actions taken collectively to solve the nutrition issue.

“Cannot do anything, only hope for help.”(Men FGD Meulaboh Housing) “give us money so we can buy food.” (Men FGD Meulaboh shelters)

VI.7. Communication Issues VI.7.1. Source and Channel of Information A drastic change in all life aspects of the people of Aceh also affects the behavior pattern associated to information. At present it seems that the constructed command posts are now becoming an important institution in disseminating information. This also applies to


volunteers at the command posts, where they are also asked numerous subjects. This occurs particularly at the shelters where the command post volunteers become main information source. In the housing areas, the similar situation also occurs and the head of small villages and other villages (local government) also becomes main information sources.

“Don’t know where to go, at the best we can ask the command post. Because it’s free of charge.” (Men FGD Banda Aceh Shelter) “The head of villages, small village leaders, also the local community around here.” (Men FGD Meulaboh Housing) “Information on rice, usually the head of villages or small village leaders inform the people that on a particular day there will be rice distribution, so people will come out.” (Men FGD Meulaboh Housing) (Q) Other than relatives, currently whom do you trust most on

providing information? (A)Head of villages (Men FGD Meulaboh shelters) (Q) Who becomes the main information source in this area? (A) The head of Rukun Tetangga and his wife. (Women FGD Banda Aceh Housing)

It seems that the role of information source for the people does not run well, because the content of information mentioned tends to refer to formal communication content, for example: the issue of development projects and village meetings.

“Formerly the head of the village informs us projects for the community, together we discussed the decision, because it was for public interest, and there wasn’t an announcement, but the current situation is everyday there are announcements.” (Men FGD Meulaboh Housing)

People mention that the source of information on health issues are formal community leaders other than the medical volunteers in the command post where health facilities still exists, such as Puskesmas and hospital.

“If there is medical aid from foreign countries they come here and inform the head or leaders of the villages then they inform the information to their community.” (Men FGD Meulaboh shelters) “Like I’ve mentioned previously, the health issue for instance is from the head of the village...If the people... based on the type of illness for example suffers from coughing or a fever, and a family cannot afford to heal it,


they meet the village leader.” (In-depth Interview of a man in Meulaboh Housing) (Q) If you need information on health, where do you go? (A) To the hospital, Puskesmas, Command Posts, that’s all “well, the command post. Currently there is information on fogging.” (Men FGD Banda Aceh shelters)

Aside from obtaining information from the aforementioned sources, many people also acquire information on health from the printed media. This occurs in urban and rural areas.

(Q) Do you read medical posters a lot? (A) Only in hospitals. For example on the issue of dengue and leprosy. (Men FGD Banda Aceh Housing) “Yesterday I went to a hospital and read (a brochure) on the diarrhea prevention method...I prefer posters because posters have illustrations...they’re colorful and big, I don’t like these kind of papers (newspaper).” (Men FGD Banda Aceh Housing)

One of the most favorable communication media is the poster, especially with large, colorful pictures and the information is printed clearly.

“...I prefer posters because posters have illustrations...they’re colorful and big, I don’t like these kind of papers (newspaper).” (Men FGD Banda Aceh Housing) “People easily comprehend the one with pictures. Such as a picture of a Moslem praying, this is the place, the clothes should be Moslem clothing. Like the picture of a person praying, totally complete.” (Men FGD Meulaboh Housing) “The printing must be clear, colorful, has pictures...there should also have information below.” (Men FGD Banda Aceh shelters)

Informal community forums such as religious teachings, social gathering and others have been used as means of disseminating information.

“During community work, meetings and religious teachings.”(Men FGD Meulaboh shelters)

Many men in Aceh spend their time at numerous coffee stalls. In these coffee stalls social contact and dissemination of various information may occur.


(Q) Other from the newspaper, where do you obtain information? Where is the source?

(A) For example at the coffee stalls. Stories between friends.

(Men FGD Banda Aceh Housing)

When delivering medical information (indirectly or through the media), the people of Aceh prefer to use Aceh language. Not because they do not understand Bahasa Indonesia, but rather to ease comprehension of information.

“The Aceh people use Bahasa Indonesia, they understand it but cannot speak the language. Bahasa Indonesia should be used because the coverage is for the public.”(Men FGD Meulaboh shelters) “So it’s easier to understand, like this gentleman here he doesn’t understand Bahasa Indonesia much, but if the Aceh language is used then it will be much easier for him to understand. There are also people who understand Bahasa Indonesia but have difficulty to speak the language so it’s much easier if Aceh or Jame language is used.”(Men FGD Meulaboh Housing)

Based on observations, interviews and FGDs, the radio is the main media tool they have access to. The price of a radio is relatively affordable and many are supplied by Non-Governmental Organizations. Television is the most favorable media, but its availability is scarce because most do not function any longer due to the disaster. VI. 7. 2. Required Information The survivors in general demand information on the tsunami, particularly the provision and location of barracks that are built or news on their family because many have lost their relatives. They are also interested in the news about politics.

(Q) What about mass media? What kind of information do you

read? (A) Well, about the tsunami, the issue of house provision,

and their locations. (Men FGD Banda Aceh shelters) (Q) what are other interesting subjects? (A) well, politics (Men FGD Banda Aceh shelters) “News in particular...News about stranded children. Many of us have lost our children.” (Men FGD Meulaboh Housing) (Q) What do you listen to most on the radio? (A) News, because news it what we mostly need now. (Men FGD Banda Aceh shelters)


VI. 7.3. Communication Barriers The most influential public figure other than the village leaders is the religious leader but most mushollas (small mosque) are destroyed so religious teachings can only be done in mosques.

“The people mostly believe in the village leader and the mosque, the leader/imam of the mosque (Tengku Imum). Whatever they say will be heard.” (In-depth Interview of man in Meulaboh Housing) “But mushollas do not exist any longer, there used to be a musholla in every small village but not anymore, so now religious teachings are at mosques.” (Men FGD Banda Aceh Housing)

Source of information on health through printed media (brochure, leaflets, and posters) is only available at the hospitals. The existence of the information source at the command posts or Puskesmas does not show in the FGD.

(Q) Do you often read medical posters? (A) The posters are at hospitals. For example posters on

dengue and leprosy. (Men FGD Banda Aceh Housing) “Yesterday, I went to the hospital and I read (brochure) on how to prevent diarrhea...”

Television is the most favorable media, but its availability is scarce because most do not function any longer due to the disaster. Newspaper no longer exists because the distribution is disturbed.

(Q) Between the newspaper and TV, which one do you prefer? (A) TV, because there’s entertainment and pictures, there’s

some pornography, right...it’s entertainment for us. (Men FGD Banda Aceh Housing) “TV. Watch the news, soap operas.” (Men FGD Banda Aceh Housing) “I prefer TV, but it’s impossible for the government to supply us with a TV set, but I think the government can afford to give us a radio. There’s live broadcast and we can know who is missing.”(Men FGD Meulaboh Housing) (Q) Do you read newspaper often nowadays? (A) No, because there is no newspaper coming in, but for those who enjoy reading a newspaper, even past edition papers are read. (Men FGD Meulaboh shelters)


(Q) What about TV? (A) No, because we don’t have a TV any longer...Previously almost everyone had one. (Men FGD Banda Aceh Housing)

Although many NGOs distribute radios but the distribution is not even, some shelters did not receive the radios.

“No TV, no radio, we listen to nothing...There should be a radio for every tent.” (Women FGD Banda Aceh shelters)

Based on the interviews, it is apparently that there is no definite coordination among the volunteers and health workers themselves also between volunteers and the health workers. The following is an illustration of the condition:

• Health workers from Walubi (Indonesian Buddhist Organization) only understand what their organization does. They do not know what kind of activities is performed by the Salvation Army (located beside Walubi’s tent in Meulaboh).

• The Salvation Army only performs activities that were previously the responsibility of the Office of Health (Dinas Kesehatan). Beyond the responsibility of running the role of Dinas Kesehatan, they do not have any other information.

• There are many donated medicine that cannot be used because the health workers on duty have no knowledge on how to use them.

• Since there is assistance from Hasan Sadikin Hospital Bandung at Cut Nyak Dien Hospital in Meulaboh the local health workers who survived the disaster never comes to the hospital although a work schedule has been made for them.

• The local office of health does not have clear data and information on medical activities in their jurisdiction.

“The problem is that here we manage health. We only inform the people who come for medication. We don’t worry too much on the issue of communication. We meet them a lot, so we only give them information.” (In-depth Interview of health worker in Banda Aceh) “Based on my observation there is no coordination between the Health Office and us. We’ve never received any information.” (In-depth Interview of health worker in Banda Aceh) (Q) where does new information usually come from? (A) our friends from the Indonesian Red Cross too. (In-depth Interview of health worker in Banda Aceh)

In the period of managing and rehabilitation, the community leaders either male or female consider that they can fulfill their roles on the issue of health improvement such as providing guidance or including messages on health in lectures. But the problem is they lack knowledge of health problems, so they expect to be able to be provided with the knowledge first.


Besides that community leaders also see the potentials of documentary films as a mean to attract people’s attention on health issues. VII. Conclusion Based on the above findings, health problems in the tsunami disaster are derived comes from two main factors:

• Unhealthy habits and attitudes

• Insufficient and uneven distribution of facilities (health service facilities, lavatory/ washing /bath facilities, etc) and material supply (food, medicine, etc).

In general, it can be said that the problem of unhealthy habits and attitudes occur more in rural areas. In urban environments, the second factor dominates. Nevertheless, it cannot be said that the problem in rural areas is only related to habits, and vice versa, the problem in urban areas is caused only by the factor of facilities and supplies. Both of these factors occur in both categories of research locations. A difference also shows between people living in shelters and those living in their original areas (residential areas). People living in residential areas have experienced and appear to be more exposed to more health problems as compared to hose living in living in shelters, although there are still issues related to health problems in both living situations. A. Hand Washing The barriers to hand washing with soap include a lack of awareness about the importance of correct hand washing and how it can reduce diarrhea diseases and access to an adequate supply of soap and clean water. While most participants realize the importance of hand washing with soap, this activity is not yet a priority, with men demonstrating less interest than women. Hand washing with soap is correlated more to hand cleanliness and is not strongly connected with prevention of diarrhea disease. Furthermore, from the availability of soap in shelters and residential areas limits one’s ability to wash hands properly. This situation beyond shelters is complicated by the lack of clean water. B. Clean Water Lack of access to clean water arises from the uneven supply and distribution of clean water. People cannot rely on PDAM water supply because: first: not all disaster-struck areas have clean water lines; second: part of PDAM water lines have been damaged and cannot be used, third: water from the remaining functioning PDAM lines is turbid. As a result, individuals are highly depends on distributed water supplies yet it is known that distributed water does not reach all people and the supply is not sufficient. Consequently, some individuals buy clean water using their personal remaining available funds, or resort to using unclean water for washing clothes and cooking utensils, bathing, and washing themselves. The perception that clean water corresponds to boiled water is still very strong among the Aceh people. Even if water is provided to them ready to drink (i.e. distributed supply) they still boil the water and so the behavior related to boiling is conditioned. This also affects the usage of water purifying agent in form of chlorine. This is a brand new scheme, both in the usage procedure and water taste.


C. Sanitation C.1. Disposal of Human Waste It was found that human waste disposal presents a big health concern in all locations. In urban areas, this problem is mainly related to the usage of toilet (BAB/BAK=defecation/ urination) facilities. In residential areas, toilets cannot be used because they have been demolished. Meanwhile, in shelters, toilets are available although the total of units is insufficient for the total number of users. This causes a long queue and difficulty in maintaining cleanliness. Impatient people or those who cannot delay their urge to go to the toilet relieve themselves in ditches, trenches, small rivers, or open fields, and this occurs more commonly after sunset. Meanwhile, in rural areas, this issue is more closely related to culture. The urination/defecation activity is carried on open fields, trenches, or “floating toilets”. C.2. Garbage Disposal Just as toilets, garbage disposal areas are also destroyed by tsunami. The resulting garbage is piled up on street sides or burned because garbage transport trucks do not show up as often. This activity is more individual, thus it’s still limited on residential areas or tent sites of each shelter area. The people willing to clean their surrounding environment also face the difficulty of lack of equipment. D. Maternal and Neonatal Health A difference exists between rural and urban groups in terms of their awareness of maternal and neonatal health, with rural groups having lower rates of awareness. Meanwhile, in urban areas, the awareness about health, both general health and maternal and neonatal health is good, although urban dwellers still face a lack of medical facilities and health officers that provide services. There is still lack of specific services, such as expecting mother and specialists. Additionally, there are still issues with supplied medicines, such as (1) limited amount, (2) perception of the medicine as ineffective, so people go buy their own at pharmacies, (3) the directions for use of some foreign aid medicine use foreign language, so even health officers find difficulties on how to use them. E. Family Planning The largest issue in family planning is the supply of contraceptive devices that occurred when the family planning service locations were demolished and deaths of many Family Planning service officers occurred. Furthermore, there are also intentions of those to have more children after many children died because of the disaster. Some contraceptive devices can be acquired but the price is substantially higher than before the tsunami. F. Nutrition Individuals lack access to a healthy food supply and this is the main reason why most feel that diarrhea diseases exist. The health of pregnant women and their fetus are affected by the lack of nutritious food. People that still have money have been found to have greater access to nutritious foods than those with smaller amounts of money.


G. Communication Issue Communication source and channels used by the Aceh people are still limited to formal communication source and channels, such as formal figures (Lurah for neighborhood issues, doctors/midwives for health issues) and formal institutions (such as Puskesmas/ hospitals for health issues, etc). Informal sources and channels have not played a significant role. Since the tsunami, new figures and communication lines have emerged as Health officers and volunteers (which mainly are volunteers from other areas) are now viewed as trusted informal sources for the people. Informal information channels such as religious studies and social gatherings are not used much although they have expressed an interest in participating on sharing health messages and should be tapped into in future programming efforts. Printed media can be effective information channels, such as newspapers and posters. Nevertheless, among the volunteers in the same sector (for instance: health sector) have not shown a good coordination. In turn, this reality affects the effectiveness of program they run. For example, problematic clean water and food supplies, which are caused mostly by this lack of coordination that, leads to bad distribution.

formative study: health communication program...

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