SITUATIONAL ASSESSMENT OF CHILD HEALTH PRACTICES
IN TIMOR-LESTE
TAIS, 2006
KEY BEHAVIORS AND SUB-BEHAVIORS
Key Behaviors Analyzed
Mothers and other caregivers:
 Make a birth plan
 Deliver with a skilled attendant
 Make at least four prenatal visits
 Breastfeed exclusively for six months
 Give adequate complementary feeding from about 6-24 months with continued breastfeeding for at least two years
 Give appropriate nutritional care of sick and severely malnourish children
 Ensure adequate vitamin A intake for yourself and young children
 Ensure adequate iron intake for yourself and young children
 Purchase and use only iodized salt
 Obtain long-term treated bed nets and use them as recommended
 Minimize the exposure of babies and young children to smoke
 Treat mild illness at home and look for danger signs
 Take a child with one or more danger signs immediately to a trained health provider
 Ascertain understanding of providers’ treatment instructions and follow them completely
 Wash hands with soap and water after going to the bathroom or contacting feces, and before eating, feeding or cooking
 Safely dispose of the feces of all family members
 Treat water you are about to drink or use for cooking
 Bring children to immunization service delivery points at the ages (and with the correct intervals between doses) in the national
schedule
Health workers:
 Make patients/clients feel as comfortable as possible
 Give people essential information, confirm their understanding, and invite their questions
2
NEONATAL HEALTH
Key Behavior: Make a birth plan
Participant group (caregivers, etc.): mothers, fathers, other family members, community at large
EXISTING INFORMATION ON PRACTICES
Sub-behaviors
Current Practices
Discuss and reach
agreement on where
you will give birth,
who will attend, what
emergency signs are,
and if you have one,
where will you go for
emergency care, how
you will get there
quickly, who will
accompany you, who
will take care of other
children and animals,
how you will pay, and
who will donate blood,
if needed
Fathers and
grandparents play a
major decision
making role in
planning for delivery.
Often plans include
skilled birth attendant
assistance only in
case of complications.
[1-HAI]
ANALYSIS BASED ON SITUATIONAL ASSESSMENT
Is this sub-behavior
practiced?*
Nationally, 37.3% of
women reported to
have discussed during
pregnancy the place
where they will deliver,
22.2% discussed
transportation, 47.1%
discussed who will
assist with the delivery,
24.9% discussed
payment, and 11.2%
discussed who will
donate blood.[2-DHS]
During pregnancy for
the most recent birth in
the five years
preceding the survey,
38.7% of men
discussed the place of
deliver, 12.9%
discussed transport,
51% discussed delivery
assistance, 15.6%
discussed payment,
and 6.5% discussed
blood donor.[2-DHS]
3
Known barriers**
Belief that giving birth
is a normal event, so it
does not require extra
care or planning;
people feel planning is
difficult because they
can’t predict timing of
delivery; skilled birth
attendant lives too far
away; fear that there is
no private space at the
clinic; no ability to heat
water at the clinic to
apply traditional hot
compresses and wash
mother and baby after
birth; clinics are not
supportive of upright
birthing positions.[1HAI]
A strong belief that
reproduction is a
woman’s duty and,
therefore, does not
represent a risk in
itself..[27-Oxfam]
Known motivations
and supports***
Fathers play an
active role in birth
preparations; limited
financial barriers to
having a skilled birth
attendant assist with
delivery.[1-HAI]
Generally younger
married women,
living in urban areas,
who have more
education and who
tend to be from the
wealthier households
are more likely to
discuss issues of
preparation for
delivery.[2-DHS]
Remaining
Questions
Do communities
have emergency
transportation plans
or capacity?
Do people make
long-term plans for
anything? If so, for
what?
Do families or
communities
practice any type of
mutual savings
scheme?
Key Behavior: Deliver with a skilled attendant
Participant group (caregivers, etc.): mothers, fathers, other family members
EXISTING INFORMATION ON
PRACTICES
Sub-behaviors
Identify and
make
arrangements
with a doctor,
nurse, or
trained
midwife to
attend your
birth
Current
Practices
Contact with
trained care
providers is
not sought
until
complications
or
emergencies
arise.[3Livermore]
Many births
assisted by a
family
member,
dukun or no
one at all.[1HAI]
Maintain close
contact with
this person as
the birth
approaches
ANALYSIS BASED ON SITUATIONAL ASSESSMENT
Is this sub-behavior
practiced?*
Very few deliveries occur
at health facilities; about
half of women deliver with
a midwife [bidan or
dukun?] at home.[4-HAI]
A skilled practitioner
(doctor, nurse, midwife or
auxiliary midwife) assisted
only 24% of women giving
birth during the year
preceding the MICS
survey; the figure was only
12% in highland areas.[5MICS]
Eighty-one percent of
women delivered at home
with untrained birth
attendants.[2-DHS]
Known barriers**
Known motivations and supports***
Deterred by
dukuns.[6-HAI]
On-call delivery services (24 hours)
available at all government health
facilities [hospitals?].[4-HAI]
General perception
that the trained
midwife should only
be called when
complications
arise.[1-HAI]
Traditional beliefs
that women may be
violated, lack of
confidentiality and
lack of privacy at
health facilities.[7DevBul]
Traveling at night,
should the woman go
into labor, is
considered unsafe.[1HAI]
Long distances
between home and
health facility and
lack of
transportation.[4-HAI]
4
Remaining
Questions
Of those
deliveries
attended by
skilled
attendants, how
many are normal
deliveries? How
many are due to
obstetrical
emergencies?
What are the
most important
barriers and
motivations?
Some of the mobile clinics increase
contact between mother and skilled
birth attendant.[4-HAI]
The maternal waiting house is a
recent innovation which will allow
women beyond 36 weeks gestation
and those at high risk to stay in a
friendly home-like place near a health
center with appropriate staff, medical
equipment and referral network.[7DevBul]
Can all mobile
clinics provide
prenatal and
postnatal care?
How many
MWHs exist and
are planned?
Are there any
evaluation
results?
Sub-behaviors
Comply with all
recommendatio
ns by skilled
attendants
Current
Practices
Commonly
resist referral
when
recommended.
[6-HAI]
Women report
that midwives
do not give
recommendati
ons.[4-HAI]
Is this sub-behavior
practiced?*
Known barriers**
Associated cost, lack of
permission from family
decision makers.[1-HAI]
Lab services are very
rarely available and
therefore rarely
recommended.[4-HAI]
Families rarely
bring neonates
to health
facilities.[4HAI]
5
Known motivations and
supports***
Remaining
Questions
Key Behavior: Make at least four prenatal visits
Participant group (caregivers, etc.): pregnant women, influencers (fathers, grandmothers, health providers)
EXISTING INFORMATION ON PRACTICES
Sub-behaviors
Current Practices
Find out where
to go and
make the first
visit before
you are three
months
pregnant
Only seek care when in labor or
when a problem develops (e.g.,
bleeding or baby not moving).[6-HAI]
Women (usually urban and more
educated) come for ANC after
noticing first month of
amenorrhea.[6-HAI]
Dukuns are often the frontline of
care for pregnant women.[1-HAI]
Some health facilities are not staffed
with a midwife and many nurses
who provide these services have not
been trained in ANC, delivery or
PNC.[4-HAI]
About 43% of all women giving birth
had at least one ANC visit with
skilled medical or paramedical
personnel, e.g., doctor, nurse,
midwife or auxiliary nurse.[5-MICS]
ANALYSIS BASED ON SITUATIONAL ASSESSMENT
Is this subbehavior
practiced?*
Often among
more educated
and urban
women, less
frequently by
rural and less
educated
women.[6-HAI]
Less than one
in four women
had their first
antenatal care
visit during the
first trimester
(less than four
months
pregnant).[2DHS]
Known barriers**
Known motivations and
supports***
Remaining
Questions
Shyness, fear of/
embarrassed by male
doctors; lack of
acknowledgement of
pregnancy before
second or third term;
permission required from
husband, mother-in-law
and/or mother; too busy
(nobody to care for other
children); planning is
too time consuming;
long distance to ANC
clinic, cost of transport;
lack of understanding of
need for ANC; mistrust
of ANC (belief in
traditional medicine).[6HAI]
MOH sponsored “Safe
Motherhood” campaign
in November 2004;
women stated they
would use HF if there
were associated
incentives (e.g.,
mosquito net, soap or
baby clothes).[6-HAI]
What if any
incentives or
packages of care
are currently
offered?
Husband and/or
family/parents key
decision makers; desire
to “…be healthy for
myself and my baby.”[1HAI]
Did/do promotional
messages target
husbands and other
decision makers?
Pregnancy is viewed as
commonplace and it is
therefore not necessary
to seek care.[1-HAI]
Sixty-one percent of mothers
interviewed received antenatal care
from a medical professional.[2-DHS]
Women 35 years and older are more
likely to go through pregnancy
without ANC.[2-DHS]
6
Some dukuns refer
mothers to ANC
clinic.[1-HAI]
Immunizations, vitamins
and position of the baby
all cited my mothers as
benefits of ANC.[1-HAI]
What is the ANC
coverage of mobile
outreach clinics?
Sub-behaviors
Current Practices
Comply with
all recommendations by
providers
Most recommendations that women
receive come from dukuns and
traditional practitioners.[1-HAI]
Is this subbehavior
practiced?*
Known barriers**
Prefer to deliver at home
where they have more
comfort, choice and
control; fear of death in
clinics.[6-HAI]
7
Known motivations and
supports***
Remaining
Questions
What is content of
traditional medicine
and practices? Is it
beneficial or
harmful? Possible
to have cooperation
between ANC
practitioners and
dukuns?
CHILD HEALTH
Key Behavior: Breastfeed exclusively for six months
Participant group (caregivers, etc.): mothers, influencers (fathers, grandmothers, TBAs, health providers)
EXISTING INFORMATION ON PRACTICES
Sub-behaviors
Current Practices
Initiate
breastfeeding
within one
hour of birth,
from the
child’s own
mother
Breastfeeding is delayed
for up to 3 days until “white
milk” comes in; feeding
delayed until placenta
delivered; first give baby
boiled water and sugar
until the baby burps; give
baby to another lactating
woman.[6-HAI]
Overall 10% of children
received a prelacteal liquid
and 7% received a
prelacteal semisolid
food.[2-DHS]
Give frequent,
on-demand
feedings, day
and night,
from both
breasts for first
six months;
give baby no
other food or
drink during
this period
Overall, about 16% of
children aged 0-4 years
received bottle feeding
(28% for children age 1223 months). Bottle feeding
is more common in urban
areas and among wealthier
and/or more educated
mothers.[5-MICS]
ANALYSIS BASED ON SITUATIONAL ASSESSMENT
Is this sub-behavior
practiced?*
Half of women immediately
breastfeed; colostrum is
commonly discarded;
breastfeeding is nearly
universal.[1-HAI]
According to the 2003 DHS
47% were breastfed within
the first hour of being born,
while 87% were breastfed
within the first day of
birth.[2-DHS] [this seems
too high]
Thirty-nine percent of
children aged 0-4 months
are exclusively breastfed,
but this drops to 18% for
children under 6 months.[2DHS]
Fifty-three percent of
mothers exclusively
breastfeed their infants from
0-3 months.[8-Tilman]
By four months of age, only
about 20% of children were
still being exclusively
8
Known barriers**
Belief that
colostrum is not
good for the
baby.[6-HAI]
“Colostrum is
dirty.”[1-HAI]
Introduction of
infant formula,
cow’s milk and
complementary
foods sharply
increases for
children between
4-6 months old.[2DHS]
Almost 13% of
children under 6
months are fed
using a bottle with
a nipple.[2-DHS]
Known motivations and
supports***
People feed prelacteals
to wash the stomach
and remove the blood
clots for 3 to 4 hours
after delivery.[6-HAI]
The use of prelacteal
semi-solid foods is more
common among
children delivered with
the assistance of a
traditional midwife
(35%) compared to 7%
for those delivered by a
health professional.[2DHS]
A National
Breastfeeding
Association has been
established and chaired
by the First Lady, and
International
Breastfeeding Week has
been celebrated to
promote awareness on
the benefits of exclusive
breastfeeding.[8-Tilman]
Remaining
Questions
Has anyone been
promoting
colostrum, how
and with what
result?
What are current
practices?
How many women
feed their infants
formula? Do they
dilute it with an
appropriate
quantity of clean
water?
What breastmilk
substitutes do
women feed their
infants and how
breastfed. The Western
Region of the country has
lower rates of exclusive
breastfeeding than the
Central and Eastern
Regions.[5-MICS]
are they fed?
How common is
the use of
pacifiers?
How common is
wet nursing, for
what age babies?
Reasons?
A very high percentage of
women breastfed their
children under 6 months of
age more than six times in
the 24 hours prior to
interview.[2-DHS]
Use proper
attachment
and
positioning
Seek help
from a trained
provider if
breastfeeding
problems
develop
Unknown
What are current
practices?
If the baby does not feed
well, mothers don’t force
it.[6-HAI]
Belief that the
grandmother’s
spirit is not
happy.[6-HAI]
Establishment of a
Breastfeeding
Counselling Room at
the Dilli National
Hospital.[8-Tilman]
Alola Foundation has
developed “Mothers
Support Groups” which
provide lactation
management support to
a small number of
women.[9-Schaetzel]
9
How correct and
appropriate is
providers’s advice
on breastfeeding
problems?
Key Behavior: Give adequate complementary feeding from about 6-24 months with continued breastfeeding for at least two
years
Participant group (caregivers, etc.): mothers and other primary caregivers, influencers (fathers, grandmothers, health providers
EXISTING INFORMATION ON PRACTICES
Sub-behaviors
Current Practices
Feed foods that
are not too watery
The most frequently consumed
foods by non-breastfeeding children
are food made of grains, liquids, and
other milk/cheese/yoghurt. The most
common complementary food given
to breastfeeding children is infant
formula.[2-DHS]
Feed or add
calorie and
nutrient-dense
foods such as oil,
mashed nuts or
seeds, fruit,
vegetables, and
animal products
The most common, and often the
only, complementary foods given to
young children are rice water, rice or
maize porridge.[8-Tilman]
Among breastfeeding children ages
0 to 35 months, 50% had consumed
fruits/vegetables, 16% consumed
food made from legumes, 23%
consumed meat/fish/shellfish/poultry
/eggs, and nearly 15% consumed
food made with oil/fat/butter during
the day or night preceding the
interview.[2]
ANALYSIS BASED ON SITUATIONAL ASSESSMENT
Is this sub-behavior
practiced?*
No. Rice water or
watery rice is
commonly the first
supplemental food
provided for infants.[9Schaetzel]
Known barriers**
Between the ages of 6
to 59 months, high
rates of stunting
indicate low quantity
and nutritional quality
of foods given to
children.[5-MICS]
The “hungry
season” lasts from
November to March
each year during
which there are
limited food
resources.[10Oxfam]
Overall 44% of the
children under five are
underweight and 14%
are severely
underweight; 48% are
stunted and 27% are
severely stunted; 12%
are wasted and 2.7%
are severely
wasted.[2-DHS]
10
Known motivations
and supports***
Remaining
Questions
How watery
are the rice
and maize
porridge?
How widely
used is infant
formula?
Malnutrition
admissions at the
Dili National
Hospital (DNH)
peak during the
rainy season Dec –
March.[11-Bucens]
Coconuts, bananas,
fish and cashews
are locally
available.[12-Agus]
Sub-behaviors
Current Practices
Is this sub-behavior
practiced?*
Give 3 to 4
substantial meals
(at least 3 to 5
tablespoons each
time, depending
on the child’s age)
plus healthy
snacks and breast
milk
Practice good
hygiene re: food
storage/reheating,
hand washing,
protection from
flies, avoiding
bottles and
pacifiers
Either feed the
baby or supervise
eating to ensure
that the child
finishes his/her
food
Continue some
breastfeeding at
least until the baby
turns two
Known barriers**
Nearly 7% of
households reported
food shortage for
children under 6
years.[2-DHS]
People have low
knowledge of the
reasons for washing
hands before
eating.[10-Oxfam]
Known motivations
and supports***
Remaining
Questions
What are the
current
practices?
What are the
current
practices?
What are the
current
practices?
The overall mean and median duration
of any breastfeeding is 17.7 and 18.5
months respectively.[2-DHS]
Median duration of breastfeeding is just
over 15 months and by 20-23 months
of age only about 10% of children are
still being breastfed.[5-MICS]
Only 35% of
mothers continue
breastfeeding to two
years (although
80% continue to one
year).[9-Schaetzel]
Among children <24 months admitted
at DNH for malnutrition, only 30% were
still drinking breast milk and 29% were
not drinking milk at all.[11-Bucens]
11
It is hypothesized
that high fertility and
relatively short birth
intervals are a factor
in the short duration
of breastfeeding.[5MICS]
Key Behavior: Give appropriate nutritional care of sick and severely malnourished children
Participant group (caregivers, etc.): mothers and other primary caregivers, influencers (fathers, grandmothers, health providers)
EXISTING INFORMATION ON
PRACTICES
Sub-behaviors
Current
Practices
ANALYSIS BASED ON SITUATIONAL ASSESSMENT
Is this sub-behavior
practiced?*
Known barriers**
Known motivations
and supports***
Remaining Questions
What are the current
practices?
Continue
breastfeeding and
other feeding if the
child is sick
Give extra fluids to a
child with diarrhea or
fever (extra breast
milk for babies under
6 months, breast or
other safe liquids for
older children
What are the current
practices?
Use extra patience
and persistence in
feeding a sick child
and give favorite
foods if necessary
What are the current
practices?
Feed extra food for at
least a week during
recuperation
Bring a child who
Only 7% of
children followed
recommended
procedures of
drinking more
and continuing
eating following
an episode of
diarrhea.[5MICS]
What are the current
practices?
Poor breastfeeding is
12
What are the current
refuses food and drink
to a trained provider
perceived as a danger
sign requiring medical
care by only about
18% of respondents.
[5-MICS]
Providers give vitamin
A to treat measles
cases, as
recommended
practices?
What are the current
practices?
13
Key Behavior: Ensure adequate vitamin A intake for yourself and young children
Participant group (caregivers, etc.): mothers, influencers (fathers, grandmothers, health providers)
EXISTING INFORMATION ON
PRACTICES
Sub-behaviors
Eat/feed locally
available
yellow/orange/red
fruits and dark
green leafy
vegetables rich in
vitamin A daily and
eat/feed animal
products when
possible
Ensure that
children 6 months
to five years old
receive a vitamin A
capsule every 6
months (and
deworming at the
same times, when
offered, for
children at least
one year old)
Visit a provider to
receive a vitamin A
supplement for
yourself within a
month of giving
birth
ANALYSIS BASED ON SITUATIONAL ASSESSMENT
Current
Practices
In the week
preceding the
survey 62% of
children
consumed
foods rich in
vitamin A.[2DHS]
Is this sub-behavior
practiced?*
In Liquica the most accessible
and commonly consumed
foods are corn, cassava and
rice.[12-Agus]
Known barriers**
Known motivations
and supports***
Living in an urban
area increases
likelihood of
consuming both
vitamin A-rich foods
and vitamin A
supplements.[2-DHS]
Remaining
Questions
What are
common
perceptions
and
consumption
levels of
vitamin A-rich
fruits and
vegetables?
In the 6
months
preceding the
survey 34% of
children 6 to
59 months
received
vitamin A
supplements.[
2-DHS]
Vitamin A supplementation
coverage for children<5 years
is 43%.[8-Tilman]
Significant numbers of children
with nutritional blindness in the
mountainous parts of the
country.[8-Tilman]
Thirty-nine percent of
children receiving
vitamin A got the
latest dose during a
routine clinic visit,
19% during a sick
child visit, and 25%
during a national
immunization day
(the remaining 17%
don’t know).[5-MICS]
How often is
deworming
offered at the
same time as
vitamin A?
The percentage of post-natal
women who received vitamin A
is considerably lower than that
for children above 6 months;
this suggests that health
worker contact with post-natal
women is limited and/or health
workers are less aware of a
Younger women with
more education and
belonging to
wealthier households
are more likely to
receive vitamin A
supplements after
birth.[2-DHS]
Are mothers
willing to seek
vitamin A
supplements?
Do they
accept it when
offered?
Ermera, Aileu: belief that
postpartum women should not
eat papaya, banana, garlic or
fish.[6-HAI]
Just over 50% of children aged
6-59 months had received a
high dose Vit A supplement;
35% had received a dose
within the past 6 months.[5MICS]
Overall 23% of women
received vitamin A
postpartum.[2-DHS]
Vitamin A supplementation
coverage for postpartum
women is 27%.[8-Tilman]
14
Only 28% of mothers received
a vitamin A dosage during the
first two months after giving
birth.[5-MICS]
mother’s need for
supplementation.[5-MICS]
15
Key Behavior: Ensure adequate iron intake for yourself and your young children
Participant group (caregivers, etc.): pregnant and nursing mothers, influencers (fathers, grandmothers, health providers)
EXISTING INFORMATION ON
PRACTICES
Sub-behaviors
Current Practices
Eat dark green leafy
vegetables daily,
and at least every
two weeks eat liver
or food made with
red meat
ANALYSIS BASED ON SITUATIONAL ASSESSMENT
Is this sub-behavior
practiced?*
Overall 29.1% of children
age 0 to 59 months have
anemia, 5.6% have
moderate to severe
anemia, and 0.8% have
severe anemia. The
highest prevalence of
anemia is seen in children
aged 0 to 23 months.[2DHS]
Known barriers**
Known motivations and
supports***
Most of the anemia
seen in children is
related to iron
deficiency rather
than malaria.[2DHS]
Remaining
Questions
What are the
current practices?
Among pregnant women
36.5% are anemic.[2-DHS]
Drink something
other than tea with
meals; avoid giving
tea to babies and
young children
Visit a health
provider to obtain
iron tablets by the
second trimester of
pregnancy
What are the
current practices?
The majority of
women who took
an iron supplement
during pregnancy
took them for less
than 60 days.[2DHS]
Just under half (47%) of
women received iron
tablets during the course of
their pregnancy.[2-DHS]
Belief that iron
tablets will cause a
large baby and
therefore a difficult
birth.[6-HAI]
Women have a good
understanding that
“vitamins make the blood
strong” and “you must eat
good food [during
pregnancy].”[1-HAI]
Women in wealthier
households, with more
education, living in urban
areas, and with a lower
birth order were most likely
to receive iron tablets
16
during pregnancy.[2-DHS]
Sub-behaviors
Current Practices
Is this sub-behavior
practiced?*
Known barriers**
Take a ferrous
sulfate tablet daily
as directed by the
provider
Known motivations and
supports***
Remaining
Questions
What are the
current practices?
Consult a trained
provider in case of
serious side effects
What are the
current practices?
Store tablets
protected from heat
and humidity, in a
visible place, away
from children
Go for re-supply
when necessary
What are the
current practices?
Where is re-supply
available? Is
community-based
distribution
acceptable to
MOH and
families?
17
Key Behavior: Purchase and use only iodized salt
Participant group (caregivers, etc.): mothers and fathers, other family members; providers
EXISTING INFORMATION ON PRACTICES
Sub-behaviors
Add salt at the table,
not during cooking
Current Practices
ANALYSIS BASED ON SITUATIONAL ASSESSMENT
Is this sub-behavior
practiced?*
Known barriers**
Belief that postpartum women should
not eat salt.[6-HAI]
Only about 70% of the
salt in country is
iodized and none of
the locally produced
salt is iodized. Local
salt production is
increasing since the
end of the Indonesian
occupation.[9Schaetzel]
About 72% of
households use salt
with adequate iodine
content; in the
Western Region only
about 60% of
households use
iodized salt.[5-MICS]
18
Known motivations
and supports***
Much of the salt used,
even in rural areas, is
imported from
sources where
iodination is standard
practice.[5-MICS]
Remaining Questions
Can local salt be
iodinated?
What is the cost to
consumers of various
salts?
Key Behavior: Obtain long-term treated bed nets and use them as recommended
Participant group (caregivers, etc.): mothers and fathers
EXISTING INFORMATION ON PRACTICES
Sub-behaviors
Current Practices
Obtain one or more
treated bed nets at
prenatal consultations
or community-based
distributions
Approximately 8090% of eligible
families are
receiving LLINs in
the TAIS/CRSassisted distribution
Ensure that pregnant
women and children
under five sleep under
a treated net every
night, all year round
ANALYSIS BASED ON SITUATIONAL ASSESSMENT
Is this sub-behavior
practiced?*
Very low percentage
of families own a
bed net (10% rural,
34% urban).[13Parada]
Known barriers**
Lack of permethrin for
treatment of nets in rural
areas.[13-Parada]
Known motivations and
supports***
Knowledge and attitudes
about the use of bed nets is
positive.[13-Parada]
Less than half of those
surveyed knew how
malaria was
transmitted.[13-Parada]
Knowledge of malaria
terminology and recognition
of the symptoms is high.[13Parada]
TAIS and partners are in the
process of distributing
120,000 LLITNs to pregnant
women and U5 children.
Currently ITNs are distributed
free of charge to all pregnant
women who go to MOH
facilities for ANC.[14Schubert]
Many families with
ITNs do not use
them as
consistently as
intended.
Even if a family has
a bednet it is usually
not being used in
the way that it
should.[13-Parada]
Belief that “Children are
the most susceptible to
malaria, due to lack of
attention from their
parents.”[13-Parada]
60% of children in
lowland areas and
22% of children in
highland areas use
bed nets. However,
only about 8
percent of those
using bed nets had
them treated with
insecticide.[5MICS]
Only 4% of U5
children slept under
an ITN during the
night preceding the
survey.[5-MICS]
Limited knowledge of the
risks malaria pose for
pregnant women.[13Parada]
Monitoring (reported
by C. Hasselblad)
found that most
families were
waiting for the rainy
season to begin
using their new
nets.
19
Remaining
Questions
If bed nets
are
conveniently
available, is
there any
refusal to
obtain them?
If so, why?
More detail
on current
practices and
motivations
How
sustainable
over time is
consistent
use?
Wash the treated net
only when absolutely
necessary (not too
often)
Avoid using bed nets
for fishing, clothing or
any other use other
than for protection
when sleeping
Virtually nobody re-treats
their bednet with an
insecticide.[13-Parada]
In Manufahi bed
nets are reportedly
used for fishing.[13Parada]
Suggested that non-use or
misuse of bed nets is
because previous
distributions did not include
any health promotion or
community education.[13Parada]
20
Current
practices
Is
retreatment
available?
Current
practices and
motivations
Key Behavior: Minimize the exposure of babies and young children to smoke
Participant group (caregivers, etc.): mothers and fathers, other family members, TBAs
EXISTING INFORMATION ON PRACTICES
Sub-behaviors
Current Practices
If you feel you must
“sit fire,” reduce the
size of the fire,
increase your and
your baby’s distance
from it, and increase
ventilation in the room
Common for mothers
and newborns to stay
near a fire for 1 to 3
months (HAI and
other studies)
Keep children as far
away as possible from
indoor fires and
smoke and increase
ventilation in the room
where the fire is
Use of inefficient
wood stoves, indoors
and under poorly
ventilated and
crowded conditions is
a major cause of
respiratory infections
in children.[5-MICS]
ANALYSIS BASED ON SITUATIONAL ASSESSMENT
Is this sub-behavior
practiced?*
Known barriers**
Strong belief,
especially among
rural women, that
sitting fire is very
important for assuring
the health and wellbeing of mother and
baby.[1-HAI]
Belief that the baby
must not get cold.[6HAI]
21
Known motivations
and supports***
Fase matan
ceremony provides
opportunity for
newborn checkup and
counseling within a
few days after birth.[1HAI]
Remaining Questions
Fase matan
ceremony provides
opportunity for
newborn checkup and
counseling within a
few days after birth.[1HAI]
Current practices and
willingness to modify
them
People’s willingness
to modify this
traditional practice
Key Behavior: Treat mild illness at home and look for danger signs (see also nutritional care of sick children, above)
Participant group (caregivers, etc.): mothers and fathers, other adults and older children in the home
EXISTING INFORMATION ON PRACTICES
ANALYSIS BASED ON SITUATIONAL ASSESSMENT
Sub-behaviors
Current Practices
Is this sub-behavior practiced?*
Known barriers**
Treat diarrhea with
extra liquids and
food (breast milk
only for babies
under 6 months;
see above)
Ninety-six percent of
children with an episode
of diarrhea received
some form of
recommended
treatment, mainly either
water with feeding
(58%), ORS packets
(57%) or gruel (49%).[5MICS]
Only 7% of children followed
recommended procedures of
drinking more and continuing
eating during their latest episode
of diarrhea.[5-MICS]
DD attack communities
during the lean period
when food insecurity is
high.[12-Agus]
Treat fever in
children under five
with an
appropriate antimalarial drug
Presumptive malaria
treatment is reported as
chloroquine followed by
SP followed by quinine if
no response – not
effective in TL due to
resistance.[13-Parada]
??
The most common
treatment for a child with
a fever is
Only 7% of children with
diarrhea were given more fluids
than usual, while 43% were
given less fluid or none at all.
Four percent were given more
food than usual, however, 63%
were given less food or none at
all.[2-DHS]
Sixty percent of children with
diarrhea were treated with ORS
packets, and 75% were given
either ORS, recommended
homemade fluids or increased
volume of fluids.[2-DHS]
According to the 2003 DHS,
14.3% of U5 children ill with a
fever were treated with
Chloroquine/Nivaquine, and 5%
were treated with Fansidar. The
most common drug to be
administered to children with
reported fever was
acetaminophen or paracetamol
(71%).[2-DHS]
Eighty percent of respondents
22
Known motivations
and supports***
Overall 81% of
mothers know about
ORS packets.[2DHS]
Remaining
Questions
About 40% of children
with diarrhea were
treated with pills or
syrup presumably
purchased without
medical advice.[2-DHS]
Anorexia and vomiting
during episodes of
diarrhea make it difficult
to continue giving
children food during the
episode because the
child may refuse
food.[2-DHS]
Traditional medicine
leaves on the infant’s
head are used to bring
down fever.[6-HAI]
Where do
people
obtain
medicines
Paracetamol.[5-MICS]
Twenty-seven percent
of U5 children
experienced fever in the
two weeks preceding
the MICS survey and
about half of these
children received antimalarial drugs.[5-MICS]
said they would bring a child
with malaria convulsions for
treatment in a health facility.[13Parada]
Children in highland areas are
less likely than children in
lowland areas to receive an
appropriate anti-malarial drug.[5MICS]
Treat cough or
sore throat with
locally
recommended
liquid mixtures to
sooth the child’s
throat
Current
practices?
What useful
local
ingredients
are
available/
used?
Treat fever
following
immunization with
acetaminophen
&/or sponging or
baths with tepid
water
HWs normally give no
warning or advice about
side effects (various
sources)
Especially in sick
children, actively
look for danger
signs: fast or
difficult breathing,
diarrhea that lasts
for two weeks,
refuses to eat or
drink, excessive
vomiting,
convulsions,
Danger signs are
described as not moving
well, doesn’t cry,
mucous in their nose,
being too small, having
a fever, not passing
urine, or having hot
urine.[1-HAI]
Current
practices
Recognition of serious malaria in
children is high; described as
“unresolved fever, chills,
anorexia and vomiting.[13Parada]
Knowledge of danger signals for
seeking immediate medical
attention is fairly low. 60% of
caregivers could recognize at
least two danger signals,
23
Mothers and fathers
have incomplete
understanding of signs
of newborn illness; if
recognized signs are
often ascribed to
supernatural or social
causes.[1-HAI]
Current
practices
excessive
sleepiness, great
thirst &/or sunken
eyes, any high
fever that does not
have a clear cause
such as an
immunization or a
tooth coming in
predominantly “child becoming
sicker” and “developing a
fever.”[5-MICS]
24
Key Behavior: Take a child with one or more danger signs immediately to a trained health provider
Participant group (caregivers, etc.): mothers and fathers
EXISTING INFORMATION ON PRACTICES
Sub-behaviors
Current Practices
Actively look for
danger signs,
especially in sick
children
Bring the child
immediately to a
trained health worker
(do not delay trying
home remedies or
getting care from an
untrained person in
the community)
ANALYSIS BASED ON SITUATIONAL ASSESSMENT
Is this subbehavior
practiced?*
Known barriers**
Known motivations
and supports***
Limited knowledge of
childhood illnesses and
importance of
treatment.[12--Agus]
Home or traditional
treatment highly likely
first.
Among children with
symptoms of ARI
and/or fever, 23.8%
sought treatment from
a health facility or
provider (does not
include pharmacy,
shop or traditional
practitioner).[2-DHS]
Mothers and fathers have
incomplete understanding
of signs of newborn
illness; if recognized signs
are often ascribed to
supernatural or social
causes.[1-HAI]
Sitting fire – a woman and
newborn will not leave the
house if she is still
bleeding, even if the child
shows danger signs.[6HAI]
Remaining Questions
Current practices
Midwife home visits
one week postpartum.[6-HAI]
Current practices
Long distances to health
facilities, loss of
productive work, and lack
of knowledge of health
facility and mobile clinic
schedules.[12-Agus]
Discuss where you
will bring a child with
danger signs, how
you will go there, and
how you will pay for
the trip and medicines
Current practices
25
Key Behavior: Ascertain understanding of providers’ treatment instructions and follow them completely
Participant group (caregivers, etc.): mothers and fathers
EXISTING INFORMATION ON PRACTICES
Sub-behaviors
Current Practices
ANALYSIS BASED ON SITUATIONAL ASSESSMENT
Is this sub-behavior
practiced?*
Known barriers**
Known motivations
and supports***
Remaining Questions
Current practices
Ask questions during
a consultation so you
never leave confused
about what you need
to do
Will providers
welcome questions?
Follow instructions
completely,
particularly
concerning when,
how, and how long to
give medicine; what
danger signs to look
for; and if and when
you need to bring the
child back
Current practices
26
Key Behavior: Wash hands with soap and water after going to the bathroom or contacting feces, and before eating, feeding
or cooking
Participant group (caregivers, etc.): mothers, all other family members
EXISTING INFORMATION ON
PRACTICES
Sub-behaviors
Set up a convenient
place for
handwashing and/or
obtain water
Current Practices
ANALYSIS BASED ON SITUATIONAL ASSESSMENT
Is this sub-behavior
practiced?*
Known barriers**
Known motivations
and supports***
Most communities lack access to
clean water and sanitation
facilities.[12-Agus]
Remaining
Questions
Current practices
Over 70% of the urban population
have access to safe water; only
50% in rural and highland areas
have access to safe water.[5-HAI]
Wet your hands
Current practices
Rub with soap or an
acceptable soap
substitute (ash,
sand)
Current practices
What cleansing
materials are
acceptable?
Current practices
Rub well, especially
the fingers, at least
three times
Current practices
Clean nails while
washing
Rinse well using
running or poured
water
Limited quantity of water
especially in rural areas and
during the dry season may cause
less use of water for “auxiliary”
purposes such as hand
washing.[5-MICS]
27
Mothers from
households with
piped water or a
protected well
were more likely to
wash their
hands.[2-DHS]
Current practices
Dry hands on a
clean cloth or in the
air (i.e., avoid drying
on potentially
contaminated cloth
or clothes
Current practices
28
Key Behavior: Safely dispose of the feces of all family members
Participant group (caregivers, etc.): mothers and fathers, all other family members
EXISTING INFORMATION ON
PRACTICES
Sub-behaviors
Current Practices
Build and/or use
a sanitary latrine
to dispose of all
family members’
feces
Throw infants’
and young
children feces
into a sanitary
latrine
Encourage
children to
always use a
latrine and make
it easy for them
The most common
reported methods of
disposal were to throw
the stools outside the
dwelling (21%) or
outside the yard (19%)
both of which are
uncontained methods
of disposal. Other
methods of disposal
are to rinse away (9%),
throw into a
toilet/latrine (10%),
bury in yard (6%), or
for the child to use the
toilet/latrine (4%).[2DHS]
ANALYSIS BASED ON SITUATIONAL ASSESSMENT
Is this sub-behavior
practiced?*
Close to 45% of the
population do not use any
form of toilet facility, in
effect relying on ponds
and fields for excreta
disposal. In major urban
centers of Dili and
Baucau, more than 90%
of the population use
some form of toilet
facility.[5-MICS]
Only 10% of mothers
report throwing their
children’s stools into a
toilet/latrine.[2-DHS]
Known barriers**
Known motivations and
supports***
Women are not allowed
to participate in projects
that involve
infrastructure activities.
[27-Oxfam]
Remaining
Questions
What existing
programs
encourage/
facilitate
building
latrines?
Mother’s education and the
level of household wealth
are associated with the
likelihood of contained
disposal of stools. Also,
urban households are
more likely than rural
households to contain their
children’s stools.
Containment of stools is
more likely if the family had
access to a private toilet as
opposed to a shared,
public or no toilet.[2-DHS]
Almost 45% of the
population has no toilet
facility and of those with
toilet facilities, less than
half can be considered
29
Current
perceptions
and practices
to do so (e.g., by
placing a step,
providing a
sanded board or
smaller seat to
reduce the hole
size
safe. In highland areas
close to 90% of the
population either have
no toilet facilities or rely
on simple squat holes or
open pits for excreta
disposal.[5-DHS]
30
Key Behavior: Treat water you are about to drink or use for cooking
Participant group (caregivers, etc.): mothers and fathers, all other family members
EXISTING INFORMATION ON PRACTICES
Sub-behaviors
Current Practices
ANALYSIS BASED ON SITUATIONAL ASSESSMENT
Is this sub-behavior
practiced?*
Known barriers**
Known motivations
and supports***
Remaining Questions
Current practices
Either boil then cool
the water, treat it with
an appropriate
amount of chlorine,
treat it by solar
disinfection, or use an
effective water filter
Availability and cost of
chlorine or other
chemical treatment,
water filters, etc.
Store the treated
water in a covered
container and never
put hands or dirty
utensils in it
Current practices
Availability of covered
containers (homemade or for sale)
31
Key Behavior: Bring children to immunization service delivery points at the ages (and with the correct intervals between
doses) recommended in the national schedule
Participant group (caregivers, etc.): mothers and other primary caregivers
EXISTING INFORMATION ON PRACTICES
Sub-behaviors
Current Practices
Bring children to
immunization service
delivery points at the
ages (and with the
correct intervals
between doses)
recommended in the
national schedule
Thirty-seven percent of
children aged 12-23
months received BCG
vaccine, 35% at least one
dose of DPT, 37% at
least one dose of polio
and 28% a measles
vaccination. Only 5% had
been fully protected and
58% of children aged 1223 months had never
been vaccinated.[5-MICS]
According to the 2003
DHS, 75% of children
aged 12-23 months
received BCG vaccine,
68% at least one dose of
DPT, 69% at least two
doses of polio, and 56% a
measles vaccination.
Only 23% of children
have received the first
dose of HB.[2-DHS]
Following the Oct. ’03
campaign, measles
immunization coverage
ranged from an estimated
76% in Liquica to 115% in
Ermera for a total
coverage rate of 99%.[15UNICEF]
ANALYSIS BASED ON SITUATIONAL
Is this sub-behavior
Known barriers**
practiced?*
A significant proportion of
Low awareness of
children have failed
immunization sessions,
achieving “full
benefits, schedule, time
immunization” largely due
and place; health staff
to failure to receive third
rarely explains need for,
doses of DPT and polio
time of, and importance of
vaccine.[5-MICS]
follow-up doses; difficult
access and low use of
Overall the immunization
other services; community
drop out rate is high at
continues to expect
77% for DTP and 72% for
incentives; great concern
polio.[2-DHS]
over (normal) side effects;
families have limited
Among the poorest quintile understanding of rationale
of the population, more
for prevention; families
than 70% of children aged
move residences in search
12-23 months were
of livelihood; shortage of
reported as never having
staff, low morale, poor
had an immunization.[5planning, irregular,
MICS]
unreliable sessions, high
dropout and missed
Forty-two percent of
opportunities.[16-UNICEF]
children aged 12-23
months had not received
Parental belief that booster
any immunizations.[2-DHS] doses of vaccines are not
necessary.[15-UNICEF]
32
ASSESSMENT
Known motivations
and supports***
Communication
strategies and
social mobilization
activities, e.g.,
street parades,
poster, pamphlet
and banner
campaigns, a
national
immunization week
launching
ceremony, art and
mural initiatives,
and live bands
playing measles
campaign “jingles”
have all been used
in support of the
Mass Measles
Immunization
Week.[15UNICEF]
Remaining
Questions
Sub-behaviors
Current Practices
Bring each child’s
health or vaccination
card to each health
visit
Twenty-nine percent of
children were reported to
have vaccination cards, but
for only 5% of the children
could the cards be made
available to the
interviewer.[5-MICS]
During the Mass Measles
Immunization campaign,
some areas had no
emergency transportation
or drugs available to treat
children who have adverse
reactions.[15-UNICEF]
Treat side effects as
recommended
Seek/accept tetanus
toxoid immunizations
for yourself (applicable
to women of
childbearing age in
general)
Is this sub-behavior
practiced?*
Only 12% of children aged
12-23 months had their
health cards available at
the time of interview.[2DHS]
An estimated 84% of
women who received
tetanus toxoid
immunization had
received them during
their last pregnancy.[5MICS]
An estimated 41% of
women giving birth during
the previous year received
recommended tetanus
toxoid injections.[5-MICS]
Among women who had a
live birth in the five years
preceding the survey,
48.7% received no TT
injection, 7.7% received
one injection, and 42.5%
received two or more
33
Known barriers**
Parents concerned about
side effects from 1st dose,
such as fever, rash,
diarrhea.[13-Parada]
Parents and communities
have refused future
immunization following
cases of the child
developing a fever postimmunization.[15-UNICEF]
Known motivations
and supports***
Children of urban,
better educated,
wealthier mothers
are the most likely
to have a health
card.[2-DHS]
Remaining
Questions
Current
practices
Current
practices
during pregnancy for the
most recent birth.[2-DHS]
For campaigns, bring
children of the
recommended ages to
immunization sites on
the day(s)
recommended. For a
house-to-house
strategy, keep those
children around the
home and have them
immunized when the
team arrives
Major reasons cited for not
seeking care/immunization
are long distances to reach
the health facility and a
perception that the
illnesses are not
serious.[15-UNICEF]
Timor-Leste MOH
has set
immunization as
one of its top
priorities, and the
Transitional
Administration had
undertaken a
national
immunization drive
in 2000 and
another in 2002.[5MICS]
Immunization is
more prevalent in
urban, lowland
areas and among
children of more
educated
mothers.[5-MICS]
34
Current
practices
HEALTH WORKERS
Key Behavior: Make patients/clients feel as comfortable as possible
Participant group (caregivers, etc.): health workers (individually and as a team in each facility)
EXISTING INFORMATION ON PRACTICES
Sub-behaviors
Current Practices
ANALYSIS BASED ON SITUATIONAL ASSESSMENT
Is this subbehavior
practiced?*
Known barriers**
Known
motivations and
supports***
Remaining
Questions
Take steps to minimize
waiting time and maximize
comfort of people waiting
Current practices
Attend to patients/clients in
the order in which they arrive,
with the sole exception of
persons with true
emergencies
Current practices
Provide privacy in
consultations
Women fear care
providers will spread
rumors about
them.[6-HAI]
Feasibility of
improvements
Most facilities lack a
private space for
delivery.[4-HAI]
Explain what you are going to
do and what you are doing
Always treat people with
respect and understanding
(never physically or verbally
abuse people)
Midwives have been found to
not speak with the patient at
all during ANC visits;
counseling is almost always
cursory.[4-HAI]
There is a perception that
some health workers have
unpleasant attitudes.[7DevBul]
Willingness and
ability to change
Willingness and
ability to change
35
Key Behavior: Give people essential information, confirm their understanding, and invite their questions
Participant group (caregivers, etc.): health workers
EXISTING INFORMATION ON PRACTICES
Sub-behaviors
Current Practices
For curative encounters:
explain the diagnosis in
simple language, the
treatment, and what the
caregiver needs to do after
the consultation (e.g., how
to give medicine, the
importance of giving all the
medicine; food and drink for
a sick child; danger signs
that should trigger an
immediate return visit);
confirm understanding and
invite questions
For preventive encounters
(immunization, vitamin A,
growth promotion, prenatal
visit): explain what you are
doing and its importance in
simple language, thank the
caregiver for their efforts,
explain what the caregiver
needs to do next (e.g., when
they should return), confirm
understanding, and invite
questions
ANALYSIS BASED ON SITUATIONAL ASSESSMENT
Is this subKnown
Known motivations Remaining
behavior
barriers**
and supports***
Questions
practiced?*
Current practices
ANC visits rarely include quality
counseling; communication with
patients is generally poor.[4-HAI]
Health
education
materials for
maternal,
neonatal and
child health
are very
limited.[4HAI]
Less than one quarter of men
interviewed (24%) spoke to a doctor
or health provider about the
pregnancy care or health of the
mother of their last child in the five
years preceding the survey. Topics of
discussion were types of foods eaten
during pregnancy, how much rest she
should have during pregnancy and
type of health problems for which she
should get immediate medical
attention.[2-DHS]
36
Current practices
Instructions:
*If possible go beyond simply yes or no. Say “almost all,” “most,” “some,” “a few,” etc. Also note any information on differences
among rural/urban, province or cultural group.
**See the list of barriers that may apply.
***People’s motivations may be very different from the scientific reasons why WE believe people should carry out practices. Please
record only information based on what people have actually said. Supports are existing factors that facilitate behaviors, e.g. most
people already have soap in their homes, which would be a support to hand washing.
Please number all sources of information (documents and key informant interviews) and put the sources of information in
parentheses in the chart, e.g. (19).
Barriers to Behavior Change
Possible BARRIERS to (positive, desirable) changes in practices. (SUPPORTS to improved behaviors are often the opposite of
these (e.g., no money vs. sufficient money for transport)
EXTERNAL
BARRIERS
Lack of money
Lack of time
Poor access to
services and
technologies
Examples or Description
 Limited or no money to buy essential products, pay for services, pay for transportation
 Limited or no time to do new behavior
 Limited availability of water, latrines, soap, and other essential and appropriate hygiene products and technologies
 Poor physical access, because of long distances to services, no public transportation to reach services, and poor
condition of roads to reach services throughout the year
 Poor access to essential technology (e.g., soap, bed net, vitamin A capsules, iron pills, contraceptives, etc.) or other
Poor quality of
services and
technologies
essential resources
Insufficient or unreliable availability of health personnel, drugs/vaccines, blood, medical supplies or equipment
Limited days and hours of services
Poor quality of service compared to best practices
Service norms and provider behavior that do not accommodate local cultural beliefs and perceptions, and/or client
preferences
 Poor provider treatment of clients, public humiliation and abuse
 Health system problems such as lack of interest and encouragement of client orientation and lack of funding or




37
appropriate technical norms, which may limit providers’ ability to change practices or procedures
Negative policies
Non-supportive
cultural norms
Lack of needed
skills
INTERNAL
BARRIERS
No or low intention
 Bad quality of some technologies (e.g., condoms that break, latrines that fill up with water)
 Current policies discourage key practices (e.g., taxation on bed nets, charges for services, which providers may





perform specific services)
Cultural norms limiting independence of mothers to carry out improved behaviors
New behavior contradicts firmly-held cultural beliefs or values
Lack of skills and confidence to do the new behaviors
Difficulty of doing the new behavior (i.e., skill level and/or degree of other environmental and cultural barriers)
Difficulty of people remembering what to do, when and how (e.g., date for the next vaccination, maternal or child
health danger signs, when to wash hands)
Examples or Description
 Lack of awareness of the problem and/or of feasibility of doing something about it
Emotion that
discourages action
Lack of practical
knowledge
Perceived risks
 Perception that one should not try to do anything (including fatalism resulting from belief in destiny, God’s will,
Perceived
consequences
Negative perceived
norms
Lack of self-efficacy
 Judgment that benefits of the new behavior not worth the effort required
curses, etc.)
 No or low knowledge of what to do and/or knowledge and skills of how to do new behavior
 Fear of bad consequences/perception that the new behavior may lead to physical or psychological harm (e.g., fear of
criticism or punishment, or belief that a vaccine or medicine will have serious side effects, including sterilization)
 Perception that new behavior is not the group norm
 Low or no confidence in one’s ability to do the behavior
38
Cross-Cutting Issues
Service Utilization

Quality: Most health facilities lack of running water and/or electricity and many have no on-site radio communication.[4-HAI]
According to another source, all districts have ambulances and community health centers have radios.[17-Snell]
There are complaints that drugs are often unavailable in clinics.[13-Parada]
When the population was asked about their overall satisfaction with the services provided by the health care facility closest to
their home, the median satisfaction score of 5.8 (on a scale of 1 to 10) indicates modest satisfaction, i.e., “not very good yet also
not very bad.”
A Maternal and Child Health District Programme Officer is assigned to each district health team and responsible for improved
quality of care. [17-Snell] Supportive supervision and on-the-job training of health care providers is the responsibility of the district
health service staff but this type of monitoring and capacity building is limited, especially for isolated health posts.[18-Snell]

Facilities: In the public sector services are provided by six hospitals, 67 Community Health Centers, 174 health posts and 87
mobile clinics. These facilities serve a population of about 925,000 divided between 13 districts, 65 sub-districts and 446 sucos
(villages).[18-Snell]

Access and Use: Heavy rains during the peak rainy season (December – February) make access to health facilities impossible
or unsafe for many communities. Only district capitals have on-site transport for emergencies, but low fuel budgets and limited
number of vehicles are common constraints.[4-HAI]
Many women are shy, frightened, and/or embarrassed to be examined/treated by male doctors. Women may need permission
from their husband or mother/mother-in-law. People lack understanding of need for care, mistrust services, and believe strongly
in traditional medicine.[2-DHS]
According to the 2003 DHS, ever-married women who reported that they have “big problems” in accessing health care for
themselves identified the following difficulties: distance to health facility (63.6%), having to take transport (62.2%), not wanting to
go alone (61.7%), getting money for treatment (59.3%), knowing where to go (26.7%), getting permission to go (17.9%), concern
about no female provider (4.4%), and any of these specified reasons (75.9%).[2-DHS]
Approximately 1 in 10 households report not using any health care provider when a household member is ill.[2-DHS]
39
For curative health care encounters 58.9% occur in community health centers, 24.6% in government hospitals, 11.4% in private
clinics, 3% at health care provider’s home and 2.1% in mobile clinics. Findings suggest that some people are bypassing their
community health center and instead seeking care at the nearest hospital. Mean travel time to the usual first health care provider
is 35 minutes and this travel is predominantly done on foot.[2-DHS]

Total Fertility Rate: The TFR is estimated to be among the highest in the world (between 7.4 and 8.4) and rising. According to
age specific rates, 1/3 of young women are giving birth in any given year.[2-DHS] The exceptionally high TFR has implications for
potential ANC, delivery and postnatal/partum service demand. It also suggests very short birth intervals, which are highly
correlated with increased maternal and infant mortality.

Nurses: According to interviews, the main first-contact health provider in rural areas is the local nurse. In urban areas, doctors
and nurses are nearly equal in terms of being the usual first-contact health provider.[2-DHS]
The National Centre for Health Education and Training (NCHET) has established training programs for nurse practitioners,
nurses and other technical personnel.[19-Povey]

Fear of using health care facilities was widespread due to post-referendum violence, including chronic intimidation of patients and
physicians by militias and Indonesian army troops, militarization of health facilities and violence toward health care workers.[7Stein]
Barriers to Improved Practices

Malaria Prevention: Groundwater and sewage drainage canals are dammed to produce areas of sludge that are used to grow
green leafy vegetables to sell. These areas of sludge are prime mosquito nurseries and for this reason should be cleared;
however, doing so would decrease the amount of fresh vegetables available as well as remove a source of income for poor
families.[19-Povey]

Malnutrition: In areas such as Ermera, coffee cultivation for export often takes the place of subsistence farming and hence
reduces food availability.[19-Povey]
According to national and other health surveys, mean rates of wasting range from 12% - 18.7%, stunting from 41% - 58.9%, and
underweight from 42.6% - 65.4% among children under five.[11-Bucens] [Unofficially the 2006 CARE survey found stunting at
almost 70% of under 5s.]
40
There is a high case-fatality rate (12.9%) for children admitted to Dili National Hospital and treated for severe malnutrition, which
may in part be due to limited monitoring facilities, unavailability of essential drugs and milk, poor ward hygiene, grossly
inadequate plumbing, and low nursing standards within the hospital.[11-Bucens]

Reproductive Health: Discussion of sexuality is taboo, an attitude reinforced by Catholic influence. Forced contraception is
reported to have been common during the Indonesian occupation, and as a result health officials do not want to promote family
planning too strongly. Additionally, the Catholic Church has endorsed the Papal prohibition against any form of artificial birth
control, including condoms.[19-Povey]

Women’s Role in Decision-making: At the community level, tradition rules and the right to make decisions is directed by
gender, age and kinship. There is a strong cultural belief that women only have a minimal role in decision making at the
community level, although older women may have some say, as they have more social status than young women, especially if
they are from noble families. Women are considered to have a voice in decisions at the family level. [27-Oxfam]
Feasible Behaviors

Delivery with Skilled Birth Attendant: Delivery at a health facility goes against traditional practices, facilities are largely
inaccessible to a woman once labor has begun, there is a lack of private space for deliveries as well as materials women
traditionally use for birth, e.g., rope hanging from the rafters for support, fire, bamboo platforms and large quantities of hot water.
It is likely more feasible to increase women’s contact with and use of skilled birth attendants by promoting outreach through
mobile clinics and home visits. Otherwise, health facilities might consider providing more of the comforts of home as they are
appropriate for safe delivery. [1-HAI]

Cultural Practices: Mothers stay indoors, sometimes for as long as three months postpartum. There appear to be strong beliefs
about wind and cold making infants sick. Also, the sun must not touch the baby. These beliefs have implications for postpartum
health facility visits: it may be necessary to do home visits instead.[6-HAI]
In general, young people do not want to neglect traditional values and believe that these values should be modified but not
disappear. For young women this issue is more challenging than for young men, as there is no gender equality in traditional
customs. The concept of women participating in decision making and sharing power with men is relatively new.[22-Wigglesworth]
Media and Materials
41

Traditional Media: Songs and poetry, widely known by older people, are usually performed at marriage ceremonies and
funerals. Traditional information dissemination usually involves a “trusted messenger,” but these messengers are sometimes
confused and people often do not trust their accuracy. Messengers are often traders, priests, government officers, or police
officers.[23-ComHab]
Support of community leaders is beneficial for health promotion messages, but people have more trust in health workers for
health-related information.[13-Parada]

Modern Mass Media: In Manatuto district, 50% of respondents listen to radio. The favorite listening time is between 18:00 and
20:00 (29.91%) and “RTTL” is the most popular radio station. There also exist community radio stations. News is the favorite type
of radio program, followed by music and religious programming. People in Manatuto expressed a desire for a greater range of
mass media and programming.[23-ComHab]
Radio ownership in rural areas is less than 30% and only about 10% of rural households have a TV.[5-MICS]
Women are less likely to be exposed to the media than men.[2-DHS]
Urban dwellers are more likely than rural dwellers to receive health messages via mass media. Rural dwellers tend to get their
health information from public talks or lectures.[13-Parada]
In Baucau, the District Administrator has an hour radio slot every Sunday on community radio for local news. Community radio
may be a good mechanism for spreading messages on a regular basis.[14-Schubert]
For about three years, CARE has been involved in the production of a colorful educational magazine for students called Lafaek.
CARE produces two other magazines: one for younger children just beginning to read, and one for teachers. These magazines
include health topics and reach about 50% of the population.[14-Schubert]

Languages: In Manatuto, 98.6% of respondents understand Tetun, 78% understand Galolen and 72.8% understand Bahasa
Indonesian. Although less than 15% of respondents understand Portuguese, it was preferred for reasons of “obeying regulations.”
Many in East Timor favor Tetun as an official language as a means of enhancing national self-esteem; English is rapidly
becoming the second language, because the major providers of aid, trade, and jobs use English.[23-ComHab]
In schools teachers predominantly use a combination of Tetun and Portuguese depending on their own strengths and the ability
of the students to use these languages. While Tetun is identified as the most commonly spoken language, Bahasa Indonesian is
significantly represented in schools.[24-Quinn]
Many people in isolated communities are most comfortable using their own local language.
42

Literacy: Adult literacy, presumably including Portuguese and Indonesian, is estimated at 10%.[19-Povey]
Two-thirds of women and half of men between the ages of 15 and 60 are illiterate; between 10% and 30% of primary school age
children still are not attending school.[25-UNDP]
Primary school attendance among 7-12 year-olds is around 90% in Dili/Baucau, but in rural and highland areas only about 70%.
About half of adults claim to be literate, with higher rates among males, highland dwellers, and urban dwellers.[17-UNDP]
Women and girls have low access to education. Husbands don’t allow women to study because there is much work to be done at
home, but then use women’s lack of education as a reason for excluding them from important decisions.[27-Oxfam]

Health Workers: For information on malaria, survey participants indicated that most came from talks/lectures or posters by
health workers. Despite this, some community leaders stated that they have never heard any campaigns about malaria.[13Parada]

Women’s time: Women are busy with washing, preparing food, organizing food from the gardens, weeding gardens, gathering
water, feeding animals, selling, making handicrafts, gathering firewood, etc. They do not having time to attend meetings.[27Oxfam]
Family Dynamics

Decision Making: Over 50% of women in both rural and urban areas make decisions jointly with husbands regarding health
care. Only about 32% of women interviewed may decide freely about their own health care.[2-DHS]

Fathers play a role in taking care of the mother and child right after birth: they look for firewood, make tea and rice porridge for
the mother, bathe the child, heat water, look for good food for his wife and child, and look for traditional medicines. Fathers often
care for infants to help the mother during meal preparation times. Fathers are aware of the health of their children and often play
an active role when the mother or child is sick.[26-Oxfam]

A World Vision baseline in Bobonaro District found that a grandmother was the most common child caretaker (37%), followed by
mothers (25%), husbands (17%) and others.[25-UNDP]

On average, women spend more hours awake and have a greater variety of tasks than men.[12-Agus]
43

Three percent of children under age 15 are not living with a biological parent and just over 5% have lost one or both parents.
Among 10-14 year olds, the figures are 5% and 9% respectively.[5-MICS]
Community Dynamics

Weddings, newborn celebrations and funerals are all very important social activities attended by family and non-family
members. Other important social events with high attendance include Independence Day celebrations, harvest celebrations,
Istilu, and Karementan.[23-ComHab] High attendance rates may indicate good community cohesion.

Village chiefs are sources of information, primarily on issues of village development, public service and on moral and social
relationships.[23-ComHab]

Religious leaders are highly respected and generally considered good sources of information; people accept the church’s role in
disseminating information on any issue. [23-ComHab] Churches are known in Timor-Leste for their ability to mobilize people and
disseminate messages.[15-Schubert]
Under Indonesian occupation, in large part due to the power of the Church as a source of resistance and humanitarian aid, 90%
of East Timorese became at least nominally Catholic, while continuing animistic practices.[19-Povey]

General health information is usually obtained from the medical care center (32%), health official (13%), local apparatus (13%)
and media (13%). Information on child bearing is obtained from local political party (62%), health official (13%) and friends
(5%).[23-ComHab]

Perceptions of poverty: The perception of poverty is not directly related to the amount of assets one has, but to the hamlet’s
(aldeia) system of kinship relations. People are poor if they have broken kinship ties, such as widows, widowers, young orphans;
are old people (men and women) who have no sons and cannot work for themselves, or are disabled people who have no family,
etc.[27-Oxfam]

Gender Based Violence: Communities’ believe that violence is a legitimate form of education and punishment. Both men and
women participants consider certain forms of aggression as normal.[27-Oxfam] More than half of women report intimate partner
violence and 41.5% reported physical injuries. Common types of reported violence include refusal to give money for food, insults
and swearing, threat of injury, threatened with a weapon, hair pulling, slap or arm twist, hit with fist, pushed or kicked, choked and
forced sex with partner. Arguments over money and children are reported as the most common factors that contributed to their
partner’s abuse. Higher rates of violence were generally associated with lower levels of education and literacy and rural women
were at significantly greater risk for sexual coercion by a partner.[21-Hynes] Rape was a common traumatic event during the
period of conflagration, and the culture stigmatizes raped women and children born of rape.[19-Povey]
44
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