Published on International Journal of Health, Nursing, & Medicine
Publication Date: July 4, 2019
Nur Wulan Andadari
Department of Environmental and Development Sciences Studies, Universitas Brawijaya
When urban women attack each other on social media because of fashion, two other mothers die every hour while struggling in labor and it can be said that the mortality rate is quite high. The high maternal mortality rate does not only occur in remote areas, but also in areas that can be categorized as close to urban areas, where one of them is Kediri Regency. For these problems, the research was conducted to examine the impact of beliefs and culture on healthy living behaviors from the perspective of the health beliefe important models to do. The research approach used is a positivist or scientific approach using SEM-PLS analysis techniques. The data used are primary data distributed to 100 respondents. The results of this study indicate that the entire direction of influence in the research model proved to have a significant effect. So that it can be said that the research model built on theory is in accordance with the facts in the field. However, with still high maternal and infant mortality rates, the quality of Indonesian health services is still low, especially in villages, knowledge and cultures that have not been oriented to health and safety. The existence of health promotion and education about the healthy behavior of pregnant women who will later be able to avoid themselves from the dangers of death, will make mothers become more confident (Self-Efficacy).
Keywords: Confidence & Culture, Healthy Living Behavior, Health Belief Model, AKI & AKB.
When urban women attack each other on social media because of fashion, two other mothers die every hour while fighting in labor. A case that had also been experienced by Kartini’s mother in the past. At least about 20,000 women die from complications giving birth every year in Indonesia, and until now Indonesia still receives red report cards for high maternal and infant mortality cases (Putri, 2019).
This is evidenced by data that shows that the Maternal Mortality Rate (MMR) and Mortality Rate (IMR) in Indonesia are still high. In 2017, the mortality rate after birth (neonatal) is 15 per thousand live births. With that number, Indonesia is in ten countries with the highest neonatal mortality rate in the world (Utami, 2018).
In fact, based on the 2017 World Bank Report, in one day there were four mothers in Indonesia who died from childbirth. In other words, there is one mother in Indonesia who dies every six hours. Through data One of the data presented is data from the ASEAN Millennium Development Goals (MDGs) in 2017. The data shows that in 2015 maternal deaths in Indonesia still reached 305 per 100 thousand. This figure is three times higher than the Indonesian MDG target, which is 102 per 100 thousand. This figure places Indonesia as the country with the second highest death rate in Southeast Asia. The first place was placed by Laos with a mortality rate of 357 per 100 thousand (Priyambodo, Noorputeri, & Yordan, 2018).
Referring to this phenomenon, the Indonesian government itself is not without effort. This is evidenced by the achievements of the Indonesian Ministry of Health in 2015-2017 which showed a decline in the number of cases of maternal deaths. If in 2015 MMR reached 4,999 cases, in 2016 it decreased slightly to 4,912 cases and in 2017 it experienced a sharp decline to as many as 1,712 cases of AKI. However, despite the decline, it seems that AKI is still one of the government’s main focuses in realizing a healthy Indonesian society (Agung, 2019).
This does not seem to be a figment, considering the issue of the Maternal and Child Mortality Rate is also the focus of the campaign program of Prabowo and Sandiaga Uno, which in fact is still a candidate for president and vice president. The presidential and vice presidential pairs are also enthusiastic to think of effective strategies and ways to deal with the problem. Prabowo-Sandi wants to ensure that the causes of death of one of these two Indonesian mothers can be reduced and completed with programs that ensure a reduction in mortality in mothers and infants (Gatra, 2019).
However, it can be ascertained that these efforts will not be easy. This is because Indonesia’s territory is so vast and has characteristics (both natural and social) and extraordinary and diverse cultural diversity. For this reason, mapping and categorization are based on priority scale for handling.
In an effort to accelerate the reduction of MMR, since 2012 the Ministry of Health launched a Maternal and Neonatal Survival (EMAS) program which is expected to reduce maternal and neonatal mortality by 25%. The program is implemented in provinces and districts with a large number of maternal and neonatal deaths, namely North Sumatra, Banten, West Java, Central Java, East Java and South Sulawesi. The basis for the selection of provinces was due to 52.6% of the total incidence of maternal deaths in Indonesia originating from the six provinces. So that by reducing maternal mortality in these six provinces it is expected that it will significantly reduce maternal mortality in Indonesia (Budiyanto, Yudianto, Hardhana, & Soenardi, 2016).
Referring to the six provinces, the authors are interested in pursing the study into the East Java province. This is because through information obtained from the results of USAID’s focus group discussion (FGD) with the media, it is known that one of the causes of high MMR and IMR in East Java is the low awareness of the dangers of pregnancy. Married wives often do not know the dangers awaiting when they bear the baby (Rahman, 2018).
Although there are also data that show that MMR and IMR in East Java tend to decline, although it is not significant, there are special records for horseshoe areas, namely Pasuruan, Probolinggo, Lumajang, Jember, Situbondo, Bondowoso, and Bayuwangi. Where in the 7 districts, during 2017 there were 125 cases of maternal deaths and 878 cases of infant deaths. This condition can occur because of the inherent role of culture in society (Rahman, 2018).
In the midst of problems that have not been completed as happened in the 7 horseshoe districts, there are 1 regency or region in East Java that make such efforts to reduce MMR and IMR and can be categorized as achieving positive results. The district is Kediri (SGI, 2017). During the years 2008-2016 or within the last 9 years there has been a positive progress even though it is not significant, it will be presented in full in the following figure (Laksono, 2016):
Figure 1. Number of maternal deaths in Kediri in 2008-2016
From these data, it reminds us all that in 2012 Kediri Regency was once the ministry locus with 37 deaths and should be grateful because in 2-14 and 2015 we could go down the same level, namely 17, then in 2016 it fell to 16 mothers . Then for the infant mortality rate in Kediri Regency for the last 10 years, the progress was not much different, experiencing positive progress but not significant. The full data will be presented in the figure below (Laksono, 2016):
Figure 2. Infant Mortality Rate in Kediri Regency in 2007-2015
Speaking of causative factors, maternal obstetric status died in Gravida II with a productive age. For birth attendants before death 63% were helped by DSOG and 38% were helped by midwives. This figure shows that the regional government should be. further improve the quality of human resources so that the mortality rate can be reduced to a minimum. The highest mortality period was during the puerperium, which was 44% on day 8-14 days as much as 57% so that it is proper for health workers to be more careful in handling postpartum mothers (Laksono, 2016).
Then the causes of maternal mortality in 2016 were more dominated by Bleeding and Pre Eclampsia, each weighing 45.45% while the remaining 9.09% with other causes. This is very different from last year where the PE and Bleeding rates were very small at 17.65. While delivery assistance was 62.5 childbirth assistance assisted by SpOG with the type of labor 55.6% of the sectarian section and 37% were assisted by the midwife (Laksono, 2016).
Furthermore, in infants the cause of death with Asphyxia returned to the top of the list above the LBW last year in the top rank. The mortality rate from asphyxia which was originally 39% increased to 44%. While the number of cases is 252 with 52 deaths so that CFR is 20.6. Followed by LBW 44%, congenital malformations 20%, infection 4%, and other causes 1% so that it requires high intervention and focus. Maternal perinatal audit with the aim of maintaining and improving the quality of MCH services through efforts to implement clinical governance is one of the efforts to reduce MMR and IMR. HR improvement through trainings and refresing include management of fiction, management of LBW management and Integrated Management of Young Babies (Laksono, 2016).
In an effort to reduce the MMR, the Government of Kediri District through the Health Office has since 2014 launched an effort to approach and familiarize it with the Family Care Movement program with the aim of accelerating the improvement of nutrition and maternal and child health focusing on the first 1000 days of life. all relevant agencies, both government and private, make efforts to protect and support programs to accelerate the reduction of MMR and IMR. This program ensures all roles of all parties to contribute to health problems, especially maternal and child health. So that it is expected that AKI and AKB can go down significantly (Laksono, 2016).
This is in accordance with the health promotion theory proposed by WHO (1986) in the Ottawa Charter charter which states that Essentially the Basic Thought of Health Promotion is an activity to convey health messages to the community, groups or individuals. There are many health problems in Kediri Regency, including the emergence of Extraordinary Events (KLB) which are closely related to the behavior of the community itself, for example, AKI and AKB (WHO, 1986).
Elements of community behavior that are still closely related to culture and trust try to be eliminated by the government by cooperating with shamans to become partners of midwives who will be fostered by health workers. This is because trust in culture is done without a foothold, especially in the health domain, especially the health of pregnant women, of course, will provide a very large risk opportunity for the safety of mothers and babies (Juariah, 2018).
This condition is supported by research conducted by Devy & Haryanto which states that the majority of respondents still believe and carry out maintenance of pregnancy in accordance with the form of elements of Madura cultural ideas, activities, and relics. Madurese culture in the care of pregnancy is hereditary expressed by the family and community of respondents, so that the behavior carried out and beliefs held will continue to follow these beliefs and culture (Devy & Haryanto, 2011).
Furthermore Juariah (2018) who also gave a suggestion that the Karangsari Village community still followed the habits that mothers must carry out during pregnancy and also restrictions / prohibitions that should be avoided by pregnant women, with the belief that the abstinence would be harmful and would cause bad things for the mother and the baby she was carrying. The Karangsari Village community also maintains the traditional monthly and seventh opat ceremonies, although in its implementation it is adjusted to the abilities of pregnant women and their families. The husband is involved in his wife’s pregnancy by following the necessity and abstinence and believes there will be bad consequences if he does not follow the habit. Health workers and their utilization are side by side, although maraji has authority, especially in ceremonial rituals (Juariah, 2018).
Furthermore Nurhidayanti et al (2018) who gave the opinion that the people he studied preferred shamans as birth attendants because the community believed that shamans were more experienced in assisting childbirth, traditional birth attendants were also considered more attentive and patient in serving their patients. The selection of shamans as birth attendants is related to the services provided and the trust of the community itself (Nurhidayanti, Margawati, & Irene, 2018).
Masyudi et al (2017) In the study, it was given a different opinion that the public trust in shamans due to cultural factors and had fallen down, traditional birth attendants became traditional leaders in the Central Kluet community and entered into the village structure, it would increasingly make the midwives face the tough challenges of serving in the Kluet Tengah region is considered to be the Central Kluet Location which is far from the Government Center, access to difficult areas and the lack of available Health Facilities and exacerbated by cultural orthodoxy that is inherent in its village structure (Masyudi, Winandar, & Indiraswari, 2017).
Other contradictory opinions that assume that trust and culture will increasingly make the confidence of pregnant women to be healthy and safe, the lower are the opinions expressed by Morris et al (2014) which states that high maternal mortality rates reveal a number of traditional health care practices and beliefs that have an impact on women’s health seeking behavior. The following socio-cultural barriers to health are identified: 1) lack of knowledge, 2) risky practices, 3) delay in seeking biomedical care, and 4) family and community expectations (Morris, Short, Robson, & Andriatsihosena, 2014).
Referring to the phenomenon and background of the problem described earlier, the author feels that research on the impact of beliefs and culture on healthy living behavior is reviewed from the perspective of the health beliefe an important model to do.
2. Theoritical Study
2.1. Health Belief Model
The Health Belief Model theory is a theory of health behavior change and a psychological model used to predict health behavior by focusing on individual perceptions and beliefs about an illness. According to this theory, individual behavior is influenced by the perceptions and beliefs of the individual itself regardless of whether the perceptions and beliefs are appropriate or not in accordance with reality. In this case it is important to be able to distinguish objective and subjective health assessments (Priyoto, 2014).
According to the World Health Organization (WHO) what is meant by health or health is a body condition that is complete physically, mentally and socially, and is not only free from an illness and disability or disability, whereas according to law No.36 of 2009 About Health, health is a healthy condition, both physically, mentally, spiritually and socially, which enables everyone to live productively socially and economically.
Belief in English means trust or belief. According to researchers belief is a belief in something that gives rise to certain behaviors. For example individuals believe that learning before an exam will affect the test scores. This type of trust is sometimes without the support of other theories that can be explained logically.
The model is someone who can be used as a role model or example in the behavior, ideals and goals that an individual will achieve. Usually this modeling theory is very effective in the development of children at an early age, but in this research material modeling theory is included in an issue or experience of a pregnant woman who has a history of illness and is trying to get alternative treatments or treatments that are safe and not threatening the safety of her soul.
The health trust model (HBM), developed by Becker and Maiman 1975, is useful for explaining self-care activities such as diabetes management recommendations and has a focus on behaviors related to disease prevention. The basis of HBM is that individuals will take actions to prevent, control or treat health problems if they feel the problem is getting worse; If they feel that the action will produce or produce the expected results; And because of the negative consequences of therapy (Adejoh, 2014).
2.2. Health Belief Model Dimension
The HBM theory is based on understanding someone will take actions related to health based on their perceptions and beliefs. This theory is outlined in five aspects of thought in the individual, which influences decision making in the individual to determine what is good for him (Priyoto, 2014). Whereas Champion and Skinner (Cited by Glanz et al, 2008) expresses the existence of six aspects of health belief model (HBM), i.e. (Galanz, Barbara, & Viswanath, 2008):
a) Perceived Susceptibility
Perceived Susceptibility is a person’s belief in the perceived vulnerability of the possibility of being exposed to an illness. This refers to a person’s subjective perception regarding the risks of his health condition.
b) Perceived Saverity
Perceived severity is related to an individual’s beliefs or beliefs about the seriousness or severity of a disease if he gets it and does not handle it, including evaluation of medical and clinical consequences. Feelings about the seriousness of an illness include evaluation of the condition of his health.
c) Perceived Benefits
When accepting perceptions of self-vulnerability and also being believed to be serious as a threat, it determines certain actions that might be taken.
d) Perceived Barriers
Potential negative aspects of a health effort (such as: uncertainty, side effects), or perceived barriers (such as: worry of being unsuitable, unhappy, nervous), which might act as an obstacle to recommending a behavior.
e) Cues to Action
To get the right level of acceptance of vulnerability, awareness and the benefits of action, signals are needed in the form of external factors. These factors, for example messages on mass media, advice or advice from other family members of the sick person and so on (Notoatmodjo, 2007).
Bandura Explains Self efficacy is a person’s belief in his ability to do something. People in general will not try something new without them thinking they can do it. If someone believes a new behavior is useful (perceived benefits), but does not think he is able to do it (perceived obstacles), then that opportunity will not be tried.
2.3. Belief and Culture during Pregnancy
Traditional communities in Indonesia see cultural conceptions that are different from the concept of modern health. Foster dan Anderson in Rofi’i (2013) said health problems are always related to two things, namely the system of disease theory and the system of disease care. The disease theory system emphasizes the causes of illness, techniques for treating diseases. While the disease treatment system is a social institution that involves the interaction of several people. Viewed from the point of view of a modern medical system there are different perceptions of the community towards disease and can cause problems. Among them are the problems of death and pain problems. Both the problem of death and the problem of pain are actually inseparable from socio-cultural and environmental factors in the communities where they are located. It is realized or not the factors of trust and cultural knowledge such as conceptions about various taboos, causal relationships and healthy conditions of illness, habits and ignorance often bring positive and negative effects (Rofi’i, 2013).
Even though Javanese culture currently lives in a genetic space (inheritance) without its people knowing the truth, it continues to do as an option to maintain its existence. The art of living Javanese culture is found in the message, advice, karmic order or the wisdom of its ancestors, which has grown to this day in the social or family space. The art of living Javanese culture is still coloring and guiding its people to seek their identity and identity, without having to know the meaning and meaning. The firmness of Javanese culture that humans will not be able to escape the existence of abstract or mental space and spirit in the soul, such as dreams, ideals, dreams, wishes and desires (Rofi’i, 2013).
Trust in culture is done without a foothold, especially in the health domain, especially the health of pregnant women, of course, will provide a very large risk opportunity for the safety of mothers and babies. The following will be elaborated on the habits carried out by pregnant women seen from the cultural perspective and beliefs, complete as follows (Juariah, 2018):
Culture in the community has recipes for the right food or drink to facilitate the physiological process of pregnancy which is believed to have an impact on the smooth delivery and postpartum (Helman, 2002). Food recommendations for pregnant women as stated by M’soka et al in Zambia where pregnant women believe in the need for a balanced dietary (M’soka, Mabuza, & Pretorius, 2010).
The results of the Higginbottom study in Canada also found that pregnant women should eat more and or with a larger portion, drink lots of milk (as well as apple juice) so that the baby’s skin is good and also for the health and well-being of the fetus. (Higginbottom, et al., 2014). In addition, Otoo’s research in Ghana found fruits, crabs and raw bananas both for pregnant women because fruits and crabs make healthy mothers and fetuses and raw bananas hard so as to make the fetus stronger and also give strength to the mother during labor (Otoo, Habib, & Ankomah, 2015).
The Graft study that conducted a study of 35 ethnic women in Ghana about food beliefs and practices in pregnancy concluded that traditional foods and supplements have five functions, namely preventing anemia, strengthening the body of pregnant women, improving health, minimizing physiological disorders and maximizing baby’s health (Graft, 2014).
Behavior or habits during pregnancy must also be maintained as a form of protection against the mother and fetus. The need to maintain behavior and avoid fighting is emphasized in pregnant women (Naidu & Koleki, 2013; M’soka, Mabuza, & Pretorius, 2010). Pregnant women also only eat cooked themselves or their families, use religious artifacts and carry scriptures (Aziato, Odai, & Omenyo, 2016).