Introduction

The death toll due to the coronavirus disease (COVID-19) is still growing more than two years since the virus was first discovered in Indonesia in March 2020. As of 13 December 2022, 160,255 Indonesians have died due to COVID-19, whilst global COVID-19 deaths have reached 6,6 million.Footnote 1 In response to the pandemic, new policies and protocols for the management of bodies of the dead and funerals were instituted worldwide beginning in 2020, including in Indonesia, to prevent further spread of the infection (Wallace et al., 2020). The new COVID-19 burial protocol has affected grieving families in various ways, such as by preventing family members from being by the patient’s side during their dying moments, from physically touching the deceased, and from performing the usual cultural and religious rituals (Ministry of Health, Republic of Indonesia, 2020; Yardley & Rolph, 2020).

Many cultures and communities recognize the psychological and social values of funeral rites and rituals. Whereas rites are considered a broader category, such as rites of healing or passage, rituals are the actions that make up the rites (Cardoso et al., 2020). A study in India found that the inability to perform rites and rituals negatively impacted bereaved families, prolonged their grief, and reduced their wellbeing (Hamid & Jahangir, 2020). Funeral ceremonies were also forbidden in Italy during the first year of the pandemic, making the grieving process more difficult for families (Ingravallo, 2020). Moreover, a review examining how funeral practices impacted bereaved families’ mental health, grief, and bereavement found that the benefit of funeral rituals depends on the ability of the bereaved person to say goodbye in a meaningful way (Burrell & Selman, 2020). This review also highlighted the important role of mortuary workers during the pandemic who helped bereaved families with the funeral and the grieving process.

Indonesia has the largest Muslim population in the world, and the country acknowledges six official religions (Islam, Protestantism, Catholicism, Hinduism, Buddhism, and Confucianism) as well as indigenous beliefs (Ropi, 2017). Religious and cultural funeral rituals are common in Indonesia when someone passes away. For Muslims, following the washing ritual and purification of the body, Islamic rituals dictate that bodies must be wrapped in a white cloth and buried without a casket so that the body can be laid on its right side facing the holy city of Mecca (Bayatrizi et al., 2021). However, in practice, these death rituals subtly vary across cultural groups because of the influence of local culture (Gabay & Tarabeih, 2022). For example, before and after the burial, local community members in Riau, Sumatra, visit the bereaved families to assist with the funeral rites and as a symbol of social support from the community (Susanti et al., 2022). In Jambi, Sumatra, family members give an Ajieng, which is a parcel containing matches and soap, to their neighbors who attend a funeral as a symbol of light for the departed soul and purification of the soul (Ramadani, 2022).

Cremation rituals are performed in other religions or beliefs, including among Confucians, Hindus, and Buddhists (Wardhani, 2022). The cremation rituals in Bali are called Ngaben, and they share the same philosophy as the Hindu rituals in India in that actual death is viewed as beginning during cremation; the cremation becomes the last offering to the gods (Djelantik et al., 2021; Ghosh & BK, 2022). Ngaben is perceived as a duty of the family members because it is believed that this ritual will purify the spirit of the deceased. Interestingly, due to increasingly limited burial space, cremation is also being performed among Christians in urban areas of Indonesia, following the example of other countries such as the UK and Italy (Guidetti et al., 2021; Lightbody et al., 2022).

The Christian communities in Indonesia also practice funeral rites and rituals associated with local cultures by incorporating them into Christian rituals. For instance, in Tana Toraja, Sulawesi, a famous cultural ritual is the Rambu Solo, which may be interpreted as a funeral ceremony held at sunset (Baan et al., 2022). Specifically, in the Lantang Pangngan rite (part of Rambu Solo), a person dearest to the deceased will sing a song of lamentation which shows that the deceased was very much loved by their family and community (Sudarsi et al., 2022). Also in Sulawesi, particularly in the Baebunta area, there is a traditional social practice called Turun, which resembles crowdfunding for the bereaved family (Tenrigau et al., 2021). The inability of family members to carry out such traditions and funeral rituals is considered a source of shame for that community. Elsewhere, in Nias, Sumatra, local church leaders take a critical-constructive attitude by applying interculturality in their funeral services to accommodate the local traditional death rites (Gulo et al., 2022).

Despite the diversity of funeral rites and rituals, previous studies have predominantly concentrated on the perspective of bereaved Christian families in the Global North, for example, in European countries (Hernández-Fernández & Meneses‐Falcón, 2022; Mitima-Verloop et al., 2022; Smith et al., 2022). The literature shows that understanding the funeral and grieving process from the perspective of mortuary workers could provide new insights into ways to provide better care and support for bereaved families. Therefore, this qualitative study aimed to explore the experience of not only bereaved family members who lost their relatives due to COVID-19 but also mortuary workers who performed funerals during the pandemic. Findings from this study could be used to improve funeral services for indigenous people in an emergency or crisis situation and to provide social support for the affected families and the mortuary workers.

Current study, funeral rites, and rituals in West Timor

This study focused on bereaved families and mortuary workers living in Kupang City in the West Timor area, which is administratively considered part of East Nusa Tenggara province, Indonesia. This province is located in the eastern part of Indonesia and had been consistently regarded as one of the most underdeveloped provinces in Indonesia in recent years (Beribe et al., 2022). As a region that has continually suffered from poverty, stigma, and discrimination (Bunga et al., 2021a), West Timor was strongly affected by the COVID-19 pandemic, which rapidly changed the educational (Bunga et al., 2021b) and social life of its people (Kiling et al., 2021), and could possibly further delay the overall development of the area.

Christianity is the major religion in this province. Ninety six percent of the indigenous people in the Manggarai area are Catholics, which was first introduced to the area in 1912 (Jebadu et al., 2021). Similar to other religions, acculturation processes are evident in the funeral rites and rituals among Manggaraian Catholics, such as the Kélah ritual; the local people believe that failure to perform this ritual prevents the spirit of the deceased from reaching their “final destination”. As another example, some ethnicities in West Timor have the tradition of bringing bodies to a cultural house in their hometown so that they can be buried with proper cultural rituals (e.g. prayers and dances). People in both West Timor and East Timor (Timor Leste) also have their own funeral rites and rituals, which are called haha metan (black words). In the meantime, the Tetum people on Timor island believe that to help the deceased spirit rest in peace, a series of ritualized practices must be performed to demonstrate the love their relatives have for them. Every night for a fortnight, people stay at the house of the deceased, bringing gifts such as candles and money, to offer prayers and mourn with relatives of the deceased. Then, a group of people accompanies the coffin on the burial day, saying prayers and singing hymns as they walk with the coffin. After the burial, candles and flowers are placed in the grave. Finally, everyone immediately leaves the cemetery to gather at the house of the deceased (Bovensiepen, 2014). These rituals were prohibited due to COVID-19 protocols. Consequently, conflicts arose because some bereaved families attempted to take the bodies of their loved ones to be buried traditionally with the appropriate rituals, thus not complying with the protocols (Karmini & Milko, 2020).

Methods

Study design and participants

This exploratory qualitative study used interviews as the main data collection method. An inductive approach was employed to make sure the results were derived mainly from participants’ stories and experiences. We used a simple interview guide to help the interviewers and participants focus on the main topic while also putting more emphasis on probing questions so that the interviews were directed by participants’ stories and perspectives. The interview guide consisted of five main questions, for example, “Can you share your experience with the funeral process of deceased COVID-19 patients/your family member?” The interview focused on probing questions that were tailored to each participant’s perspective.

Purposive convenience sampling was used to recruit mortuary workers. To determine eligibility, three criteria had to be met: (a) responsible for the burial process of COVID-19 patients, (b) age more than 18 years, and (c) working in West Timor. Meanwhile, purposive snowball sampling was used to recruit family members who met the following criteria: (a) lost a nuclear family member(s) due to COVID-19 in the last 12 months, (b) age more than 18 years, and (c) residing in West Timor. Four potential participants declined to participate due to being unwell or for no stated reason. In total, 10 bereaved family members and 12 mortuary workers participated in the interviews. Their details are presented in Table 1 below.

Table 1 Participant’s demographic data
Full size table

Research team

All authors except the fourth author are lecturers at a public university in West Timor. The first and third authors have lived in West Timor almost their entire life, while the second and last authors have lived there for the last 10 years. The first author has a PhD qualification in public health, the second author has a PhD in social science, the third author has a master’s degree in psychology, and the last two authors have a PhD in psychology with extensive experience in qualitative studies. Two research assistants also took part in this study as data collectors. They were undergraduate students studying at a university in West Timor. Both assistants were trained in qualitative methodology by the third author.

Research stages

The entire study took place from May 2021 to July 2021. This was during the second wave of COVID-19 in Indonesia, during which Indonesia had a 381% increase in cases within six weeks and strict health protocols were enforced nationwide.Footnote 2 The authors kept an audit trail and a diary to improve the trustworthiness of this study. An interview guide was developed by the last author to answer the research objectives regarding understanding the funeral and grieving process.

The study started with the identification of potential participants by the authors and research assistants using available medical records from two hospitals in West Timor. The research assistants then approached potential participants through personal contact. Potential participants were briefed on the study details and were asked to fill out the informed consent forms. Participants who agreed were then interviewed by phone or a WhatsApp call. During the interviews, the research assistant took the role of interviewer while one of the authors (AA, BB, or IK) provided technical support and supervised the research assistant. All interviews were conducted in a mix of Bahasa Indonesia and the local Kupang-Malay creole. The average interview time was 26 min, and several follow-up calls to participants were made to gain more information or clarify the collected data. The interview recordings were transcribed and translated into Bahasa Indonesia by the research assistants after each interview session.

Data analysis

Data were analyzed using a combination of inductive and deductive thematic analysis approaches (Braun & Clarke, 2006). We extracted codes related to the topic of the study (funerals and grieving) while also looking for unique codes that emerged from participants’ experiences (e.g. “covidized” [infected, affected, or influenced by COVID-19]). The first 10 transcripts were coded by the third and last authors and then checked by the first and second authors. These codes were then cross-checked against the remaining transcripts by all except the fourth author. The authors organized the codes and themes without using any qualitative research program or software. The themes were then discussed by all authors and sent to the participants to check whether the themes accurately represented their experiences. The drafting of the manuscript was completed by the last author with assistance from the other authors. The authors used the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist (Tong et al., 2007) as a guide when drafting the manuscript.

Results

The three themes produced from the thematic analysis were (1) covid 19 and funeral protocol; (2) inability to perform cultural and religious funeral rituals; and (3) stigma against bereaved families.

Theme 1: Covid 19 and funeral protocol

Patients who died from COVID-19 were subject to the standard COVID-19 funeral protocol published by the Ministry of Health of Indonesia (Ministry of Health, Republic of Indonesia, 2020). These procedures prioritized the safety of bereaved families and mortuary workers, including the use of personal protective equipment (PPE) by health workers, those involved in corpse decontamination, and others. Mortuary workers stated that they strongly approved of this protocol and strictly obeyed the health procedures to protect themselves and others involved in the burial. However, most mortuary workers argued that one of the major challenges they faced in following the funeral protocol was resistance from the patients’ families. They admitted that some bereaved families insisted on burying the body themselves so they could perform the funeral rituals they deemed appropriate. Some family members even accused health workers of giving a false diagnosis of COVID-19 on purpose to profit from the burial protocol. Agra describes this well:

We have applied the procedures as regulated, it is just that sometimes we were hampered by the patient’s family members. They did not accept the diagnosis that their deceased relative was infected by coronavirus, so they attacked us [verbally]. They even said that we tried to ‘covidize’ people for money. Until today, not even one cent has gone to our pockets. This complicates our job because many families have taken away the corpse by force so that they can bury the body themselves.

This resistance was also admitted by bereaved family members. Feni said in the interview that her family suspected that the health workers were trying to “covidize” deceased patients because her family did not receive a death certificate declaring that their father had tested positive for COVID-19. Bereaved family members had several other complaints, including poor coffin quality and poor time management by the mortuary workers.

Theme 2: Inability to perform cultural and religious funeral rituals

Living in a pocket of Christianity in Indonesia, people in West Timor have the habit of burying their beloved ones with both religious and cultural rituals. These rituals need time to prepare; hence, burials take place three to four days on average after the time of death. Mortuary workers stated that the COVID-19 burial protocol provided the resources and opportunity for bereaved families to do rituals during the funeral as long as the involved ritual performers (e.g. priest, cultural leader) wore standard PPE and the rituals were conducted within a short period of time. However, one mortuary worker said that due to the need to bury the body quickly—within four hours—during the pandemic, patients who died late at night often did not receive proper funeral rituals because the ritual performers were not able to arrive in time.

I also want to add that, in the future, it is better for the hospital to provide permanent [employment] for ritual performers. This is so that we will no longer have to wait for performers [hired by the family]. They usually came late to the cemetery. The body is not allowed to be outside for more than four hours, it has to be buried quickly, so we cannot afford to wait for a long time. We cannot endanger other people that are present in the cemetery. (James)

Mirroring the views of the mortuary workers, Virgin, a mourning family member, added that the short time given to prepare for burial did not allow them to conduct Catholic burial rituals. Because of this, she and her family members felt that the overall burial was “incomplete”. Other participants also added that the inability to perform rituals was hurtful to the grieving family members because they felt that they were not able to give their beloved ones a proper farewell, stating that they felt they had failed and regarded themselves as ungrateful family members. Inda and Defe said that according to their Savunese culture (an island west of West Timor), corpses should be brought back to the Savu island to be buried properly there. However, this and other similar cultural rituals could not be performed due to the burial protocol.

Theme 3: Stigma against bereaved families

In addition to the negative psychological effects caused by the inability to perform rituals, almost all the interviewed family members reported that they experienced stigma and discrimination. These experiences arose from the fact that they had a family member who had died because of COVID-19. People living around them were “afraid” of them and sometimes would refuse to meet with them, even after the burial. Virgin further shared her story of stigma and discrimination:

There is one thing that made everything so hard after the passing of my mom. One of our neighbors came to our house and started asking questions about what caused my mom’s death and then after that started accusing my mom of getting the virus because of us, the children, who carried the virus to our family. That person said that we disobeyed the protocols. Imagine that, saying these kinds of words to grieving families. Not just that person, but some other people, even my friends, had also asked some questions that really should not be asked. This has not helped me at all. Not at all.

Discussion

Using a qualitative approach, we gathered and presented the stories of bereaved families and mortuary workers in West Timor, Indonesia, two of the most vulnerable communities during the pandemic period. This section discussed the three themes that arose from the analysis: (1) covidisation and funeral protocol; (2) inability to perform cultural and religious funeral rituals; and (3) stigma against bereaved families. The primary issue related to the first theme of the funeral protocol is the health workers’ issuance of the death certificate, which was important to reduce the infection’s further spread. Participants in this study stated that the poor delivery or quality of the death certificate could trigger the belief that health workers were trying to “covidize” patients to gain profit from them. This study shows how crucial the death certificate was for families in Indonesia as society’s distrust of how the government managed the death of COVID-19 patients and the overall pandemic rose (Gill & DeJoseph, 2020). A previous study also found distrust towards healthcare professionals and services among Islamic families in Indonesia, which might be caused by unclear communication and information regarding COVID-19 funeral management (Nurhayati & Purnama, 2021). Another possibility is that these bereaved families were experiencing an “infodemic” that resulted in misleading information on the funeral protocol (Liem et al., 2021).

This finding also supports findings in previous literature (Burrell & Selman, 2020; Hamid & Jahangir, 2020; Ingravallo, 2020) that the funeral protocol prevented bereaved families from performing the cultural and religious funeral rituals they considered necessary. As previous literature has highlighted (Gabay & Tarabeih, 2022), care professionals have an important role in providing the basic right of a peaceful and dignified death to patients and in supporting the family through their grieving and bereavement, such as among religious minorities – Muslim families in Israel in the Gabay & Tarabeih (2022) study. Families in the current study who felt incomplete due to not being able to give their family member the proper funeral rituals shared a sense of guilt similar to that of bereaved families in the UK (Lightbody et al., 2022). In other studies, such disrupted bereavement and grieving processes were found to be associated with prolonged grief symptoms because the final memory of a loved one might become distorted (Bayatrizi et al., 2021; Djelantik et al., 2021; Gabay & Tarabeih, 2022; Smith et al., 2022).

Furthermore, mortuary workers in this study suggested that it is important that the government facilitates the support for bereaved families offered by religious leaders who perform rituals as needed. In light of this finding, a previous study noted that spiritual healers and religious leaders are an important part of Indonesian culture and belief systems (Liem, 2020). Previous studies among Muslims in Iran (Bayatrizi et al., 2021) and Jews in the US (Dajani et al., 2022) also highlighted the importance of engaging religious leaders in communicating the COVID-19 funeral protocol to bereaved families. These religious leaders are trusted by the community and can be helpful if modification of the funeral rites and rituals is needed (Suwalowska et al., 2021), and they can also provide pastoral care to the bereaved families (Gulo et al., 2022; Lightbody et al., 2022).

The last important issue found in this study, which is related to the third theme, was the fact that, in a close-knit community typical of developing areas such as West Timor, stigma and discrimination are highly threatening to the wellbeing of bereaved families. This has also been found in countries with similar settings, such as the Philippines (Kahambing & Edilo, 2020) and Colombia (Cassiani-Miranda et al., 2020). Stigma and discrimination toward bereaved families have been linked to loneliness and depressive symptoms (Bayatrizi et al., 2021). Similar to the families in West Timor in the current study, fear of stigma could lead people to refuse to believe that their loved one died because of COVID-19. The study among Muslim families in Iran found that families would request that a different cause of death be written on the death certificate to prevent discrimination by their neighbors (Bayatrizi et al., 2021; Ostadhashemi et al., 2022).

Limitations and strengths

The main limitation of this study was that it is possible that the different social statuses between the authors and the bereaved family members created differential power positions. All authors were lecturers, and all the interviewed family members were young adults who were mostly undergraduate students. This could possibly have affected their interview responses. However, the authors mitigated this by tasking student research assistants to do the data collection rather than the lecturers/researchers. A key strength of the current study, however, is that it provides perspectives from two participant groups, namely the bereaved family members and mortuary workers. This allows rich insights into an underinvestigated topic, particularly in a Global South country such as Indonesia.

Implications

Based on the interviews with the bereaved families and mortuary workers, five implications can be drawn to improve funeral services and social support for affected families and mortuary workers. First, internet and technology use such as videoconference sessions or recorded messages, both prior to the patient’s passing and during the funeral arrangements, should be made available to family members. Second, volunteer mortuary workers (including ritual performers) should work together with professionals who are experienced in managing funerals and funeral rituals, as suggested in a previous study (Wang et al., 2020).

Third, the providers of funeral services should maximize the use of technology and take a creative approach, for instance by posting obituaries through social media such as Zoom, YouTube, Instagram, and Facebook to engage the community members of the deceased person (Corpuz, 2021). A recent study showed that digital media has helped maintain interconnectivity between family and friends of Maori and Samoan people during their grieving (Enari & Rangiwai, 2021). As indigenous people with similar cultures and traditions, West Timorese might benefit from the same digital space, an interesting tool that the government and stakeholders should take advantage of.

Fourth, since the root of stigma is fear, it is of utmost importance for the government to continually educate society about the spread of COVID-19, reduce people’s fear of the unfamiliar disease, and promote togetherness to combat stigma and COVID-19. In particular, we highly recommend the involvement of religious leaders as they are trusted and respected members of society (Lightbody et al., 2022; Suwalowska et al., 2021). Fifth, stakeholders should pay attention to the wellbeing of mortuary workers as both their physical health risks (e.g. infection by COVID-19) as well as mental health risks (e.g. experiencing traumatic events, high on-the-job demands, and overexposure to death) are at stake (Overmeire & Bilsen, 2020). Thus, it is recommended that pastoral counselling be provided not only for the family members but also for the mortuary workers, considering that the mental exhaustion that they may experience could lead them to engage in maladaptive coping strategies and a decrease in empathy (Guidetti et al., 2021).

Conclusion

While the government and other stakeholders have concentrated on efforts to reduce the spread of COVID-19, bereaved families and mortuary workers are often left uncared for. Support is especially needed in regard to better funeral management, better education, and socialisation related totigmatizationn and COVID-19. Furthermore, mental health support specifically developed for mortuary workers is also necessary.