Bedouin Rural Health Project Children Safety in Northeastern Badia of

Jordan

Fadia Hasna, PhD

Mohammed Al-Smairan, PhD

Arab Children Health Congress 2010

Bedouin Rural Health Project

Funded by the European Commission

Framework 6 Programme -International Co-operation Programme (INCO-DEV)

With 2-3 Third Member Countries & 2 European or Associated Countries

Theme- health system reform

Bedouin Rural Health Project Partners

UK: University of Warwick (lead)

University of Oxford Jordan: The University of Philadelphia Lebanon: American University of Beirut France: Cermes, Inserm Sweden: The University of Stockholm

Northeastern Badia of Jordan

Lifestyle and Behavior affecting Child Safety

Lifestyle and Behavior affecting Child Safety

Clinics Location

Data Collection Methods

Method Location Total

A. In-depth non-structured interviews

1. Policy makers

2. Providers

3. Women in the community

B. Semi-Structured interviews

with women in the clinics

Policy makers Public sector, Royal Court, BDRP (MOH and Army), NGOs

RHCL village center, Azraq

(Public sector, MOH and private sector)

Alternative healers (private)

SSCL, NBCL, MACL, AZCL, RWCL, SACL, RHCL

SSCL, NBCL, MACL, AZCL, RWCL, SACL, RHCL

Public sector (MOH and Army),

10

RHCL: 3 with physician, nurse and driver

1 with private physician in Azraq

5 in Ruweishid, Northern Badia and Safawi regions

7 interviews with women users of services

7 interviews with women non-users of services

Total in-depth interviews: 33 interviews

6 per clinic

Total semi-structured interviews: 42 interviews

Data Collection Methods (Continued)

C. Audit clinic statistics and outreach immunization activities

SSCL, NBCL, MACL, AZCL, RWCL, SACL, RHCL

Public sector (MOH and Army) 7 clinics and 4 health directorates

D. Non-participant observation

MAQ check list as an instrument

SSCL, NBCL, MACL, AZCL, RWCL, SACL, RHCL

Public sector (MOH and Army)7 clinics to include comprehensive health centers CHCs, primary health centers and village centers

E. Focus Group Discussions

1. Providers

2. Women in the catchment communities of the clinic

3. Men in the catchment communities of the clinics

SSCL, NBCL, MACL, AZCL, RWCL, SACL, Mafraq hospital and private practitioners

Public sector (MOH and Army) and private sector

SSCL, NBCL, MACL, AZCL, RWCL, SACL, RHCL

Same households but men separately

8 to include comprehensive health centers CHCs, primary health centers as well as Mafraq hospital and private practitioners

7 for women

7 for men same households separately (culturally-sensitive)

Total FG Discussions: 22

F. Mapping

1. Location of clinics

2. Women interviewed in clinics residence

3. Households where FG Discussions done men and women

4. Households of women users and non-users (in-depth interviews)

5. Outreach locations of clinic services and health directorates for immunisations

SSCL, NBCL, MACL, AZCL, RWCL, SACL, RHCL

Zarqa, Mafraq, Ruweishid and Northern Badiia Directorate

7

42

7

14

Many

Total Maps: 5 to 6

Situation Analysis: Fertility & Mortality

Fertility in the Badia is higher than the other parts of Jordan : 7.8,while the national rate is 3.4

Uncontrolled, close to a natural regime where duration of post-partum amenorrhea is the principle factor affecting the length of inter-birth intervals

Slow decline in mortality over the last twenty years, but the overall mortality levels are still slightly high by national standards.

Causes of high Mortality

The high infant mortality rate in the Badia is a result of several sets of factors:

- Some of the babies in the Badia are still born at home especially

for nomadic Bedouins

- The short supply of clean and reliable sources of water

- Access to specialist health clinics and hospitals, especially in the remote areas

- Poor diet which leaves people exposed to infection especially during the damp cold winters

Health Status of Children

Infant mortality declined to 22 per 1,000 live births and child mortality to 27 per 1,000, (lower survival rates in rural and poorer income groups)

Child immunization levels 98 % for all antigens except for BCG (a vaccine against tuberculosis), and Jordan has been polio free for years.

Diarrhoeal diseases controlled, but risks of recurrence because of water and sanitation problems.

Acute respiratory infections (ARIs) are now the leading cause of death among infants, and young child illnesses.

Poverty and Settlement

Rural poverty is 19 % compared to 13 % urban poverty, and higher among children at 16 % because of the large family sizes and lower livelihood options

Fast population increases have caused shortages in food, water, arable land and economic opportunities.

Rapid urbanization is straining housing and other services in cities, while the scattering of rural populations in small settlements constrains equitable service coverage in remote areas

Morbidity

Poor sanitation and hygiene, malnutrition and a harsh environment go together to make the Bedouin prone to various classes and types of diseases

Respiratory diseases and chest conditions, brucella, hypertension, kidney diseases, dental caries and diabetes most common

Also hepatitis and dysentery are widely reported Other intestinal afflictions such as worms of various types are

also prevalent Inflammation of the eyes is more common among children than

among adults Milk may also be a health hazard in the region: consumed raw

and unprocessed

Diet

Food consumption patterns have changed during the past few decades

The Bedouin of the past ate less and with less variety Their meals used to consist of milk and milk products, they

hardly ever consumed vegetables and meat was limited to festive occasions

Now when the Bedouin took to a settled way of life, and especially for those who live in towns, vegetables are consumed, Pepsi always consumed as well as chips

Dental caries among children The most important health conditions relating to diet among

Bedouin children are: Anemia and stunting

Nutritional Status and Gender

The average Bedouin calorie intake is below the national average because of the living standards

For girls and women the food consumption is below that of the average male because of the prevailing traditions and cultural habits

Female early marriage and multiple pregnancies continue to act as a further drain on their health status

Immunizations

Immunization services are available at the clinics and through outreach services with regular campaigns

Sometimes unable to reach all of children of families that are nomadic or semi-nomadic to ensure complete coverage.

The Bedouins are more distant than us from civilization. We have to take the information to them. The last time we did a vaccination campaign we were searching for them because they wouldn't receive us. We would tell them that the vaccination is good for you and immunizes you from diseases. They would say no either because they were afraid or because they were far from civilization. That is what we face (AZCLP4).

In Azraq the citizens hear that there is a vaccination campaign and it's not even for them, but they come to get vaccinated although the campaign isn't for them. Since they are near in this area they come. As for the tents that are 30-40 km, if we can reach them, we vaccinate them, but if we don't reach them and the information about the campaign didn't reach them they don't get vaccinated…… in our last immunization campaign three weeks ago people ran off and refused to be immunized (AZCLP3).

Outreach Services

Outreach faces obstacles such as:- Lack of awareness among Bedouin that drives some of them to

escape the immunization campaigns - The coverage of outreach is not comprehensive due to staff, facilities

and equipment shortages - Mobility of Bedouins disturbs the comprehensive coverage of

immunization.- Mobile clinics are not cost- effective

"They are more distant than us from civilization. We have to take the information to them. The last time we did a vaccination campaign we were searching for them because they wouldn't receive us. We would tell them that the vaccination is good for you and immunizes you from diseases. They would say no either because they were afraid or because they were far from civilization. That is what we face." (AZCLP4).

Reproductive Health

Postnatal services are not systematic or regular. Family planning services are varying from area to another. Family planning in relation to Intra-uterine devices are not always

available owing to staff not being trained to insert them. There is a need for more female staff.

They are in a hurry. Most women don’t wait five minutes only when they come for immunization. They ask me to queue them because they have children at home waiting. Sometimes they don’t come and they send their mums, their sisters or their aunts. The habits and the customs also play a role in this matter. It is difficult for women to come out of their houses before 40 days of delivery (SSP4).

They come for immunization or for family planning. These things are more important to them than the puerperium period (SSP4)

Dental Health Assessment

Assessment of dental health services: what is available

Assessment of dental health of school children in Northern Badia

Health education: multi-sectoral, multi-disciplinary, participatory

School Dental Services

The present frame work of school dental services: - Dental health screening scheme by the local dentist.- Dental health education and promotion programs.- Annual smile day campaign.- Referral system of children in need for dental treatment. - Distribution of oral hygiene products such as tooth

brushes and tooth paste.- Fluoridated mouth rinse program.

Situation Analysis: School Dental Services

New concepts in Dental health education need to be considered.

Close supervision of the school food program. Condensed highly sugary milk distributed to the school children need to be stopped as it contradict the principle of preventing dental caries.

Lack of continuous professional training to dentists responsible in implementing the dental health education program.

Lack of supervision of fluoridated mouth rinse. There are documented evidences of the risk of taking higher dose of fluoride.

School Dental Health Assessment

Findings:- 107 Boys and girls in primary schools in Northeastern Badia- Only 12% of the children were completely free of dental caries - Only 18% of the participants had good oral hygiene compared to

82% with visible plaque. - Similarly the gingival scoring recorded more than half of the

children with noticeable gingival inflammation, while only the third experienced healthy gingivae

- Marked disparity between male and female related to oral cleanliness, the boys group had the worse condition in the three categories with 85%, 71% and 18%

Dental Health Intervention

Instructional sessions on importance of oral health and prevention of gum diseases and dental caries

Session followed by a motivational and educational animation program performed by two clowns who acted, played music and performed songs promoting key oral health messages.

At the end of the two sessions tooth brushes and tooth pastes were distributed to all children with leaflets

Table 1

On the first table there will be some articles of fruits, bread, sugar, chocolate bar, mars bar. Fizzy drink and crisps. The objective of this, is to correctly identify the cariogenic food by the participants

Photos

Photos

Table 2

The second table will have an illustration of the basic parts of the tooth and the tissue surrounding. The objective to correctly identify the basic part of the tooth and the importance of the surrounding tissue

Photos

Photos

Table 3

The third table will have an illustration of the decayed tooth and inflamed gum. The objectives is to correctly understand the healthy tooth and the gum and the common symptoms of both decayed and diseases gum.

Photos

Photos

Table 4

The fourth table will contain tooth brushes, dental floss with illustration how to practice proper brushing and flossing.

Photos

تنظيف أسنانك مرتين يوميا

تنظيف أسنانك مرتين يوميا من أجل إبتسامة

: دائمة , عليك بتناول الفواكه

والخضروات وإبتعد عن السكريات

تناول الفواكه والخضروات وإبتعد عن

السكرياتوال تنسى زيارة طبيب

أشهر6األسنان كل

وال تنسى زيارة طبيب إستخدام الخيط أشهر6األسنان كل

الطبي بين األسنان يوميا

إستخدام الخيط الطبي بين األسنان يوميا

Photos

Jordan's Badia School Location Effects on the Perception of Child Safety 

A study done by Al-Hmoud and Al-Aoun (2009) showed that because of the lack of effective planning, most of Jordan's Northeast Badia schools are located in dispersed areas away from residential communities, which force most children to walk for more than 5 minutes on dangerous traffic spines.

Methodology: (random sample) 263 teachers from 72 schools representing 50 villages of the Northeast Badia, in addition to interviews and field observations

Findings

The findings suggest that some public safety measures can positively affect perceived children's safety.

Situation Analysis - Disabilities

The exact number of children with disabilities is not known.

The health system needs to be better prepared To detect disabilities among children and cases of child

abuse. Consanguineous marriages are common, but their

contribution to the disability incidence among Jordanian children has not been researched.

Pre-marital testing and counselling services are being extended, but access is not yet universal, and compulsory genetic testing only covers thalassaemia.

Disability services in North Badia

The disability in Northern Badia is slightly high because of the relatives marriage

The disabilities concentrated in the field of mental, hearing and movement disability

Most of these disabilities are concentrated in male, but may be covered disability in females

In Northern Badia, there is just one society that deals with this group of community

Child Caring Society is the only one that is found in Northern Badia at Al-Saydiya village, 25 kilometer east of Mafraq and run by a Bedouin

الخيرية الطفل رعاية جمعية

Alternative Healers Locations in North Badia

Traditional Medicine

The most common diseases are the diseases related to children, for example the disease that doctors call measles, we call it "Fushit Dam", and we give the child "sheep Magher" which is the colouring on the sheep's back like red soil. We mix it with water and give it to the child to drink, and then we dress the child with a red dress, and with God's help he cures the next day (AZAH1).

We have a proverb which is "give a child Marmaka and Anzout (herbs) and through him away". It means when the child drink from these herbs he will be recovered. We used to spread the child body with Marwaha (herbs) if he has sun stroke and ask him to sleep until he sweat. Then he will become fine. We use Marmaka for diarrhoea (AZAH1).

I order the things from herb seller. They are expensive, for instance, if a mother became pregnant while she is breastfeeding a previous child, her child will suffer from severe diarrhoea. In this case we give the child a mix of honey and (Biradeh) which is prepared by the herb seller. Another example, we cauterise the woman who has repeated miscarriages, and give her Ja'edeh and another herb. We boil the mix and ask her to drink it (SAAH2).

Continue

I buy the stuff I need from a herb seller in Mafraq. After I buy them I grind the ingredients and bring some incense and ember, I then put the stuff on the ember. After that I bring some Za'ut, put some incense with it, and if a person is vomiting or has diarrhoea and you gave it to him, they become better immediately (NBAH3).

For Ukht IlA'iel, it's when the child stops eating, vomits and has diarrhoea. He eats food and after that he collapses, it's like he gets poisoned, and the child also suffers from stomach aches (NBAH4).

After the hospital opened I stopped delivering babies. They bring children to me as to treat them. Dr.A (a doctor who used to work in the hospital) used to send women to me to treat their children. Doctors have science, while we Dayahs have life experience. I used to go with my mother and see how women give birth. I helped women deliver their babies two times on my own, one of those times a woman gave birth to twins (RUAH5).

Recommendations

1. Health education and awareness programs targeting women:

• Marriage patterns• Fertility and family planning and relationship to

health status• Nutrition• Children safety

Nowadays, a number of women in the North Badia have a good level of education, highest university education level per capita in Jordan (DOS)

Mostly employed in the Ministry of Education and Ministry of Health

Recommendations

2. Health promotion activities and programs in schools

• Dietary guide lines to the school’s cafeteria to reduce the sugar intake and promote a healthy reduced sugary food in the national food program.

• Oral health education3. Legislation for nurses to be trained to deliver and

insert IUDs to remedy shortage in female physicians

4. Provide more ambulance services for deliveries

Recommendations

5. Coordinate transport issues with military services and civil defense

6. National diet group need to be developed with representative from the dental health department, dental school academic with interest in preventive dentistry , delegate from ministry of education and representative of the food suppliers to review periodically on the national food program at schools and monitor closely the implementation with particular attention on reduction in the frequency of sugar consumption.

7. Preventive school treatment programs with dental fissure sealants

Recommendations

Provision of school buses Construction of one comprehensive school for each

cluster of villages by the Ministry of Education The school itself monitoring students' arrival and

departure. Planning authorities and municipalities must plan

more effectively and implement land use plans for safe locations for schools.

Thank you