The Impact of Behavioral Economics-Based Counseling and Mobile Phone Text Educational and Reminder Messages on the Use of Modern Family Planning in Jordan: A Cluster Randomized Controlled Trial

BACKGROUND

Favorable attitudes toward modern family planning methods (MFPMs) among Jordanian and Syrian women do not always translate into behavioral changes, and the availability and cost of MFPMs do not appear to be related to either prior stalls in fertility rates in Jordan or to the current and likely temporary decline in fertility rates. This study aimed to determine whether behavioral economics (BE)-based family planning interventions influence the use of any family planning method, MFPMs use, continuation of MFPMs use, and pregnancy rates among women in Jordan. The BE-based family planning interventions included personalized text messaging and augmented counseling based on framing and identity-priming BE principles, with their effects tested over a 9-month period in the postpartum period following the birth of a child.

METHODS

A parallel-group cluster randomized controlled trial was conducted to compare two interventions, augmented counseling based on framing and identity-priming BE principles and personalized mobile phone text messages reminders, aiming to improve the utilization of MFPMs among postpartum women over status quo family planning services in comprehensive health centers in the north of Jordan.

RESULTS

In total, 1032 participated in the study: 295 women in the control group; 326 women in Intervention Group 1, which received only augmented counseling; and 411 women in intervention Group 2, which received augmented counseling and monthly text messages. The rates of using MFPMs in the counseling group and the counseling and messages group 3 months (54.7% and 57.1%, respectively), 6 months (50.0% and 51.7%, respectively), and 9 months (49.5% and 52.0%, respectively) were significantly higher than the rates among women in the control group (40.6% at 3 months, 37.6% at 6 months, and 34.3% at 9 months). Overall, 26.8% of women in the control group, 42.1% of women in the counseling-only group, and 45.2% of women in the counseling and messages group used MFPMs continuously for all 9 months. At 9 months, the pregnancy rate was significantly much higher in the control group (13.7%) compared to women in the counseling-only group (7.0%) and to women in the counseling and messages group (7.4%).

CONCLUSIONS

Simple BE-based interventions can be effective methods for enhancing the use of MFPMs and maintaining the anticipated decline in Jordan's total fertility rate.

Perceived Barriers of Using Modern Family Planning Methods among Women in Jordan: A Qualitative Study

BACKGROUND

Some cultural and social factors may discourage the use of modern family planning (MFP) methods. The purpose of this study was to better understand the barriers and social norms that might affect women's ability to take optimal advantage of the free family planning services offered by the Jordanian Ministry of Health (MOH).

METHODS

Using a qualitative descriptive design, 7 focus group discussions were conducted from January to February 2018, with a purposive sample of 52 married women. Each group consisted of 6-12 participants. Ethical approvals were obtained. Data were analysed using inductive thematic analysis.

RESULTS

Data analysis revealed three main themes and four subthemes. The first theme 'conforming to social and cultural norms' included the following subthemes: 'to conform to family and social pressure to bear children' and 'to prioritize having male children'. The second theme 'unmet needs in expected family planning counselling' included the following subthemes: 'need for consistency across providers in family planning counselling', and 'need for follow-up counselling'. The third theme was the 'undesirable side-effects' of the MFP methods, which included both the 'experienced' and the 'anticipated' side effects.

CONCLUSION

This study identified a number of women's perceived barriers to using MFP methods. These included conforming to the social pressure, inconsistency of the counselling process, and undesirable side effects. Their perspectives should be carefully addressed in any family planning program.

Modifiable Factors and Delays Associated with Neonatal Deaths and Stillbirths in Jordan: Findings from Facility-Based Neonatal Death and Stillbirth Audits

OBJECTIVE

 This study employed the "three-delay" model to investigate the types of critical delays and modifiable factors that contribute to the neonatal deaths and stillbirths in Jordan.

STUDY DESIGN

 A triangulation research method was followed in this study to present the findings of death review committees (DRCs), which were formally established in five major hospitals across Jordan. The DRCs used a specific death summary form to facilitate identifying the type of delay, if any, and to plan specific actions to prevent future similar deaths. A death case review form with key details was also filled immediately after each death. Moreover, data were collected from patient notes and medical records, and further information about a specific cause of death or the contributing factors, if needed, were collected.

RESULTS

 During the study period (August 1, 2019-February 1, 2020), 10,726 births, 156 neonatal deaths, and 108 stillbirths were registered. A delay in recognizing the need for care and in the decision to seek care (delay 1) was believed to be responsible for 118 (44.6%) deaths. Most common factors included were poor awareness of when to seek care, not recognizing the problem or the danger signs, no or late antenatal care, and financial constraints and concern about the cost of care. Delay 2 (delay in seeking care or reaching care) was responsible for nine (3.4%) cases. Delay 3 (delay in receiving care) was responsible for 81 (30.7%) deaths. The most common modifiable factors were the poor or lack of training that followed by heavy workload, insufficient staff members, and no antenatal documentation. Effective actions were initiated across all the five hospitals in response to the delays to reduce preventable deaths.

CONCLUSION

 The formation of the facility-based DRCs was vital in identifying critical delays and modifiable factors, as well as developing initiatives and actions to address modifiable factors.

KEY POINTS

· Death review committees play key roles in identifying critical delays and modifiable factors.. · The "three-delay" model was successful in identifying preventable neonatal deaths and stillbirths.. · Death review committees are central in developing actions to reduce preventable deaths..

Barriers to implementing palliative care in intensive care units: perceptions of physicians and nurses in Jordan

BACKGROUND

Palliative care (PC) aims to relieve a person's suffering and provide the best possible quality of life (QoL) to people with chronic illnesses. Despite the significant impact of PC services on the QoL of patients, barriers exist that prevent healthcare providers from facilitating PC in intensive care units (ICUs).

AIM

The purpose of this study was to explore the perceived barriers to implementing PC in ICUs.

METHODS

A qualitative approach was used to conduct 17 semi-structured interviews with clinicians across two ICUs (urban and suburban) in Jordan. Thematic analysis was used for the transcribed interviews.

RESULTS

Five main themes emerged: the ICU is a demanding and complex care environment; lack of preparation to implement PC; PC is a nicety, not a necessity; healthcare system-related barriers; and lack of cultural acceptance of PC. Lack of knowledge and training was identified as a major barrier for the effective implementation of PC by both physicians and nurses.

CONCLUSION

Equipping healthcare providers with the knowledge and expertise to provide PC is essential to dispel myths related to PC and facilitate PC provision. Developing an interdisciplinary care team will support the effective implementation of PC services in any setting. Establishing national PC policies will foster the ethical and legal practice of PC in Jordan.

Caring for a Child with Cancer: Experiences of Jordanian Mothers

The diagnosis of childhood cancer is one of the most serious and unexpected experiences a mother can endure. A descriptive phenomenological approach was used to explore the experiences of mothers of children diagnosed with cancer in Jordan. Themes that emerged include (1) Emotional response on knowing the diagnosis (feelings of shock, lack of preparedness, denial, and feelings of "paralysis"), (2) Fear of the dreaded disease (fear of suffering and fear of death), and (3) The challenges of the treatment journey (inadequate financial resources, role transition, and feeling socially isolated). This study describes the experiences of Jordanian mothers who care for their children diagnosed with cancer so that health care providers can develop strategies to provide adequate psychological support to these mothers.

The usability of Jordan stillbirths and neonatal deaths surveillance (JSANDS) system: results of focus group discussions

Background

Jordan Stillbirths and Neonatal Deaths Surveillance system (JSANDS) is a newly developed system and is currently implemented in five large hospitals in Jordan. This study aimed at exploring the healthcare professionals’ perception about the usability of JSANDS.

Methods

A descriptive qualitative approach, using focus group discussions, was adopted. A total of 5 focus groups including 23 focal points were conducted in five participating hospitals in Jordan.

Results

Data analysis identified nine main issues related to the JSANDS system: the system usefulness, the system performance, data quality, the system limitations, human rights, female empowerment, nurses’ competencies strengthened, the sustainability of the JSANDS, and COVID-19 impact on the system. Users reported that JSANDS data were useful, the system was simple and easy to use, and the data were accurate and complete. However, some users reported that some technical issues need to be enhanced.

Conclusions

JSANDS was perceived positively by the current users. According to them, it provides a formative and comprehensive data on stillbirths and neonatal deaths and their causes, and therefore, was recommended to be adopted by its users and scaled up.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-021-00551-1.

Rate, Risk Factors, and Causes of Neonatal Deaths in Jordan: Analysis of Data From Jordan Stillbirth and Neonatal Surveillance System (JSANDS)

Background: It has been estimated that 27.8 million neonates will die worldwide between 2018 and 2030 if no improvements in neonatal and maternal care take place. The aim of this study was to determine the rate, risk factors, and causes of neonatal mortality in Jordan. Methods: In August 2019, an electronic stillbirths and neonatal deaths surveillance system (JSANDS) was established in in three large cities through five hospitals. Data on all births, neonatal mortality and their causes, and other characteristics in the period between August 2019 and January 2020 were exported from the JSANDS and analyzed. Results: A total of 10,328 births [10,226 live births (LB) and 102 stillbirths] were registered in the study period, with a rate of 14.1 deaths per 1,000 LBs; 76% were early neonatal deaths and 24% were late deaths. The odds of deaths in the Ministry of Health hospitals were almost 21 times (OR = 20.8, 95% CI: 2.8, 153.1) higher than that in private hospitals. Low birthweight and pre-term babies were significantly more likely to die during the neonatal period compared to full-term babies. The odds of neonatal mortality were significantly higher among babies born to housewives compared to those who were born to employed women (OR = 2.7; 95% CI: 1.2, 6.0). Main causes of neonatal deaths that occurred pre-discharge were respiratory and cardiovascular disorders (43%) and low birthweight and pre-term (33%). The main maternal conditions that attributed to these deaths were complications of the placenta and cord, complications of pregnancy, and medical and surgical conditions. The main cause of neonatal deaths that occurred post-discharge were low birthweight and pre-term (42%). Conclusions: The rate of neonatal mortality have not decreased since 2012 and the majority of neonatal deaths occurred could have been prevented. Regular antenatal visits, in which any possible diseases or complications of pregnant women or fetal anomalies, need to be fully documented and monitored with appropriate and timely medical intervention to minimize such deaths.

Rate, determinants, and causes of stillbirth in Jordan: Findings from the Jordan Stillbirth and Neonatal Deaths Surveillance (JSANDS) system

BACKGROUND

Annually, 2.6 million stillbirths occur around the world, with approximately 98% occurring in low- and middle-income countries. The stillbirth rates in these countries are 10 times higher than the rates in high-income countries.

METHODS

An electronic stillbirths and neonatal deaths surveillance system (JSANDS) was established in five large hospitals located in three of the largest cities in Jordan in August 2019. JSANDS was developed as a secure on-line data entry system to collect, organize, analyze, and disseminate data on stillbirths, neonatal deaths, and their contributing conditions. Data on births, stillbirths and their contributing conditions, and other demographic and clinical characteristics in the period between August 2019 - January 2020 were extracted and analyzed.

RESULTS

A total of 10,328 births were registered during the reporting period. Of the total births, 102 were born dead (88 antepartum stillbirths and 14 intrapartum stillbirths), with a rate of 9.9 per 1000 total births. The main contributing fetal conditions of antepartum stillbirths were antepartum death of unspecified cause (33.7%), acute antepartum event (hypoxia) (33.7%), congenital malformations and chromosomal abnormalities (13.3%), and disorders related to the length of gestation and fetal growth (10.8%). The main contributing maternal conditions of antepartum stillbirths included complications of the placental cord and membranes (48.7%), maternal complications of pregnancy (23.1%), and maternal medical and surgical conditions (23.1%). Contributing fetal conditions of intrapartum stillbirths included congenital malformations, deformations and chromosomal abnormalities, other specified intrapartum disorders, and intrapartum death of unspecified cause (33.3% each). Contributing maternal conditions of intrapartum stillbirths included complications of the placental cord and membranes. In the multivariate analysis, small for gestational age (SGA) pregnancies were associated with a significant 3-fold increased risk of stillbirth compared to appropriate for gestational age (AGA) pregnancies.

CONCLUSIONS

Although the rate of stillbirth is lower than that in other countries in the region, there is an opportunity to prevent such deaths. While the majority of stillbirths occurred during the antepartum period, care should be taken for the early identification of high-risk pregnancies, including the early detection of SGA pregnancies, and ensuring adequate antenatal obstetric interventions.

Assent and consent in pediatric and adolescent research: school children's perspectives

Background

School students’ views and perceptions of informed parental consent and child assent about child participation in research in the Middle East are not known.

Methods

Focus group interviews were conducted to understand high school students’ perspectives toward child and adolescent assents and consents in research including the importance of, and depth of information needed in consent and assent, and perception toward written vs verbal consent and assent.

Results

The majority of students agreed that it is necessary to take parental approval and that they would not participate in research if their parents refused. Furthermore, the majority of male students agreed that if the research requires only questionnaires to be completed, then child’s approval is sufficient whereas measures, such as blood sugar screening required approval from both the parent and child. Females believed it is enough to provide parental consent to participate in research unless information provided is adequate, then child approval is enough. All students stressed the importance of including detailed information; however, parental consent needs to have more detailed information than child assent.

Conclusion

Parts of the students’ perceptions were congruent, whereas other views were not congruent with proper conduct of pediatric research. Such a situation warrants further research and actions.

The relationship between plasma ferritin levels and body mass index among adolescents

Circulatory Ferritin concentration varies with age, sex, and body composition. Studies that determine the relationship of different body weight measurements with plasma ferritin concentration in adolescents are lacking. A descriptive cross-sectional design was utilized. Data collection involved self-reporting demographics, blood samples, and body composition measures for a sample of 814 healthy Jordanian adolescents. Ferritin deficiency was observed in 55.8% of the study population. Simple linear regression showed that BMI, gender, location, and smoking status 2.5%, 3.9%, 0.4%, and 0.4%, respectively, associated positively with plasma ferritin level (p < 0.05). After controlling for gender, location, and smoking status, additional hierarchal multiple linear regression showed that BMI explained 2.2% of plasma ferritin (p < 0.000). However, the obesity-stratified hierarchal multiple linear regression, showed that BMI explained 2.1% of plasma ferritin in the overweight and obese (HI) adolescents (p = 0.02), but not in the under and normal weight (LO) adolescents (p = 0.91). After controlling for gender, location, and smoking status, the ANCOVA showed that plasma ferritin level was greater (p < 0.000) in the HI (19.00 ± 13.6) versus the LO (15.20 ± 10.4) obesity group. Our results indicated that normal ferritin level among obese people does not necessarily indicate normal iron storage.

Evaluation of maternal and newborn health services in Jordan

Objectives

This study aimed to assess the maternal and newborn services in Jordanian hospitals to provide policymakers, health professionals, and researchers with a clear picture about the current status of maternal and newborn health services.

Methods

A total of 32 main hospitals that provide maternity services in Jordan were assessed. The study involved direct observations of these hospitals and interviews with basic health and hospital staff, with the purpose of assessing and evaluating the availability of various services for mothers and newborns, availability of resources, equipment and supplies, documentation and staff training, and provision of the health care services.

Results

Some hospitals had shortages of obstetricians and gynecologists, pediatricians, neonatologists, and midwives/nurses. Antenatal care was not provided systematically in many hospitals across the country. A lack of necessary equipment, drugs, and supplies was evident in some hospitals. Admission departments of some hospitals had insufficient supplies. The operation theaters in many hospitals lacked a variety of necessary equipment including some basic items such as thermometers and some advanced items such as resuscitation sets for babies. Only two-thirds of all delivery rooms in the selected hospitals had radiant heaters and obstetrical stethoscopes available. A significant lack of neonatal ICU equipment was found such as incubators, resuscitation tables, continuous positive airway pressure, O2 oximeters, and phototherapy.

Conclusion

The findings revealed an overall satisfactory quality of maternal and newborn care and services, however, some deficiencies existed. The findings are expected to aid policymakers, health professionals, and researchers to recognize the gaps in the processes, supplies, and quality of care related to the provided services at maternal facilities and help them to design and implement evidence-based health programs in order to provide effective health services and promote the health of mothers and newborns.

Parents' Knowledge and Beliefs about the Impact of Exposure to Media Violence on Children's Aggression

The current study aimed to assess Jordanian parents' knowledge and beliefs about the effects of violent media on children's aggressive behavior. A sample of 262 parents of children aged 6-11 years completed a Media Quotient questionnaire about children's media habits, media effects, and children's aggressive behavior. Parents reported that their children spend an average of 4.83 h (SD = 2.12) watching TV, 3.20 h (SD = 2.29) playing video games, 1.07 h (SD = 0.88) listening to music, and only 0.52 min (SD = 0.67) reading for pleasure per day. Parents have a moderate level of knowledge about the media effect (M = 15.49, SD = 3.439). Children of parents who have adequate knowledge about the media effect, spend less time watching TV (r = -.355, p < .001), playing video games (r = -.265, p < .001), and listening to music (r = -.347, p < .001). Ninety-two percent (n = 241) of parents were concerned about the amount of sexual and of violent content their children see in movies or on TV. Children who spend more time playing video games (r = -.201, p = .004) show aggressive relational behavior. This study suggests that increasing parents' knowledge of media of evidence-based programs may have a protective effect on children's behavior.