Risk as catalyst for positive change: lessons learnt from public health readiness for cholera in Jordan

This case study highlights how a looming health crisis was leveraged as drivers for positive change for the health sector, in line with the health security agenda. In Jordan, several authorities are mandated by law to manage health emergencies. Following the declaration of outbreaks of cholera in Iraq, Lebanon and Syria, health authorities in Jordan called for a series of emergency meetings during September 2022 to discuss implications around travel and trade as well as shared waters. WHO was part of the consultations and provided guidance on the application of the International Health Regulations 2005. As the risk for cholera importation persisted, the Ministry of Health assumed its leadership role for the overall health sector response while the Jordanian Center for Disease Control assumed a coordinating function. Roles and responsibilities were enshrined in the National Cholera Preparedness and Response Plan. In consideration of the vulnerability of refugee camps and settlements towards Cholera, the existing Jordan humanitarian coordination platforms such as the Health Sector Working Group were used to share information and to coordinate activities. A whole-of-government risk assessment during December 2022 was complemented by a field visit at Zaatari refugee camp. This helped assess the risk and readiness for a cholera outbreak in Jordan and informed priority activities, such as the establishment of a national risk communication and community engagement working group as well as training on case management.

Risk factors for miscarriage in Syrian refugee women living in non-camp settings in Jordan: results from the Women ASPIRE cross-sectional study

Background

Syrian refugee women face health care disparities and experience worse pregnancy outcomes, including miscarriage. We investigated risk factors for miscarriage in Syrian refugee women living in non-camp settings in Jordan to identify targets for interventions.

Methods

We analyzed data from Women ASPIRE, a cross-sectional study of gendered physical and mental health concerns of 507 Syrian refugee women (≥ 18 years old) living in non-camp settings in Jordan. We recruited women using systematic clinic-based sampling from four clinics. We limited our analyses to women who had a history of pregnancy and whose most recent pregnancy was single, took place in Jordan, and ended in term live birth or miscarriage (N = 307). We grouped the women by the primary outcome (term live birth or miscarriage) and compared the sociodemographic and clinical characteristics of the two groups. We used Pearson’s χ² test or the Mann–Whitney U test to obtain unadjusted estimates and multivariable binomial logistic regression to obtain adjusted estimates.

Results

The most recent pregnancies of 262 women (85%) ended in term live birth and another 45 (15%) ended in miscarriage. Since crossing into Jordan, 11 women (4%) had not received reproductive health services. Of 35 women who were ≥ 35 years old, not pregnant, and did not want a (or another) child, nine (26%) did not use contraception. Of nine women who were ≥ 35 years old and pregnant, seven (78%) did not plan the pregnancy. The adjusted odds of miscarriage were higher in women who had been diagnosed with thyroid disease (aOR, 5.54; 95% CI, 1.56–19.07), had been of advanced maternal age (aOR, 5.83; 95% CI, 2.02–16.91), and had not received prenatal care (aOR, 36.33; 95% CI, 12.04–129.71). Each additional previous miscarriage predicted an increase in the adjusted odds of miscarriage by a factor of 1.94 (1.22–3.09).

Conclusions

We identified several risk factors for miscarriage in Syrian refugee women living in non-camp settings in Jordan. The risk factors may be amenable to preconception and prenatal care.

Implementation Road Map of Health Technology Assessment in Middle-Income Countries: The Case of Jordan

OBJECTIVES

Health technology assessment (HTA) can increase the appropriateness and transparency of pricing and reimbursement decisions. Jordan is still in the early phase of its HTA implementation, although the country has very limited public resources for the coverage of healthcare technologies. The study objective was to explore and validate priorities in the HTA road map for Jordan and propose to facilitate the preferred HTA status.

METHODS

Health policy experts from the public and private sectors were asked to participate in a survey to explore the current and future status of HTA implementation in Jordan. Semistructured interviews with senior policy makers supported by literature review were conducted to validate survey results and make recommendations for specific actions.

RESULTS

Survey and interview results indicated a need for increased HTA training, including both short courses and academic programs and gradually increasing public funding for technology assessment and appraisal. Multiple HTA bodies with central coordination can be the most feasible format of HTA institutionalization. The weight of cost-effectiveness criterion based on local data with published reports and explicit decision thresholds should be increased in policy decisions of pharmaceutical and nonpharmaceutical technologies.

CONCLUSION

Currently, HTA has limited impact on health policy decisions in Jordan, and when it is used to support pharmaceutical reimbursement decisions, it is mainly based on results from other countries without considering transferability of international evidence. Policy makers should facilitate HTA institutionalization and use in policy decisions by increasing the weight of local evidence in HTA recommendations.

Perceptions of Health and Seeking Care: The Experience of Midlife Women in Ain Al-Basha, Jordan

Women's health in the developing world should not be limited to measuring morbidity and mortality, but understanding why women may or may not seek care for their health complaints. This article explores what are the health complaints of midlife women and why women choose to seek health care for some complaints, but not for others. The intention here is to better understand what factors might be influencing these women's decisions, and what the health care system can do to address their needs. The percentage of women in this community seeking health care for their perceived health complaints was found to be highly variable, ranging from 100 percent of the women with cancer seeking care to 6 percent of the women with signs of urinary incontinence doing the same. The authors suggest why women treat some conditions and not others is dependent upon women's perception of health, illness and a host of sociocultural and environmental factors.

Home visits to improve breast health knowledge and screening practices in a less privileged area in Jordan

Background

Breast cancer is the most common cancer afflicting women in Jordan. This study aimed to assess the effects of an educational intervention through home visits, including offering free mammography screening vouchers, on changing women’s breast health knowledge and screening practices for early detection of breast cancer in a less privileged area in Jordan.

Methods

Two thousand four hundred breast health awareness home visits were conducted and 2363 women aged 20-79 years (median: 41) answered a pre-test interview-administrated questionnaire to assess their breast health knowledge and practices at the baseline. After a home-based educational session, 625 women aged 40 years or older were referred to free mammography screening. Five hundred and ninety six homes were revisited six months later and out of these 593 women participated in a post-test. The women’s retained breast health knowledge, the changes in their reported breast health practices and their usage of the free mammography voucher, were assessed.

Results

The mean knowledge score increased significantly (p < 0.001) from 11.4 in the pre-test to 15.7 in the post-test (maximum score: 16). At the six month follow-up the post-test showed significant (p < 0.001) improvement in women’s perceived breast self-examination (BSE) knowledge, reported BSE practice and mammography screening. Out of 625 women that received a voucher for free mammography screening 73% attended the mammography unit, while only two women without a voucher went for mammography screening at the assigned unit. Women who received a follow-up visit were more likely to use the free mammography voucher compared to those who were not followed-up (83% vs. 67%; p < 0.001).

Conclusions

Home visits by local community outreach workers that incorporated education about breast cancer and breast health in addition to offering free mammography screening vouchers were effective in improving women’s breast health knowledge and practices in a less privileged area in Jordan.

"Would a man smell a rose then throw it away?" Jordanian men's perspectives on women's breast cancer and breast health

BACKGROUND

Breast cancer is the most common malignancy afflicting women, and the most common cancer overall in Jordan. A woman's decision to go for screening is influenced by her social support network. This study aims to explore Jordanian men's individual and contextual perspectives on women's breast cancer and their own role in the breast health of the females within their families.

METHODS

An explorative qualitative design was used to purposively recruit 24 married men aged 27 to 65 years (median 43 years) from four governorates in Jordan. Data in the form of interviews transcriptions was subjected to qualitative content analysis.

RESULTS

Three themes were identified: a) Supporting one's wife; b) Marital needs and obligations; c) Constrained by a culture of destiny and shame. The first theme was built on men's feelings of responsibility for the family's health and well-being, their experiences of encouraging their wives to seek health care and their providing counselling and instrumental support. The second theme emerged from men's views about other men's rejection of a wife inflicted by breast cancer, their own perceptions of diminished femininity due to mastectomy and their own concerns about protecting the family from the hereditary risk of breast cancer. The third theme was seen in men's perception of breast cancer as an inevitable act of God that is far away from one's own family, in associating breast cancer with improper behaviour and in their readiness to face the culture of Eib (shame).

CONCLUSIONS

Jordanian men perceive themselves as having a vital role in supporting, guiding and encouraging their wives to follow breast cancer early detection recommendations. Breast health awareness campaigns could involve husbands to capitalize on family support.

"Voices of fear and safety" women's ambivalence towards breast cancer and breast health: a qualitative study from Jordan

Background

Breast cancer is the leading cause of cancer mortality among Jordanian women. Breast malignancies are detected at late stages as a result of deferred breast health-seeking behaviour. The aim of this study was to explore Jordanian women’s views and perceptions about breast cancer and breast health.

Methods

We performed an explorative qualitative study with purposive sampling. Ten focus groups were conducted consisting of 64 women (aged 20 to 65 years) with no previous history and no symptoms of breast cancer from four governorates in Jordan. The transcribed data was analysed using latent content analysis.

Results

Three themes were constructed from the group discussions: a) Ambivalence in prioritizing own health; b) Feeling fear of breast cancer; and c) Feeling safe from breast cancer. The first theme was seen in women’s prioritizing children and family needs and in their experiencing family and social support towards seeking breast health care. The second theme was building on women’s perception of breast cancer as an incurable disease associated with suffering and death, their fear of the risk of diminished femininity, husband’s rejection and social stigmatization, adding to their apprehensions about breast health examinations. The third theme emerged from the women’s perceiving themselves as not being in the risk zone for breast cancer and in their accepting breast cancer as a test from God. In contrast, women also experienced comfort in acquiring breast health knowledge that soothed their fears and motivated them to seek early detection examinations.

Conclusions

Women’s ambivalence in prioritizing their own health and feelings of fear and safety could be better addressed by designing breast health interventions that emphasize the good prognosis for breast cancer when detected early, involve breast cancer survivors in breast health awareness campaigns and catalyse family support to encourage women to seek breast health care.

National maternal mortality ratio for Jordan, 2007-2008

OBJECTIVE

To estimate the number of maternal deaths per 100000 live births during 2007-2008 among Jordanian women; to identify the causes of maternal mortality; and to compare the results with those of the last report for 1995-1996.

METHODS

Reproductive-age mortality study of maternal deaths among women aged 15-49 years in Jordan in 2007-2008.

RESULTS

Among 1406 identified deaths of reproductive-aged women, 76 maternal deaths were identified out of 397588 live births, for a maternal mortality ratio of 19.1 deaths per 100000 live births. Forty-three (56.6%) deaths were attributable to hemorrhage, thrombosis and thromboembolism, and sepsis. Avoidable factors were present in 53.9% of women, 52.6% had substandard care, and 31.5% had 3 or fewer antenatal visits. Of those with available information on family planning, only 29.4% had ever used any form of contraception.

CONCLUSIONS

Maternal deaths in Jordan are declining. The maternal mortality ratio of 19.1 deaths per 100000 live births reported for 2007-2008 showed a remarkable reduction of 53.9% achieved in the 12 years since the 1995-1996 report (a 4.5% annual reduction), which is approaching the 75% reduction recommended by Millennium Development Goal 5.

Educational intervention to improve breast health knowledge among women in Jordan

BACKGROUND

Breast cancer is the most common cancer among women in Jordan and on average 70% of the cases present at advanced stages. The aim of this study was to assess the effectiveness of a public educational campaign conducted by the Jordan Breast Cancer Program to improve breast health knowledge among Jordanian women and to relate their knowledge to breast health practices.

METHODS

The campaign was conducted in five governorates in Jordan with a total of 105 public group lectures about breast cancer focusing on early detection. The total number of participants was 2,554 women with a median age of 37 years (range: 15-73 years). Median number of women per lecture was 24 (range: 9-38). Before the lectures, the women answered a structured questionnaire about their knowledge and practices. After the intervention 2,418 of them filled a post-test questionnaire with the same content. Correct answers on the 15 knowledge questions yielded a maximum score of 15. Determinants of breast health practices were identified using multivariable logistic regression analysis.

RESULTS

The mean knowledge score increased significantly from 10.9 in the pre-test to 13.5 in the post-test (p<0.001). The percentage with a minimum of 14 correct answers to the 15 questions increased from 18 to 63% (p<0.001). Adequate breast health practices were generally low but increased significantly with increasing age and attendance at a previous lecture on breast cancer. Breast health practices were also higher among married women and housewives, and significantly associated with older age and greater breast health knowledge (p<0.001).

CONCLUSIONS

Group educational lectures appeared effective for improving breast health knowledge among Jordanian women. However, even with the noticeable level of knowledge at the baseline, there were low breast health practices among the study participants. This necessitates further in-depth research to explore womens experiences and socio-cultural barriers to breast health seeking behaviour in Jordan.

Barriers to the diagnosis and treatment of depression in Jordan. A nationwide qualitative study

BACKGROUND

Depression is one of the most common causes of morbidity in developing countries. It is believed that there are many barriers to diagnosis and treatment in the primary care setting, but little research exists.

METHODS

Five focus groups were conducted with the goal of exploring themes related to barriers to the diagnosis and treatment of depression, with a purposeful nationwide sample of 50 primary health care providers working in the public health clinics of the Jordanian Ministry of Health (MOH). Participant comments were transcribed and analyzed by the authors, who agreed on common themes.

RESULTS

Lack of education about depression, lack of availability of appropriate therapies, competing clinical demands, social issues, and the lack of patient acceptance of the diagnosis were felt to be among the most important barriers to the identification, diagnosis, and treatment of patients with depression in this population.

CONCLUSIONS

Continuing medical education for providers about depression, provision of counseling services and antidepressant medications at the primary care level, and efforts to destigmatize depression may result in increased rates of recognition and treatment of depression in this population. Systematizing traditional social support behaviors may be effective in reducing the numbers of patients referred for medical care.

The effect of prenatal knowledge of fetal sex on birth weight: a study from Jordan

In this article we seek to determine the effect of the knowledge of prenatal fetal sex, through the use of ultrasound, on infant mean birth weight and the proportion of low birth weight (LBW) babies. A sample population of 1,195 women (cases, n = 640; control, n = 555) were studied in relation to their knowledge of the sex of the fetus in three hospitals in Amman, Jordan. It was found that prenatally known males had the highest mean birth weights (MBWs) as compared with females. It is proposed that these differences could be attributed to behavioral factors related to son preference. The authors conclude that further research on the actual link between prenatal detection of fetal sex and health behavior as indicated by birth weight is needed.

MEASURING REPRODUCTIVE MORBIDITY: A COMMUNITY-BASED APPROACH, JORDAN

Our objective in this study was to determine the prevalence of reproductive and related nonreproductive morbidities in a group of reproductive-aged women living in Jordan. The study was designed as a two-phase survey. The first phase consisted of a structured personal interview and the second phase was a follow-up physical examination. Three hundred seventeen women aged 18-49 years were randomly selected and answered the questionnaire in the first phase of the study. Two hundred sixty agreed to both the general physical and pelvic examination. The main outcome measures were selected reproductive and related nonreproductive morbidities. Results show reproductive tract infections were diagnosed in 55% of the women, a presumed chlamydia trachomatis genital infection in 40%, and genital prolapse in 22%. As for related nonreproductive morbidities, 14% were diagnosed with a urinary tract infection (UTI), 24% with urinary incontinence, and 40% with anemia. Our results of the study support the idea that in this community, women's health is at risk throughout their reproductive years, not only when they are pregnant or postpartum. We suggest further research in other Jordanian communities as well as solutions addressed to the health care community.

Menopause-associated problems: types and magnitude. A study in the Ain Al-Basha area, Jordan

RATIONALE

To begin to fill the information gap on the health of menopausal women in developing countries.

OBJECTIVES

Objectives were three fold: to establish an approximate age of onset of menopause for women in the study area; to report on the physical presence of certain physical conditions; and, to record the self-reported frequency of signs/symptoms of menopause in the 6 months prior to the study.

METHODOLOGICAL DESIGN

A descriptive study of women randomly sampled from the study community.

RESEARCH METHODS

Women's homes were randomly sampled from the residential blocks surrounding the local community health centre. Women agreeing to the first phase of the study were also asked to consent to the second phase, then revisited to complete this second phase.

INSTRUMENTS

The first phase of the study involved an in-depth semistructured questionnaire and the second phase, a general and pelvic examination with laboratory tests.

OUTCOME MEASURES

To gather the information as set out under Objectives.

RESULTS

One hundred and thirty seven women were included in the study. The median age of menopause was 49 years. Women either reported or were found to be suffering from a variety of health problems including: urinary incontinence (37%), urinary tract infections (UTI) (11%), reproductive tract infections (RTI) (39%), and genital prolapse (41%).

CONCLUSIONS

Menopausal women suffer from an appreciable level of morbidity as they approach menopause. Also, the level of health awareness of these women lags behind the identified prevalence of the studied conditions.

Can a home-based pelvic examination be used in assessing reproductive morbidity in population-based studies? A Jordanian experience

RATIONALE

Most estimates of reproductive morbidity in a community are derived from health service-based studies. However, these numbers do not reflect the actual magnitude of the problem because of barriers to health care and differences in health-seeking behaviour. As a result, this study uses an alternative method to measure reproductive morbidities amongst women in a Jordanian community.

OBJECTIVE

To assess the validity of a home-based pelvic examination in detecting signs of reproductive morbidity when compared with a clinic-based examination.

METHODOLOGICAL DESIGN

Descriptive study in which women were randomly selected from the study area to participate in the study.

RESEARCH METHODS

Three hundred and seventy nine women, 18 years and above were randomly selected, and general and pelvic examinations were conducted in each woman's home. Thirty-two of these women were again randomly selected and consented to a second pelvic examination in a clinical setting.

INSTRUMENTS

Two trained female obstetricians conducted the pelvic examination which included examination of the vulva, examination of the vagina and a bimanual examination. Outcome measures. Strength of association between the presence or absence of physical signs of reproductive morbidity detected by the home-based pelvic examination and the same signs identified by the clinic-based examination, deemed in this study as the 'truth'.

RESULTS

The overall sensitivity, specificity, positive and negative predictive values of the home-based pelvic examination were 66, 86, 69 and 84%, respectively.

STUDY LIMITATIONS

The sample size was small, so further studies are recommended to replicate the findings here.

CONCLUSIONS

Results suggest home-based pelvic examinations can be used in population-based studies for a comprehensive assessment of women's reproductive morbidities.

The assessment of reproductive health services: a conceptual framework for prenatal care

This article delineates a conceptual model for defining and measuring quality in prenatal services. It addresses three issues related to women's health: (a) the emerging interest in reproductive health as a concept that encompasses the full range of women's needs, versus the more narrow concept and approach of traditional maternal and child health services; (b) the importance of prenatal services within the context of reproductive health, particularly in developing countries; and (c) the positive role that quality plays in promoting women's health. It then proposes a model for defining and measuring quality in prenatal services, styled after Donabedian's work and informed by Bruce's framework. It assesses the quality of prenatal care in terms of five elements: management, pregnant woman-provider relations, technical competence, information transmission, and continuity of care. The framework was tested in the city of Irbid, Jordan, in 1992. Findings are summarized, and recommendations for future work as discussed.