Philadelphia UniversityPhiladelphia UniversityFaculty of NursingFaculty of Nursing

Bedouin Health ProjectBedouin Health ProjectBadia Health Education ModuleBadia Health Education Module

Prepared byPrepared by

Dr. Fadia HasnaDr. Fadia Hasna

Philadelphia University, Faculty of NursingPhiladelphia University, Faculty of Nursing

Dr. Mohammad Al-SmairanDr. Mohammad Al-Smairan

Jordan Badia Research and Development CentreJordan Badia Research and Development Centre

BackgroundBackground • This Bedouin Health module is one of the proposed This Bedouin Health module is one of the proposed

interventions of the Bedouin Health Project and it interventions of the Bedouin Health Project and it utilizes findings of the data collected in Northern utilizes findings of the data collected in Northern Badia during the years 2007-2008 which builds on Badia during the years 2007-2008 which builds on policy makers, health providers in Northern Badia, policy makers, health providers in Northern Badia, alternative healers and Bedouin men and women alternative healers and Bedouin men and women interviews in the Northern Badia.interviews in the Northern Badia.

• Aim: Aim: The aim of this module is to sensitize nursing, The aim of this module is to sensitize nursing,

social work and medical students to the Bedouin social work and medical students to the Bedouin culture and health needs in Northern Badia of culture and health needs in Northern Badia of Jordan making them more aware and culturally Jordan making them more aware and culturally sensitive to this local population’s health, economic sensitive to this local population’s health, economic and psycho-social needs; it was found out that and psycho-social needs; it was found out that manymany clinic staff interviewed during our field clinic staff interviewed during our field research work had little knowledge about the research work had little knowledge about the Bedouins’ culture or way of life. Bedouins’ culture or way of life.

Chapter 1Chapter 1

The Badia of JordanThe Badia of Jordan

OutlineOutline

• Intended Learning Outcomes (ILOs)Intended Learning Outcomes (ILOs)

• The BadiaThe Badia

• Population: Change in lifestylePopulation: Change in lifestyle

• Physical CharacteristicsPhysical Characteristics

• Badia ResourcesBadia Resources

• Some Touristic Sites in the Northern East BadiaSome Touristic Sites in the Northern East Badia

• Strengths of the BadiaStrengths of the Badia

Intended Learning Outcomes Intended Learning Outcomes (ILOs)(ILOs)At the end of this unit the student will be able to:At the end of this unit the student will be able to:Knowledge and understandingKnowledge and understanding• DefineDefine Badia Badia• List seven important tribes in Northern Badia List seven important tribes in Northern Badia • Discuss five physical characteristics in Northern Badia of Discuss five physical characteristics in Northern Badia of

JordanJordanIntellectual SkillsIntellectual Skills • Differentiate between Asheera Differentiate between Asheera عشيرةعشيرة and Hamoula and Hamoula حمولةحمولة in in

Northern Badia Northern Badia • Relate five major strengths in the Northern Badia to future Relate five major strengths in the Northern Badia to future

strategic developments strategic developments • Explain resources of Badia and relate them to the Explain resources of Badia and relate them to the

opportunities for development opportunities for development Professional and Transferable SkillsProfessional and Transferable Skills• Communicate with Bedouin in a respectful style based on Communicate with Bedouin in a respectful style based on

the challenges in the Northern Badia contextthe challenges in the Northern Badia context• Change attitudes towards Bedouin by refuting Change attitudes towards Bedouin by refuting

misconceptions misconceptions

The BadiaThe Badia

- -Badia is a classical Arabic word used to describe arid to Badia is a classical Arabic word used to describe arid to semi- arid regions of the middle east, where rainfall semi- arid regions of the middle east, where rainfall averages less than 200mm, which today makes-up part averages less than 200mm, which today makes-up part

of Jordan, Syria, Saudi Arabia and Iraqof Jordan, Syria, Saudi Arabia and Iraq.. - -In Jordan, the Badia extends from north to south along the In Jordan, the Badia extends from north to south along the

eastern portion covering about 80% of the country's total eastern portion covering about 80% of the country's total areaarea..

- -At present it is home to about only 5% of the Jordanian At present it is home to about only 5% of the Jordanian populationpopulation..

- -Desertification is a common fear, which threatens that Desertification is a common fear, which threatens that region, causing degradation of resources and most region, causing degradation of resources and most painfully demographic displacementpainfully demographic displacement..

- -Desertification and wise use of natural resources is a Desertification and wise use of natural resources is a shared concern in the Middle East and throughout the shared concern in the Middle East and throughout the

worldworld..

Population: Change in lifestylePopulation: Change in lifestyle

• The total population of the Badia represents about The total population of the Badia represents about 5% of the whole population of the country. 5% of the whole population of the country.

• Today, an estimated 5-10% of the population remains Today, an estimated 5-10% of the population remains nomadic, traveling the area in their black goat hair nomadic, traveling the area in their black goat hair tents called beit shaar or "hair tent".tents called beit shaar or "hair tent".

• The majority of the population is now permanently The majority of the population is now permanently

settled in villages.settled in villages. • The Badia is home to numerous Bedouin tribes whose The Badia is home to numerous Bedouin tribes whose

history lays at the foundation of western civilization.history lays at the foundation of western civilization. • At present, the most important tribes live in Northern At present, the most important tribes live in Northern

Badia are: Al- Maasaeed, Bani Khalid, Al- Serhan, Al- Badia are: Al- Maasaeed, Bani Khalid, Al- Serhan, Al- Shurufat, Al- Sardyih, Al- Adamat, Al- Essa, Zubaid Shurufat, Al- Sardyih, Al- Adamat, Al- Essa, Zubaid and Al- Ghiath.and Al- Ghiath.

• Any one of the a above tribes composed of more than Any one of the a above tribes composed of more than one Hamouleh.one Hamouleh.

Physical CharacteristicsPhysical Characteristics • The Badia experiences huge seasonal temperature The Badia experiences huge seasonal temperature

fluctuations. fluctuations.

• In winter, the minimum mean temperatures may drop to 2o-9o In winter, the minimum mean temperatures may drop to 2o-9o degrees C and snowfall and sub-zero temperatures may occur. degrees C and snowfall and sub-zero temperatures may occur.

• The summer maximum mean temperature is around 35 -38 C. The summer maximum mean temperature is around 35 -38 C. Low humidity causes high levels of evaporation. Low humidity causes high levels of evaporation.

• Rainfall between December and March, with great differences Rainfall between December and March, with great differences in the intensity of showers and storms.in the intensity of showers and storms.

• The region is subdivided into three main geographical areas, The region is subdivided into three main geographical areas, as follows: as follows: 

-The northern Badia, comprising 26,000 km. ( shown in green ) -The northern Badia, comprising 26,000 km. ( shown in green )

-The middle Badia, comprising 10,000 km. ( shown in light blue -The middle Badia, comprising 10,000 km. ( shown in light blue ) )

-The southern Badia, comprising 38,000 km. ( shown in white )-The southern Badia, comprising 38,000 km. ( shown in white )

Badia ResourcesBadia Resources

• The Badia holds numerous and rich natural resources in The Badia holds numerous and rich natural resources in quantities adequate for overall development quantities adequate for overall development requirements. requirements.

• Besides the vast area available for development, Besides the vast area available for development, resources include mineral deposits, surface and resources include mineral deposits, surface and groundwater, tourism sites, sunny weather, renewable groundwater, tourism sites, sunny weather, renewable natural range and cultivated land suitable for improved natural range and cultivated land suitable for improved agriculture and livestock breeding. agriculture and livestock breeding.

• The area also has the potential for the development of The area also has the potential for the development of non-pollutant renewable energy sources, namely, solar non-pollutant renewable energy sources, namely, solar and wind energy.and wind energy.

• As the Badia extends into the borders of neighboring As the Badia extends into the borders of neighboring countries, there is the additional benefit of its being a countries, there is the additional benefit of its being a junction for export-import activities at the regional leveljunction for export-import activities at the regional level

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• The Badia represents a strategic depth for the The Badia represents a strategic depth for the country because it provides Jordan with: country because it provides Jordan with: 

- 60% of groundwater needs.- 60% of groundwater needs.

   

- 90% of rangelands.- 90% of rangelands.

   

- 10% of conventional energy.- 10% of conventional energy.

   

- 70% of the red meat needs.  - 70% of the red meat needs. 

- 24.36% of GDP- 24.36% of GDP

Some Touristic Sites in the Some Touristic Sites in the

Northern East BadiaNorthern East Badia

Um Al JimalUm Al JimalASEIKHIM

JAWAQasr Burqu

Strengths of the BadiaStrengths of the Badia • Northern Badia is a priority on political Northern Badia is a priority on political

agendaagenda– New mobile military field hospital established and New mobile military field hospital established and

operatingoperating– Hashemite fund for Badia Development Hashemite fund for Badia Development – Jordan Badia Research and Development CentreJordan Badia Research and Development Centre– MOH : High coordination amongst MOH, Military and MOH : High coordination amongst MOH, Military and

local instituteslocal institutes

• Existence of Network of health centers at Existence of Network of health centers at three different levels across a large rural three different levels across a large rural areaarea

- - CHCCHC

- Primary health centre - Primary health centre

- Village center- Village center

Chapter 2Chapter 2

Population Characteristics and Population Characteristics and Socio-economic ConditionsSocio-economic Conditions in in

Northern BadiaNorthern Badia

OutlineOutline

• Intended Learning Outcomes (ILOs)Intended Learning Outcomes (ILOs)

• Introduction: Transition in lifestyle in the BadiaIntroduction: Transition in lifestyle in the Badia

• Educational LevelsEducational Levels

• Marital StatusMarital Status

• Fertility and MortalityFertility and Mortality

• Causes of high MortalityCauses of high Mortality

• MorbidityMorbidity

• EmploymentEmployment - Sectors- Sectors

- Challenges- Challenges

Intended Learning Outcomes Intended Learning Outcomes (ILOs)(ILOs)

At the end of this unit the student will be able to:At the end of this unit the student will be able to:Knowledge and understanding:Knowledge and understanding:• Describe kinship relationships in the Badia and relate the to Describe kinship relationships in the Badia and relate the to

fertility behavioursfertility behaviours• Describe four marital status characteristics in Northern Describe four marital status characteristics in Northern

Badia Badia • Explore important Bedouin lifestyle habitsExplore important Bedouin lifestyle habits• List common misconceptions about BedouinList common misconceptions about Bedouin• Identify main nutritional components of Bedouin diet in Identify main nutritional components of Bedouin diet in

Northern Badia Northern Badia • List five most important health needs of the following List five most important health needs of the following

Bedouin population groups: women, children, pregnant Bedouin population groups: women, children, pregnant women, older age groupwomen, older age group

• Describe housing pattern in Northern BadiaDescribe housing pattern in Northern Badia

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Intellectual Skills: Intellectual Skills: • Relate current Bedouin lifestyle challenges to health status of Relate current Bedouin lifestyle challenges to health status of

Bedouin in Northern BadiaBedouin in Northern Badia• Discuss how nutritional status in the Badia affects the health Discuss how nutritional status in the Badia affects the health

of the local population of the local population • Relate how male preference affects reproductive behavior in Relate how male preference affects reproductive behavior in

Northern Badia Northern Badia • State fertility, morbidity and mortality trends in Northern State fertility, morbidity and mortality trends in Northern

Badia Badia • Explain causes of high mortality in Badia Explain causes of high mortality in Badia • Explain educational level of Bedouin and relate it to their Explain educational level of Bedouin and relate it to their

lifestyle challenges lifestyle challenges • Identify employment challenges in Northern Badia Identify employment challenges in Northern Badia • List household facilities and relate them to socio-economic List household facilities and relate them to socio-economic

challenges in Northern Badia challenges in Northern Badia Professional and transferable skills Professional and transferable skills • Communicate with Bedouin in a respectful manner based on Communicate with Bedouin in a respectful manner based on

an appreciation of their local contextan appreciation of their local context• Provide culturally-sensitive attitude towards Bedouin (stigma Provide culturally-sensitive attitude towards Bedouin (stigma

free)free)• Act as a health promotion advocate for the Bedouin Act as a health promotion advocate for the Bedouin

population in Northern Badiapopulation in Northern Badia

Introduction: Transition in Lifestyle in Introduction: Transition in Lifestyle in

the Badiathe Badia • Life in the desert has always depended on striking a Life in the desert has always depended on striking a balance between human and animal populations and balance between human and animal populations and the natural environmentthe natural environment

• In general, the Badia has developed and changed in In general, the Badia has developed and changed in step with the rest of the urban-based economystep with the rest of the urban-based economy

• The government has provided roads, health clinics, The government has provided roads, health clinics, water supplies, schools and other services which has water supplies, schools and other services which has directly raised living standards in the Badia, but at directly raised living standards in the Badia, but at the same time may have made an indirect the same time may have made an indirect contribution to the loss of go-ahead individuals. contribution to the loss of go-ahead individuals.

• Return flows of the earnings of migrants, especially Return flows of the earnings of migrants, especially those in the army and the police force, undoubtedly those in the army and the police force, undoubtedly make a significant contribution to the support of the make a significant contribution to the support of the families remaining in the Badia.families remaining in the Badia.

Educational LevelsEducational Levels• The level of education in the Northern Badia were The level of education in the Northern Badia were

slightly below the national average and even slightly below the national average and even below those for the settled population in rural below those for the settled population in rural areas of Jordan,areas of Jordan,

• A number of factors was responsible for these low A number of factors was responsible for these low educational levels which in turn had a bearing on educational levels which in turn had a bearing on the welfare and economic opportunities open to the welfare and economic opportunities open to the population of the Badia,the population of the Badia,

- First, the Badia population being only a small - First, the Badia population being only a small fraction of the total population, seemed to have fraction of the total population, seemed to have received less than their fair share of attention received less than their fair share of attention from the educational planners,from the educational planners,

- A second factor related to educational levels and - A second factor related to educational levels and school attendance figures was that the kind of school attendance figures was that the kind of work available in the Badia did not require the work available in the Badia did not require the kind of skills which could be obtained in schoolskind of skills which could be obtained in schools

Marital StatusMarital Status

• The Marriage was almost universal and began at an The Marriage was almost universal and began at an early age for femalesearly age for females

• The mean age at marriageThe mean age at marriage for females around 18 for females around 18 years compared to an age around 24 years for years compared to an age around 24 years for males (Abu Jaber and Gharaibeh)males (Abu Jaber and Gharaibeh)

• Girls in the Badia married earlier than their Girls in the Badia married earlier than their counterparts elsewhere on the other parts of Jordancounterparts elsewhere on the other parts of Jordan

• In general, it seems that a more traditional marriage In general, it seems that a more traditional marriage pattern prevails in the Badia with girls marrying pattern prevails in the Badia with girls marrying early and very few remaining singleearly and very few remaining single

• The marriage of widowers and of divorcees is easily The marriage of widowers and of divorcees is easily accomplished since the bridge price for second accomplished since the bridge price for second marriages is lower and the marriage ceremonies marriages is lower and the marriage ceremonies much simpler.much simpler.

Fertility and MortalityFertility and Mortality

• It seems that fertility in the Badia is high, higher It seems that fertility in the Badia is high, higher than the other parts of Jordan, where the total than the other parts of Jordan, where the total fertility rate of 7.8,fertility rate of 7.8,

• Plainly, fertility in the Badia is uncontrolled and Plainly, fertility in the Badia is uncontrolled and close to a natural regime in which the duration of close to a natural regime in which the duration of post-partum amenorrhea is the principle factor post-partum amenorrhea is the principle factor affecting the length of inter-birth intervals,affecting the length of inter-birth intervals,

• In Northern Badia, some direct evidence of a slow In Northern Badia, some direct evidence of a slow decline in mortality over the last twenty years, decline in mortality over the last twenty years, but the overall mortality levels are still slightly but the overall mortality levels are still slightly high by national standards.high by national standards.

Causes of high MortalityCauses of high Mortality

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

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

especially for nomadic Bedouinsespecially for nomadic Bedouins

- The short supply of clean and reliable sources of water- The short supply of clean and reliable sources of water

- The lack of specialist health clinics and hospitals, especially - The lack of specialist health clinics and hospitals, especially in the remote areasin the remote areas

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

MorbidityMorbidity• Low standard of sanitation and hygiene, Low standard of sanitation and hygiene,

malnutrition and a harsh environment go malnutrition and a harsh environment go together to make the Bedouin prone to various together to make the Bedouin prone to various classes and types of diseasesclasses and types of diseases

• The most common of which are internal and The most common of which are internal and respiratory diseases, such as chest conditions, respiratory diseases, such as chest conditions, brucella, hypertension, kidney diseases, dental brucella, hypertension, kidney diseases, dental caries and diabetescaries and diabetes

• Ailments such as hepatitis and dysentery are Ailments such as hepatitis and dysentery are widely reportedwidely reported

• Other intestinal afflictions such as worms of Other intestinal afflictions such as worms of various types are also prevalentvarious types are also prevalent

• Respiratory diseases especially inflammation of Respiratory diseases especially inflammation of the eyes is even more common among children the eyes is even more common among children than among adultsthan among adults

• Milk may also be a health hazard in the region. Milk may also be a health hazard in the region. One of the major products consumed raw and One of the major products consumed raw and unprocessedunprocessed

EmploymentEmployment

• SectorsSectors - Aside from self-employment in herding or farming, - Aside from self-employment in herding or farming,

work opportunities in the Badia are indeed very work opportunities in the Badia are indeed very scarcescarce

- Government is the largest single employer followed - Government is the largest single employer followed by farmingby farming

- Government sector include Jordan army mainly, - Government sector include Jordan army mainly, Ministry of educationMinistry of education

- Farming sector include herding, planting - Farming sector include herding, planting vegetables and fruits, etc.vegetables and fruits, etc.

- Private sector composed a small portion of the - Private sector composed a small portion of the employment in Northern Badia and include, trading employment in Northern Badia and include, trading in shops, livestock, land and other small businessin shops, livestock, land and other small business

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• ChallengesChallenges BedouinBedouin economy revoled around the occupation of economy revoled around the occupation of

camel, sheep and goat husbandry. In such an camel, sheep and goat husbandry. In such an economy, livestock is considered the principal asset, economy, livestock is considered the principal asset, hence, wealth as well as status were judged by the hence, wealth as well as status were judged by the size of the animal herd.size of the animal herd.

The size and composition of the herd has recently The size and composition of the herd has recently undergone considerable changes:undergone considerable changes:

- The size of the herd has decreased substantially due - The size of the herd has decreased substantially due to severe livestock losses and liquidation,to severe livestock losses and liquidation,

- Many Bedouin have taken to settled life in order to - Many Bedouin have taken to settled life in order to profit from the services provided in their habitatprofit from the services provided in their habitat

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- Manpower shortages in the region resulting from - Manpower shortages in the region resulting from adult out-migration to urban centers for adult out-migration to urban centers for employment has forced herd owners to reduce employment has forced herd owners to reduce the number of animalsthe number of animals

- The lack of industrial projects- The lack of industrial projects

- The lack of manpower training- The lack of manpower training

- Drought years- Drought years

Chapter 3Chapter 3

Determinants of Health: Determinants of Health: Community Services and Community Services and

Facilities and their Impact on Facilities and their Impact on Badia HealthBadia Health

OutlineOutline

• Intended Learning Outcomes (ILOs)Intended Learning Outcomes (ILOs)• Introduction: gradual settlement of the BedouinIntroduction: gradual settlement of the Bedouin• Determinants of HealthDeterminants of Health - Lifestyle and Behavior- Lifestyle and Behavior - Environment- Environment - Housing- Housing - Schools- Schools - Disability services- Disability services - Water and Electricity- Water and Electricity - Household Facilities- Household Facilities - Communications- Communications - Agricultural Services- Agricultural Services - Diet- Diet - Nutritional Status- Nutritional Status - Poverty and Social Welfare- Poverty and Social Welfare

Intended Learning Outcomes Intended Learning Outcomes (ILOs)(ILOs)At the end of this unit the student will be able to:At the end of this unit the student will be able to:Knowledge and understanding:Knowledge and understanding:• Explain five main strengths in health provision in the Explain five main strengths in health provision in the

Northern Badia Northern Badia • Differentiate and explain the various services in Northern Differentiate and explain the various services in Northern

Badia: schools, water and electricity, communication and Badia: schools, water and electricity, communication and agriculture agriculture

• List the determinants of health in Northern BadiaList the determinants of health in Northern BadiaIntellectual Skills: Intellectual Skills: • Relate the determinants of health to the various services in Relate the determinants of health to the various services in

Northern Badia Northern Badia Professional and transferable skills Professional and transferable skills • Provide culturally-sensitive attitude towards Bedouin Provide culturally-sensitive attitude towards Bedouin

(stigma free)(stigma free)• Act as a health promotion advocate for the Bedouin Act as a health promotion advocate for the Bedouin

population in Northern Badia population in Northern Badia

Introduction: Gradual Settlement of Introduction: Gradual Settlement of the Bedouinthe Bedouin

• A host of factors appears responsible for Bedouin A host of factors appears responsible for Bedouin settlement.settlement.

• Water is one of the most important factors Water is one of the most important factors underscoring Bedouin settlementunderscoring Bedouin settlement

• Other factor play varying role in Bedouin settlement Other factor play varying role in Bedouin settlement is the loss of much of the herds as a consequence of is the loss of much of the herds as a consequence of prolonged droughtprolonged drought

• Availability of services such as roads, Availability of services such as roads, telecommunications, electricity, schools are other telecommunications, electricity, schools are other factors responsible for Bedouin settlementfactors responsible for Bedouin settlement

• Despite government efforts aimed at providing the Despite government efforts aimed at providing the Badia with basic services, the quantity and quality Badia with basic services, the quantity and quality of these services are judged inadequate.of these services are judged inadequate.

Determinants of HealthDeterminants of Health

Lifestyle and BehaviorLifestyle and Behavior - - Some of babies in the Badia are still born at home. Some of babies in the Badia are still born at home.

The midwife (daya) or an elder women often use The midwife (daya) or an elder women often use procedures during and after delivery (e.g. wrapping procedures during and after delivery (e.g. wrapping a new baby in a cloth sprinkled with dung to a new baby in a cloth sprinkled with dung to deceive the evil eye) which are inherently deceive the evil eye) which are inherently unhealthyunhealthy

- A baby girl is universally less welcome than a boy, - A baby girl is universally less welcome than a boy, she gets less attention and more work even at an she gets less attention and more work even at an early ageearly age

- The boy eats with the men, but the girl and her - The boy eats with the men, but the girl and her mother often eat what is left of the meal mother often eat what is left of the meal

- Also, some of the lifestyle habits specific to - Also, some of the lifestyle habits specific to Bedouin that increase communicable health Bedouin that increase communicable health disease incidence in the Northern Badia are: disease incidence in the Northern Badia are: Raising livestock, drinking unpasteurized milk and Raising livestock, drinking unpasteurized milk and milk products, drinking from rain water in the ponds milk products, drinking from rain water in the ponds and some times drinking and eating from the same and some times drinking and eating from the same cub and the same dishcub and the same dish

EnvironmentEnvironment

Environmental HealthEnvironmental Health• There were a number of concerns and these There were a number of concerns and these

varied according to area.varied according to area.• The ecology of the region (dust and the average The ecology of the region (dust and the average

of the temperature in summer and winter), poor of the temperature in summer and winter), poor living conditions and low living standards are living conditions and low living standards are some of the factors affecting health in the some of the factors affecting health in the Northern BadiaNorthern Badia

• There were concerns expressed about the quality There were concerns expressed about the quality of water, water being brackish with too much of water, water being brackish with too much fluoride, and having a high dust content. fluoride, and having a high dust content.

• Sewage disposal and Solid waste management Sewage disposal and Solid waste management was a concern as in many of these encampments was a concern as in many of these encampments and villages. and villages.

• there is a lack of infrastructure and this is a public there is a lack of infrastructure and this is a public health concern.health concern.

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Also there is a problem with the water, it only comes one day Also there is a problem with the water, it only comes one day a week, and when it goes into the tanks it has rust in it. The a week, and when it goes into the tanks it has rust in it. The water is polluted, if you come and test the water you'll find water is polluted, if you come and test the water you'll find that it's not suitable for human consumption and everyone that it's not suitable for human consumption and everyone suffers from this problem (NBM2)suffers from this problem (NBM2)

We have a lot of flies and mosquitoes and the percentage of We have a lot of flies and mosquitoes and the percentage of chlorine and not chloral is high in the area. We want chlorine and not chloral is high in the area. We want something to fight all this….. Once I went to buy some something to fight all this….. Once I went to buy some bread from the bakery which was full of flies. The bread bread from the bakery which was full of flies. The bread was full of flies. The MoH must inspect the bakeries was full of flies. The MoH must inspect the bakeries (NBM4).(NBM4).

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• When the water comes. It stays running from 10 – 2 o'clock When the water comes. It stays running from 10 – 2 o'clock It is yellow and it has some soil with it. The pipe in the main It is yellow and it has some soil with it. The pipe in the main line has sediments from the past time... This is the main line has sediments from the past time... This is the main thing….. The main point is establishing a hospital for North thing….. The main point is establishing a hospital for North Badia. It is a very wide area and it needs a hospital. The Badia. It is a very wide area and it needs a hospital. The second point, we need sewage system, because the second point, we need sewage system, because the sewage is polluting the area. The whole sewage system sewage is polluting the area. The whole sewage system needs changing (NBM3).needs changing (NBM3).

• The sewage pits in the area. We don't have a sewage The sewage pits in the area. We don't have a sewage system, instead we have sewage pits all over the village. system, instead we have sewage pits all over the village. When it's summer and the weather is hot and dry with no When it's summer and the weather is hot and dry with no wind, the mosquitoes appear (RHCLM5).wind, the mosquitoes appear (RHCLM5).

Services in the BadiaServices in the Badia

• The distribution and quality of services in the Badia The distribution and quality of services in the Badia as of early 1976as of early 1976

• SchoolsSchools - Everywhere- Everywhere you go in the Badia, you find schools, you go in the Badia, you find schools,

primary, elementary and secondary for boys and girlsprimary, elementary and secondary for boys and girls

- The geographic distribution is adequate, the quality - The geographic distribution is adequate, the quality of physical facilities and teachers is often not very of physical facilities and teachers is often not very goodgood

- The educational apparatus in the Badia is far from - The educational apparatus in the Badia is far from satisfactory and suffers from two cases of problems, satisfactory and suffers from two cases of problems, physical plant and staffphysical plant and staff

- The severe shortage of trained staff is a major - The severe shortage of trained staff is a major problem. Teachers, male and female are hard to problem. Teachers, male and female are hard to recruit for the Badia, especially for the remote areas. recruit for the Badia, especially for the remote areas.

Disability services in North BadiaDisability services in North Badia

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

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

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

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

• Child Caring Society is the only one that is found Child Caring Society is the only one that is found in Northern Badia at Al-Saydiya village, 25 in Northern Badia at Al-Saydiya village, 25 kilometer east of Mafraqkilometer east of Mafraq

Water and ElectricityWater and Electricity

• The Badia draws its water supplies from multiplicity of The Badia draws its water supplies from multiplicity of sourcessources

• Piped water systems are found in about 95% of the Piped water systems are found in about 95% of the villagesvillages

• Groundwater are used for human uses where the service Groundwater are used for human uses where the service water resources are used for animals and other useswater resources are used for animals and other uses

• These sources, however are inadequate leaving the These sources, however are inadequate leaving the water supply situation critical in most of the Badiawater supply situation critical in most of the Badia

• Since the Badia is an arid region with scarce and Since the Badia is an arid region with scarce and undependable water resources, most of the population undependable water resources, most of the population relies on rainwater collecting schemes for their supplies relies on rainwater collecting schemes for their supplies especially for those that have animals.especially for those that have animals.

• In his modern day counterpart seems helpless and since In his modern day counterpart seems helpless and since he has practically settled down he has lost his traditional he has practically settled down he has lost his traditional independence and initiativeindependence and initiative

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• Electricity is universally available in the BadiaElectricity is universally available in the Badia• About 99% of the villages in North Badia are About 99% of the villages in North Badia are

offered electricityoffered electricity• In the North Badia a single company monopolizes In the North Badia a single company monopolizes

electricity generation for the whole governorate electricity generation for the whole governorate (Irbid Governorate Electricity Company) (Irbid Governorate Electricity Company)

• There are some small settlement in the There are some small settlement in the Northeastern part of the Badia near Ruwashid Northeastern part of the Badia near Ruwashid uses Renewable Energy (Photovoltaic solar uses Renewable Energy (Photovoltaic solar energy systems) for electrificationenergy systems) for electrification

HousingHousing

• The proportion of true nomads had steadily The proportion of true nomads had steadily declined and the proportion of tent-dwellers also declined and the proportion of tent-dwellers also declined,declined,

• Nowadays, a small figure of households were still Nowadays, a small figure of households were still to live in the hair tent (to live in the hair tent (bait shaarbait shaar))

• The typical tent was rectangular in shape and The typical tent was rectangular in shape and made of black goat-hair and divided by a screen made of black goat-hair and divided by a screen into two quarters, one for men and one for womeninto two quarters, one for men and one for women

• Like the rest of the population, the residents of the Like the rest of the population, the residents of the Badia now live in stone or concrete houses,Badia now live in stone or concrete houses,

• Almost all the dwellings were owner-occupiedAlmost all the dwellings were owner-occupied• House furnishing was sparse and limited to basic House furnishing was sparse and limited to basic

necessities, but however, a few modern pieces of necessities, but however, a few modern pieces of furniture in the form of steel, bedsteads, chairs and furniture in the form of steel, bedsteads, chairs and tables appeared in the houses of income familiestables appeared in the houses of income families

Household FacilitiesHousehold Facilities

• Most of the population in the Badia have piped Most of the population in the Badia have piped water either in their homes or at a stand-pipe,water either in their homes or at a stand-pipe,

• As expected in a comparatively poor population, As expected in a comparatively poor population, possession of household facilities is slightly possession of household facilities is slightly restricted,restricted,

• Electricity is widely available except in a very Electricity is widely available except in a very small groups of households with their own small groups of households with their own generators or stand-alone photovoltaic solar generators or stand-alone photovoltaic solar energy systems,energy systems,

• The most common domesticThe most common domestic appliances are appliances are radio, TV, Refrigerator and washing machine.radio, TV, Refrigerator and washing machine.

CommunicationsCommunications

• Most villages in North Badia are connected to a Most villages in North Badia are connected to a main highway by a secondary roadmain highway by a secondary road

• These secondary roads are characteristically These secondary roads are characteristically asphalted, and wide enoughasphalted, and wide enough to accommodate a to accommodate a two motor vehicle comfortablytwo motor vehicle comfortably

• In addition, most of these villages are connected In addition, most of these villages are connected to each other with a road and these roads are in a to each other with a road and these roads are in a good condition in most casesgood condition in most cases

• Telephone services is widely available in North Telephone services is widely available in North Badia, fixed or mobile, also internet services is Badia, fixed or mobile, also internet services is available in some villages in North Badia, where available in some villages in North Badia, where the first IT center in Jordan was established in the first IT center in Jordan was established in Safawi village in 2000Safawi village in 2000

• The post office is one of the most effective form The post office is one of the most effective form of long-distance communication in the Badiaof long-distance communication in the Badia

CommunicationsCommunications

• PicturePicture

Agricultural ServicesAgricultural Services

• Agricultural Services in the Badia such as cooperative, savings Agricultural Services in the Badia such as cooperative, savings and credit societies, extension and veterinarianand credit societies, extension and veterinarian services are services are not widely availablenot widely available

Social Welfare Services: Social Welfare Services:

- - Most of the social welfare services performed in the Badia have Most of the social welfare services performed in the Badia have been initiated by organizations from outside the region such been initiated by organizations from outside the region such as:as:

• Royal CourtRoyal Court

• Jordan ArmyJordan Army

• Public sector: Ministry of PlanningPublic sector: Ministry of Planning

• Hashemite fundHashemite fund

• Jordan Badia Research and Development CentreJordan Badia Research and Development Centre

• NGOs: Noor Al-Hussain Foundation and Jordan River FoundationNGOs: Noor Al-Hussain Foundation and Jordan River Foundation

- These social services in the region have had a positive effective - These social services in the region have had a positive effective and raising the living standards of the Bedouin communityand raising the living standards of the Bedouin community

DietDiet• For the Badia population, food consumption For the Badia population, food consumption

patterns have changed somewhat during the past patterns have changed somewhat during the past few decadesfew decades

• The Bedouin of the past ate less and with less The Bedouin of the past ate less and with less varietyvariety

• Their meals used to consist of milk and milk Their meals used to consist of milk and milk products, they hardly ever consumed vegetables products, they hardly ever consumed vegetables and meat was limited to festive occasionsand meat was limited to festive occasions

• Now when the Bedouin took to a settled way of life, Now when the Bedouin took to a settled way of life, and especially for those who live in towns, and especially for those who live in towns, vegetables are consumedvegetables are consumed

• Today, milk and milk products like Yoghurt, Labneh Today, milk and milk products like Yoghurt, Labneh and ghee, burghul, vegetables, bread, meat and and ghee, burghul, vegetables, bread, meat and sometimes fruit are consumedsometimes fruit are consumed

• The most important health conditions relating to The most important health conditions relating to diet among Bedouin are: Anemia, stunting and diet among Bedouin are: Anemia, stunting and osteoporosis among older women, osteoporosis among older women,

Nutritional StatusNutritional Status

• The average Bedouin calorie is to be below the The average Bedouin calorie is to be below the national averagenational average

• This situation is a reflection of the low living This situation is a reflection of the low living standards among the populationstandards among the population

• The Bedouin diet is monotonous, insufficient, The Bedouin diet is monotonous, insufficient, unbalanced and seriously deficient in animal proteinunbalanced and seriously deficient in animal protein

• For girls and women the food consumption is below For girls and women the food consumption is below that of the average male because of the prevailing that of the average male because of the prevailing traditionstraditions

• Cultural habits relating to beliefs, attitudes and Cultural habits relating to beliefs, attitudes and practices affect the nutritional status especially practices affect the nutritional status especially among femalesamong females

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

Chapter 4Chapter 4

Health ServicesHealth Services

OutlineOutline

• Intended Learning Outcomes (ILOs)Intended Learning Outcomes (ILOs)• Health Care SystemsHealth Care Systems - - Primary health care services:Primary health care services: - Differentiate between village, primary and CHCenters- Differentiate between village, primary and CHCenters - Referral system- Referral system - Network and coordination among the sectors providing - Network and coordination among the sectors providing

health serviceshealth services

• Health ServicesHealth Services - - Availability of health insuranceAvailability of health insurance - Availability of RH- Availability of RH - Availability of dental health- Availability of dental health - Availability of doctors, dentists and nurses- Availability of doctors, dentists and nurses

• Strengths of the systemStrengths of the system

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- IssuesIssues1- Centralisation of health care system1- Centralisation of health care system

2- Staff morale2- Staff morale

3- Views of staff on Bedouins3- Views of staff on Bedouins

4- Staff training needs4- Staff training needs

5-5- Reproductive Health Reproductive Health

6- Immunizations6- Immunizations

7- Outreach Services7- Outreach Services

- Views of Bedouin on Service ProvisionViews of Bedouin on Service Provision1- Communication1- Communication

2- 2- Payment policy and emergency servicesPayment policy and emergency services

3- Views of Bedouin on their situation3- Views of Bedouin on their situation

- Wasta: A common barrier for providers and - Wasta: A common barrier for providers and the community of Bedouinthe community of Bedouin

- - Traditional medicineTraditional medicine

Intended Learning Outcomes Intended Learning Outcomes (ILOs)(ILOs)

At the end of this unit the student will be able to:At the end of this unit the student will be able to:Knowledge and understanding:Knowledge and understanding:• List five environmental factors affecting health in the Northern List five environmental factors affecting health in the Northern • Recall important Bedouin lifestyle habits Recall important Bedouin lifestyle habits • List three determinants of health affecting Bedouin in Northern List three determinants of health affecting Bedouin in Northern

Badia: housing , poverty, health behaviors, occupation etc…Badia: housing , poverty, health behaviors, occupation etc…• List five communicable diseases found in Northern BadiaList five communicable diseases found in Northern Badia• List five chronic conditions found in the Northern Badia: Diabetes, List five chronic conditions found in the Northern Badia: Diabetes,

hypertension, chest conditions, skin conditions etc… hypertension, chest conditions, skin conditions etc… • List five most common herbal remedies used in the Northern Badia List five most common herbal remedies used in the Northern Badia • List other alternative therapies and healing practices in the List other alternative therapies and healing practices in the

Northern Badia Northern Badia • List five most important health challenges found in the Northern List five most important health challenges found in the Northern

Badia Badia • Discuss three types of health centers found in Northern Badia: Discuss three types of health centers found in Northern Badia:

village centers, primary health centers, comprehensive health village centers, primary health centers, comprehensive health centerscenters

• Describe the most important challenges met by Bedouin to access Describe the most important challenges met by Bedouin to access health services in Northern Badiahealth services in Northern Badia

• List unmet health needs of the following Bedouin population groups: List unmet health needs of the following Bedouin population groups: women, children, elderly and pregnant womenwomen, children, elderly and pregnant women

• Analyze ten issues in health service provision in Northern BadiaAnalyze ten issues in health service provision in Northern Badia

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Intellectual Skills: Intellectual Skills: • Explain how these environmental factors impact health Explain how these environmental factors impact health • Relate these communicable diseases to lifestyle and the Relate these communicable diseases to lifestyle and the

environment environment • Explain conditions for which these herbal remedies are Explain conditions for which these herbal remedies are

used in Northern Badiaused in Northern Badia• Explain the difference between comprehensive health Explain the difference between comprehensive health

center, primary and village health centers center, primary and village health centers Professional and transferable skills Professional and transferable skills • Explain role of traditional healers in the Northern BadiaExplain role of traditional healers in the Northern Badia• List most important service barriers met by Bedouins in the List most important service barriers met by Bedouins in the

health centers health centers • Propose strategic solutions to the challenges in service Propose strategic solutions to the challenges in service

provision provision • Provide culturally-sensitive attitude towards Bedouin Provide culturally-sensitive attitude towards Bedouin

(stigma free)(stigma free)• Act as a health promotion advocate for the Bedouin Act as a health promotion advocate for the Bedouin

population in Northern Badiapopulation in Northern Badia• Propose strategic solutions to the challenges in service Propose strategic solutions to the challenges in service

provisionprovision

Health Care SystemsHealth Care Systems

- Primary Health Care ServicesPrimary Health Care Services• The national system of three levels of primary The national system of three levels of primary

health care clinics may not necessarily be the health care clinics may not necessarily be the most suitable for this large rural area that is most suitable for this large rural area that is sparsely populated with huge distances.sparsely populated with huge distances.

• Owing to the presence of sub-centres, there is a Owing to the presence of sub-centres, there is a problem of expectations alongside quality of care. problem of expectations alongside quality of care.

• The community have unrealistic expectations of The community have unrealistic expectations of round the clock excellent primary health care round the clock excellent primary health care close to home, which is not possible to provide close to home, which is not possible to provide within the constraints and resources of the MoH within the constraints and resources of the MoH budget for primary health care.budget for primary health care.

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• Differentiate between village, primary and Differentiate between village, primary and CHCentersCHCenters

- - Village centerVillage center, mostly composed of two to three rooms , mostly composed of two to three rooms and rented in the small villages, have a nurse and visited and rented in the small villages, have a nurse and visited by doctor two to three times a week and opened three to by doctor two to three times a week and opened three to four hour a dayfour hour a day

- - Primary Health CenterPrimary Health Center, this is larger than the village , this is larger than the village center, good infrastructure, have the primary center, good infrastructure, have the primary requirement like GP, lab, pharmacy, dental, emergency, requirement like GP, lab, pharmacy, dental, emergency, immunization and ambulance and opened from eight to immunization and ambulance and opened from eight to three eveningthree evening

- - Comprehensive Health CenterComprehensive Health Center, this is larger than the , this is larger than the above two, good infrastructure, have the primary above two, good infrastructure, have the primary requirement like GP, lab, pharmacy, dental, emergency, requirement like GP, lab, pharmacy, dental, emergency, x-ray, immunization, ambulances and visited by specialist x-ray, immunization, ambulances and visited by specialist doctors two to three times a week and opened from eight doctors two to three times a week and opened from eight to three evening and twenty four hours for emergencyto three evening and twenty four hours for emergency

The Main Key Indicators of the The Main Key Indicators of the Area: Population, Area: Population, Comprehensive Health CentersComprehensive Health Centers

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• Referral systemReferral system

- - The referral system in the health caring system The referral system in the health caring system in Northern Badia is depend on the available of in Northern Badia is depend on the available of the health center, and the distance between the the health center, and the distance between the villagesvillages

- in general, when the patient visit the village - in general, when the patient visit the village center and he have the solution of his problem, center and he have the solution of his problem, then he does not need to visit other clinicthen he does not need to visit other clinic

- If no, the GP referral him to the nearest primary - If no, the GP referral him to the nearest primary health centerhealth center

- The primary health center referral the patient to - The primary health center referral the patient to the comprehensive health center for more check the comprehensive health center for more check if the patient required thatif the patient required that

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• Network and coordination among the Network and coordination among the sectors providing health servicessectors providing health services

- - High coordination amongst MOH, Military and local High coordination amongst MOH, Military and local institutes.institutes.

“ “The coordination with the private sector takes place through The coordination with the private sector takes place through municipalities and the community Health Committees that municipalities and the community Health Committees that are formed by the local community with representatives such are formed by the local community with representatives such as school principals, sheikhs, and chiefs (Mukhtars). The as school principals, sheikhs, and chiefs (Mukhtars). The purpose of such committees is to identify and classify the purpose of such committees is to identify and classify the health problems according to the priorities of local health problems according to the priorities of local community in order to solve these problems. There is community in order to solve these problems. There is cooperation with the sport clubs and youth centres in the cooperation with the sport clubs and youth centres in the field of awareness raising, health education, surveys and field of awareness raising, health education, surveys and research, and dissemination of information for the local research, and dissemination of information for the local community especially about diseases such as HIV and Aids” community especially about diseases such as HIV and Aids” (PM7).(PM7).

Health ServicesHealth Services

• Health services in the Badia are in the form of Health services in the Badia are in the form of government-operated clinicsgovernment-operated clinics

• Availability of health insurance Availability of health insurance

Health insurance is one of the problems that Health insurance is one of the problems that confront us nowadays. Many people ask for it and confront us nowadays. Many people ask for it and they ask for comprehensive health insurance. The they ask for comprehensive health insurance. The MOH of course aims to implement comprehensive MOH of course aims to implement comprehensive health insurance and we could say that we health insurance and we could say that we already have a comprehensive health insurance already have a comprehensive health insurance because the MOH covers 70 % of the cost and the because the MOH covers 70 % of the cost and the people - even those who can pay- cover the rest people - even those who can pay- cover the rest (30%) of the cost only (PM3).(30%) of the cost only (PM3).

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• Availability of RHAvailability of RH For the pregnancies and health care, we have a For the pregnancies and health care, we have a

maternity section in the health centre. The maternity section in the health centre. The obstetrician checks the female clients, and gives obstetrician checks the female clients, and gives them advice, vaccines and contraception. The them advice, vaccines and contraception. The contraception could be through the rhythm contraception could be through the rhythm method, the pills injections or by IUDs. Pregnant method, the pills injections or by IUDs. Pregnant women are checked from the beginning of women are checked from the beginning of pregnancy by an obstetrician. It is free of charge pregnancy by an obstetrician. It is free of charge Each case has a file, we have midwives who Each case has a file, we have midwives who weigh the pregnant women and monitor her weigh the pregnant women and monitor her during the pregnancy till she gives birth, These during the pregnancy till she gives birth, These services are free of charge including services are free of charge including contraception. We also have coils for those contraception. We also have coils for those women who do not want children or for spacing women who do not want children or for spacing between pregnancies. All these services are free between pregnancies. All these services are free of charge (PM5).of charge (PM5).

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The MoH provides postnatal care; however, the The MoH provides postnatal care; however, the problem is that women after delivery do not visit the problem is that women after delivery do not visit the clinic. This is a problem and we need health clinic. This is a problem and we need health education in this area. We should teach them that education in this area. We should teach them that you should not care about your health only when you should not care about your health only when you feel you are ill. You should maintain your body you feel you are ill. You should maintain your body because your body is like a machine which needs because your body is like a machine which needs regular maintenance. You need immediate regular maintenance. You need immediate intervention to fix a problem. Sometime you need to intervention to fix a problem. Sometime you need to do preventive care before any complications for do preventive care before any complications for example dental check ups (PM6).example dental check ups (PM6).

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• Availability of dental healthAvailability of dental health

The dental medicine is available in this remote The dental medicine is available in this remote area; other clinics which are 200 KM away from here area; other clinics which are 200 KM away from here like the Irbid clinic offer the same services (RUP6).like the Irbid clinic offer the same services (RUP6).

• Availability of doctors, dentists and nursesAvailability of doctors, dentists and nurses

All things are available, Pharmacy, medical All things are available, Pharmacy, medical secretary, laboratory if there is one at the health secretary, laboratory if there is one at the health centre, a dental clinic, and a medical clinic, etc centre, a dental clinic, and a medical clinic, etc (PM4).(PM4).

Of course services are available until 2 pm, full Of course services are available until 2 pm, full services from nursing to MCH and delivery, services from nursing to MCH and delivery, laboratory, pharmacy, X-ray department, laboratory, pharmacy, X-ray department, accountants, doctors and dentists. All of that is accountants, doctors and dentists. All of that is available.(AZCLP6available.(AZCLP6 ). ).

Strengths of the SystemStrengths of the System

• Availability of a databaseAvailability of a database

“ “We now have a database that we have created to capture We now have a database that we have created to capture the pattern of settlement and movementthe pattern of settlement and movement “ ( “ (PM2)PM2)

“ “I think the strongest point is that we know Bedouins’ places I think the strongest point is that we know Bedouins’ places and we can follow them. We have enough knowledge about and we can follow them. We have enough knowledge about their places and we have outreach clinics and outreach their places and we have outreach clinics and outreach teams who go out and reach them” (PM3).teams who go out and reach them” (PM3).

• Outreach activitiesOutreach activities

“ “There is health education especially during vaccinations There is health education especially during vaccinations and outreach vaccination campaigns. We go out with a and outreach vaccination campaigns. We go out with a midwife or a nurse. We also have vaccination campaigns in midwife or a nurse. We also have vaccination campaigns in schools, and we do environmental inspections at schools schools, and we do environmental inspections at schools regarding the quality of drinking water. We also visit regarding the quality of drinking water. We also visit citizens outside the centre and give them health education” citizens outside the centre and give them health education” (AZCLP1).(AZCLP1).

Tally Sheet of Monthly Reports Used In Tally Sheet of Monthly Reports Used In Northern Badia Comprehensive Health Northern Badia Comprehensive Health

CentresCentres

Tally Sheet of Monthly Reports Used In Tally Sheet of Monthly Reports Used In Northern Badia Comprehensive Health Northern Badia Comprehensive Health Centres (Cont.)Centres (Cont.)

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• National Immunization campaignNational Immunization campaign

“ “we have the national official programme which contains we have the national official programme which contains different kinds of vaccines against polio, DT (Diphtheria + different kinds of vaccines against polio, DT (Diphtheria + Tetanus), measles and the package of 5 vaccines (DPT+ H. Tetanus), measles and the package of 5 vaccines (DPT+ H. Infl+HBV: Diphtheria, Pertussis, Tetanus, Influenza and Infl+HBV: Diphtheria, Pertussis, Tetanus, Influenza and Hepatitis B virus). These vaccines are provided through a Hepatitis B virus). These vaccines are provided through a planned programme that starts from three months old and planned programme that starts from three months old and above.above.

We have mobile immunization teams that work in the field We have mobile immunization teams that work in the field in the whole Ruwaished area. They move from tent to tent in the whole Ruwaished area. They move from tent to tent in encampments in the desert. Every year we have an in encampments in the desert. Every year we have an immunization campaign against polio. The campaign immunization campaign against polio. The campaign continues for 4-5 days with two doses of polio vaccine. The continues for 4-5 days with two doses of polio vaccine. The campaigns include providing one dose of vaccine and campaigns include providing one dose of vaccine and another dose a month later. We do a comprehensive field another dose a month later. We do a comprehensive field survey and we vaccinate all children who are under five survey and we vaccinate all children who are under five years of age (PM5)”years of age (PM5)”

ContinueContinue• Availability of health insuranceAvailability of health insurance Health insurance is one of the problems that confront us Health insurance is one of the problems that confront us

nowadays. Many people ask for it and they ask for comprehensive nowadays. Many people ask for it and they ask for comprehensive health insurance. The MOH of course aims to implement health insurance. The MOH of course aims to implement comprehensive health insurance and we could say that we already comprehensive health insurance and we could say that we already have a comprehensive health insurance because the MOH covers have a comprehensive health insurance because the MOH covers 70 % of the cost and the people - even those who can pay- cover 70 % of the cost and the people - even those who can pay- cover the rest (30%) of the cost only (PM3).the rest (30%) of the cost only (PM3).

• Availability of dental healthAvailability of dental health The dental medicine is available in this remote area; other clinics The dental medicine is available in this remote area; other clinics

which are 200 KM away from here like the Irbid clinic offer the which are 200 KM away from here like the Irbid clinic offer the same services (RUP6).same services (RUP6).

• Availability of doctors, dentists and nursesAvailability of doctors, dentists and nurses All things are available, Pharmacy, medical secretary, laboratory if All things are available, Pharmacy, medical secretary, laboratory if

there is one at the health centre, a dental clinic, and a medical there is one at the health centre, a dental clinic, and a medical clinic, etc (PM4).clinic, etc (PM4).

Of course services are available until 2 pm, full services from Of course services are available until 2 pm, full services from nursing to MCH and delivery, laboratory, pharmacy, X-ray nursing to MCH and delivery, laboratory, pharmacy, X-ray department, accountants, doctors and dentists. All of that is department, accountants, doctors and dentists. All of that is available.(AZCLP6)available.(AZCLP6)

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• Availability of RHAvailability of RH For the pregnancies and health care, we have a maternity For the pregnancies and health care, we have a maternity

section in the health centre. The obstetrician checks the female section in the health centre. The obstetrician checks the female clients, and gives them advice, vaccines and contraception. clients, and gives them advice, vaccines and contraception. The contraception could be through the rhythm method, the The contraception could be through the rhythm method, the pills injections or by IUDs. Pregnant women are checked from pills injections or by IUDs. Pregnant women are checked from the beginning of pregnancy by an obstetrician. It is free of the beginning of pregnancy by an obstetrician. It is free of charge Each case has a file, we have midwives who weigh the charge Each case has a file, we have midwives who weigh the pregnant women and monitor her during the pregnancy till she pregnant women and monitor her during the pregnancy till she gives birth, These services are free of charge including gives birth, These services are free of charge including contraception. We also have coils for those women who do not contraception. We also have coils for those women who do not want children or for spacing between pregnancies. All these want children or for spacing between pregnancies. All these services are free of charge (PM5).services are free of charge (PM5).

The MoH provides postnatal care; however, the problem is that The MoH provides postnatal care; however, the problem is that women after delivery do not visit the clinic. This is a problem women after delivery do not visit the clinic. This is a problem and we need health education in this area. We should teach and we need health education in this area. We should teach them that you should not care about your health only when you them that you should not care about your health only when you feel you are ill. You should maintain your body because your feel you are ill. You should maintain your body because your body is like a machine which needs regular maintenance. You body is like a machine which needs regular maintenance. You need immediate intervention to fix a problem. Sometime you need immediate intervention to fix a problem. Sometime you need to do preventive care before any complications for need to do preventive care before any complications for example dental check ups (PM6).example dental check ups (PM6).

IssuesIssues

1- Centralisation of health care system1- Centralisation of health care system

Whilst it is strength for training staff, and providing national Whilst it is strength for training staff, and providing national care, local directors are limited in their ability to actcare, local directors are limited in their ability to act

"We don’t buy anything directly. We do not have the authority to "We don’t buy anything directly. We do not have the authority to spend.spend.

There is central controlThere is central control (PM8) (PM8)

Within the MOH there is no decentralization. The Director in the Within the MOH there is no decentralization. The Director in the health directorate does not have the power to decide on health directorate does not have the power to decide on expenditure or on appointing staff.. We do not deal with expenditure or on appointing staff.. We do not deal with financial resources as we do not have the authority. We have financial resources as we do not have the authority. We have something called financial income (that is the budget we are something called financial income (that is the budget we are allocated). As a directorate we have shortages in equipment and allocated). As a directorate we have shortages in equipment and supplies of medicines and technical staff. But the Director has no supplies of medicines and technical staff. But the Director has no power to control it . There is shortage in the supply of almost power to control it . There is shortage in the supply of almost

200 medicines (PM8).200 medicines (PM8).

ContinueContinue• We face problems in remote areas such as Azraq. The We face problems in remote areas such as Azraq. The

ministry is centralized in its structure and organization and ministry is centralized in its structure and organization and provides the staff. If there was decentralization, the work in provides the staff. If there was decentralization, the work in the health centers would be better, and administratively the health centers would be better, and administratively there would be more delegated power of decision making in there would be more delegated power of decision making in the areas of finance, administration and appointing staff. the areas of finance, administration and appointing staff. There would be no problems. Currently when the director There would be no problems. Currently when the director faces problems, these are referred to the central offices of faces problems, these are referred to the central offices of the Ministry (PM8).the Ministry (PM8).

• For example if there are maintenance problems which For example if there are maintenance problems which requiring financial expenditure, we have a problem of requiring financial expenditure, we have a problem of purchasing if there is technical or electrical defect, and purchasing if there is technical or electrical defect, and similarly if we need to fix machines, equipment and similarly if we need to fix machines, equipment and vehicles. This is centralization and is not within the vehicles. This is centralization and is not within the authority of the director. It would be better if there was authority of the director. It would be better if there was more decentralization. There was a study done on this. more decentralization. There was a study done on this. They gave two hospitals some kind of decentralized powers They gave two hospitals some kind of decentralized powers and they were well administered. The project is over"(PM8).and they were well administered. The project is over"(PM8).

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2- Staff morale2- Staff morale

• Staff feel isolated and often are living far away Staff feel isolated and often are living far away from their families, working long hours with little from their families, working long hours with little time off and feel not valued and underpaid.time off and feel not valued and underpaid.

• no extra fuel allowances and few incentives for no extra fuel allowances and few incentives for working in these areas. working in these areas.

• The accommodation is often of poor quality.The accommodation is often of poor quality.

• Rural Population very doctor focused and lack of Rural Population very doctor focused and lack of awareness to what nurses can provide. awareness to what nurses can provide.

• Qualified doctors are reluctant to serve in rural Qualified doctors are reluctant to serve in rural areas.areas.

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• Other challenges are pertinent to the best use of the Other challenges are pertinent to the best use of the resources; some times we face some problem such as the resources; some times we face some problem such as the brain drain. For instance, if we have a vacancy for a brain drain. For instance, if we have a vacancy for a physician to serve in an urban area, 30 doctors might physician to serve in an urban area, 30 doctors might apply, but if we say that the vacancy is in Ma'an 10 doctors apply, but if we say that the vacancy is in Ma'an 10 doctors might apply only for in reality none of them will accept to might apply only for in reality none of them will accept to go there. There are qualified people in Amman but they go there. There are qualified people in Amman but they refuse to serve in the rural areas (PM3).refuse to serve in the rural areas (PM3).

• We have a kitchen but it is empty. The staffs after 24 hours We have a kitchen but it is empty. The staffs after 24 hours of work have to cook for themselves. There should be of work have to cook for themselves. There should be meals for the staff that are on duty (meals for the staff that are on duty (NBCLP3)NBCLP3)..

• I wish they would let me go home at 8 o'clock instead of 10 I wish they would let me go home at 8 o'clock instead of 10 o'clock, I asked for that but they refused. I work 30 or 32 o'clock, I asked for that but they refused. I work 30 or 32 hours but they don't care about our sufferinghours but they don't care about our suffering (NBCLP12).(NBCLP12).

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3- Views of staff on Bedouins3- Views of staff on Bedouins• Many staff interviewed had little knowledge about Many staff interviewed had little knowledge about

the Bedouins’ culture or way of lifethe Bedouins’ culture or way of life

The majority of Bedouins live in the desert. This type of The majority of Bedouins live in the desert. This type of Bedouin is not interested in education, health or drinking Bedouin is not interested in education, health or drinking water. His sole object is to stay with his herd, buy, sell and water. His sole object is to stay with his herd, buy, sell and trade. So, if you ask him to bring his child to school, he trade. So, if you ask him to bring his child to school, he might ask his child to drop out from school and work as a might ask his child to drop out from school and work as a shepherd. It does not matter for him if water is clean or shepherd. It does not matter for him if water is clean or unclean. He will draw water from wherever he found water unclean. He will draw water from wherever he found water in the desert to irrigate his sheep and himself. He does not in the desert to irrigate his sheep and himself. He does not care about other things, he does not care about having care about other things, he does not care about having health awareness, or social awareness, watching TV and health awareness, or social awareness, watching TV and seeing the world or civilization. He will be away from the seeing the world or civilization. He will be away from the wider the world without water or electricity or anything as wider the world without water or electricity or anything as long as he keeps staying in the desert. He depends on the long as he keeps staying in the desert. He depends on the resources which exist in the land around him. If he finds resources which exist in the land around him. If he finds pasture he will bring his herd to graze. If he finds water he pasture he will bring his herd to graze. If he finds water he will collect it with his vehicle and drink it. (PM5)will collect it with his vehicle and drink it. (PM5)

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4- 4- Staff training needsStaff training needs• Staff are not from the area and lack knowledge Staff are not from the area and lack knowledge

about the local population. about the local population. • Lack of Bedouin staff.Lack of Bedouin staff.• Lack of communication skills. Lack of communication skills. • Staff would like more pre and in- service training.Staff would like more pre and in- service training.

They should do more courses for us. They should teach us They should do more courses for us. They should teach us more and give us training, so that we become stronger in more and give us training, so that we become stronger in our field and provide people with better services.our field and provide people with better services. (AZCLP4)(AZCLP4)

The department is equipped but it needs medical staff. We The department is equipped but it needs medical staff. We have a lack of medical staff here, especially nurses. have a lack of medical staff here, especially nurses. Unfortunately all the appointments here in the centre are Unfortunately all the appointments here in the centre are people who have a lack of experience. I mean they people who have a lack of experience. I mean they graduate from college or university and then they directly graduate from college or university and then they directly start working here in Ruwaished. So what we have here is a start working here in Ruwaished. So what we have here is a lack of practical experience ( RUP4)lack of practical experience ( RUP4)

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The MoH do not pay attention to the Badia. For example The MoH do not pay attention to the Badia. For example they don't do courses and workshops here. During the last they don't do courses and workshops here. During the last year and a half I haven't seen the MoH do any course to year and a half I haven't seen the MoH do any course to remind us of the things that we studied. They honestly remind us of the things that we studied. They honestly don't do anything like that at all.don't do anything like that at all. ( (NBCLP3)NBCLP3)

My recommendations are to enhance the health services in My recommendations are to enhance the health services in the area and provide pre-service training for the staff in the the area and provide pre-service training for the staff in the art of communication with people NBCLP7.art of communication with people NBCLP7.

We should organize training courses for staff even in the We should organize training courses for staff even in the field of culture, education, awareness raising, updating, etc. field of culture, education, awareness raising, updating, etc. …. We have some courses but they are limited and we do …. We have some courses but they are limited and we do not participate because our MoH does not participate and not participate because our MoH does not participate and rejects covering any financial fees. We need continuous rejects covering any financial fees. We need continuous education and awareness. ….The equipment is available education and awareness. ….The equipment is available but becomes out of service because the staff are not but becomes out of service because the staff are not trained to use them (NBCLP6).trained to use them (NBCLP6).

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5- Reproductive Health5- Reproductive Health• Postnatal services are not systematic or regular. Postnatal services are not systematic or regular. • Family planning services are varying from area to Family planning services are varying from area to

another. another. • Family planning in relation to Intra-uterine devices Family planning in relation to Intra-uterine devices

are not always available owing to staff not being are not always available owing to staff not being trained to insert them. trained to insert them.

• There is a need for more female staff.There is a need for more female staff.

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

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

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6- Immunizations6- Immunizations• Immunization services are available at the clinics and Immunization services are available at the clinics and

through outreach with regular campaigns but through outreach with regular campaigns but sometimes they are unable to reach all of children of sometimes they are unable to reach all of children of families that are nomadic or semi-nomadic to ensure families that are nomadic or semi-nomadic to ensure complete coveragecomplete coverage..

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

In Azraq the citizens hear that there is a vaccination campaign and 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 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 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 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 vaccinate them, but if we don't reach them and the information about the campaign didn't reach them they don't get about the campaign didn't reach them they don't get vaccinated…… in our last immunization campaign three weeks ago vaccinated…… in our last immunization campaign three weeks ago people ran off and refused to be immunized (AZCLP3).people ran off and refused to be immunized (AZCLP3).

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7- Outreach Services7- Outreach Services• Outreach faces a plethora of obstacles such as:Outreach faces a plethora of obstacles such as:

– Lack of awareness among Bedouin that drives Lack of awareness among Bedouin that drives some of them to escape the immunization some of them to escape the immunization campaigns campaigns

– The coverage of outreach is not comprehensiveThe coverage of outreach is not comprehensive due to staff, facilities and equipment shortages due to staff, facilities and equipment shortages

– Mobility of Bedouins disturbs the Mobility of Bedouins disturbs the comprehensive coverage of immunization.comprehensive coverage of immunization.

– Mobile clinics are not cost- effectiveMobile clinics are not cost- effective

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

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There are a lot of mobile Bedouins here, they live in an area There are a lot of mobile Bedouins here, they live in an area and then they move to another one. We even found this and then they move to another one. We even found this problem in schools; some students repeat the same classes problem in schools; some students repeat the same classes because of the absence. They live here for a year and next because of the absence. They live here for a year and next year they decide to live in another place. This is the year they decide to live in another place. This is the problem we face with vaccination, it’s hard to know 100% problem we face with vaccination, it’s hard to know 100% (RUP1).(RUP1).

We thought a lot about the provision of mobile clinics and We thought a lot about the provision of mobile clinics and sometimes with help from the private sector we make a sometimes with help from the private sector we make a mobile clinic for eye examinations or for other things. But mobile clinic for eye examinations or for other things. But this is not easy and it costs a lot without any profit. We this is not easy and it costs a lot without any profit. We think that these clinics cost a lot of money however the think that these clinics cost a lot of money however the number of people who are served is little. We study both number of people who are served is little. We study both sides of this issue (PM3).sides of this issue (PM3).

Views of Bedouin on Service Views of Bedouin on Service ProvisionProvisionCommunicationCommunication

• The attitudes of some staff as well as their lack of The attitudes of some staff as well as their lack of knowledge about Bedouins impairs the quality of knowledge about Bedouins impairs the quality of care owing to poor communication.care owing to poor communication.

• The lack of understanding of primary health care The lack of understanding of primary health care amongst the community also means that their amongst the community also means that their demands may be unreasonable and their use of demands may be unreasonable and their use of the health care system not optimal.the health care system not optimal.

The nurses' treatment of people is very bad. They don't The nurses' treatment of people is very bad. They don't treat us kindly, and honestly there aren't any services. So I treat us kindly, and honestly there aren't any services. So I prefer to borrow money from someone to go to a private prefer to borrow money from someone to go to a private doctor rather than go to the health centre…..They don't doctor rather than go to the health centre…..They don't treat us well. We complained to the district chief, but treat us well. We complained to the district chief, but everything stayed the same. Nobody listens. Where are we everything stayed the same. Nobody listens. Where are we supposed to go?!(AZW3).supposed to go?!(AZW3).

ContinueContinue The treatment in Mafraq hospital is not good at all. I will The treatment in Mafraq hospital is not good at all. I will

never go there for delivery if I am pregnant now. I decided never go there for delivery if I am pregnant now. I decided not to have more children after my last delivery in Mafraq not to have more children after my last delivery in Mafraq hospital. They sent me home the next day of delivery at hospital. They sent me home the next day of delivery at midnight. They did not look after patients properly. In midnight. They did not look after patients properly. In delivery, you become sick, fed up, and you are bleeding but delivery, you become sick, fed up, and you are bleeding but they do not care about you!they do not care about you!

The Refa'eat Health centre is pointless. I had fights with the The Refa'eat Health centre is pointless. I had fights with the GP and the pharmacist who works there. I always tell them GP and the pharmacist who works there. I always tell them that we come at 6:00 am and keep on waiting till 11:00 AM that we come at 6:00 am and keep on waiting till 11:00 AM and the doctor doesn't arriveand the doctor doesn't arrive ( (MACLW8).MACLW8).

There isn't an otolaryngologist at the centre, or a There isn't an otolaryngologist at the centre, or a cardiologist, or an ophthalmologist, or dermatologist. Also cardiologist, or an ophthalmologist, or dermatologist. Also we don't have a female gynaecologist here. We have a we don't have a female gynaecologist here. We have a male gynaecologist but you know it's a sensitive issue to male gynaecologist but you know it's a sensitive issue to people here. I complained more than one time about it, but people here. I complained more than one time about it, but they told me that no female doctor would come and work they told me that no female doctor would come and work here. I do not understand why can't she come here?! If she here. I do not understand why can't she come here?! If she is an employed and accepted the job that she has to be is an employed and accepted the job that she has to be committed to, the government can make her go to the end committed to, the government can make her go to the end of the world. We used to have a female doctor here in the of the world. We used to have a female doctor here in the end they transferred her (RUM3)end they transferred her (RUM3)

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Payment policy and emergency servicesPayment policy and emergency services• Bedouin who move seasonally and then attend a Bedouin who move seasonally and then attend a

clinic other than where they are registered are clinic other than where they are registered are charged an additional fee. This is deterrent to charged an additional fee. This is deterrent to completing immunizations. completing immunizations.

• Attending the clinics in the afternoon is Attending the clinics in the afternoon is sometimes necessary owing to an emergency or sometimes necessary owing to an emergency or to transport only being available in the afternoon. to transport only being available in the afternoon. Fees are charged. Fees are charged.

• When drugs are not available, people are referred When drugs are not available, people are referred to private pharmacies. to private pharmacies.

• Fees are higher if people are not insured and this Fees are higher if people are not insured and this excludes those who are more marginal.excludes those who are more marginal.

Another problem is that although there is a decision to cure Another problem is that although there is a decision to cure who are less than six years old free of charge, they still ask who are less than six years old free of charge, they still ask us to pay for those who are under six…. us to pay for those who are under six…. They ask us to pay They ask us to pay even if they are 10 tablets of Aspirineven if they are 10 tablets of Aspirin (AZM1). (AZM1).

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They use another manoeuvre; they ask us to pay 25p for They use another manoeuvre; they ask us to pay 25p for the drug, but the drug is nothing, it is just two suppositories the drug, but the drug is nothing, it is just two suppositories or some tablets of Revanin (painkiller) and they register or some tablets of Revanin (painkiller) and they register them. …..them. …..I have Asthma but I do not have insurance. I have I have Asthma but I do not have insurance. I have only the white card. I haven’t got insurance although I am only the white card. I haven’t got insurance although I am unemployed and I have got asthma. I buy the inhaler from unemployed and I have got asthma. I buy the inhaler from outside. When I go to the centre they ask me for a fee. I am outside. When I go to the centre they ask me for a fee. I am sick and unemployed. I have asthma and I want inhaler but sick and unemployed. I have asthma and I want inhaler but they refuse to prescribe medicine for me (AZM4).they refuse to prescribe medicine for me (AZM4).

The first problem with the Health Centre is related to fee. The first problem with the Health Centre is related to fee. They charge us more after working hours. They have two They charge us more after working hours. They have two different rates; one for the working hours and the other for different rates; one for the working hours and the other for the afternoon. Not only the fee but also the medicine the afternoon. Not only the fee but also the medicine becomes more expensive, almost like the regular prices becomes more expensive, almost like the regular prices outside the center's pharmacy. As a consequence, some outside the center's pharmacy. As a consequence, some patients prefer to delay their visit to the next day, and visit patients prefer to delay their visit to the next day, and visit the centre in working hours to avoid paying extra fee the centre in working hours to avoid paying extra fee (NBM2).(NBM2).

Views of Bedouin on their Views of Bedouin on their situationsituation• Bedouin felt that their community is neglected. Bedouin felt that their community is neglected.

• There were some issues in particular in Azraq at There were some issues in particular in Azraq at the clinic owing to the mixed population of the the clinic owing to the mixed population of the

town and the clinic staff being solely Druzetown and the clinic staff being solely Druze.. They don’t care about Bedouins in the eastern parts of the They don’t care about Bedouins in the eastern parts of the

country. We feel we haven’t got anything (MACLW7). country. We feel we haven’t got anything (MACLW7).

There is a lot of neglect at the health centre in Ruba'a There is a lot of neglect at the health centre in Ruba'a (SSW5).(SSW5).

The GP just asks you and writes the prescription which is The GP just asks you and writes the prescription which is mostly pain killers or aspirin or whatever is available. He mostly pain killers or aspirin or whatever is available. He tells you: "this is what I have here". There is no test or tells you: "this is what I have here". There is no test or check. We are disconnected and isolated here (SAM5)check. We are disconnected and isolated here (SAM5)

Wasta: A common barrier for providers Wasta: A common barrier for providers and the community of Bedouinand the community of Bedouin

• The exchange of favours is part of the wider society and can be The exchange of favours is part of the wider society and can be both a facilitator or a barrier to accessing health care. This can both a facilitator or a barrier to accessing health care. This can exert pressure on staff when faced with requests as well as exert pressure on staff when faced with requests as well as result in resentment amongst patients.result in resentment amongst patients.

Yes he does but he is under pressure. If we want to change the Yes he does but he is under pressure. If we want to change the arrangement, hundred Wasta will come to convince us that the drivers arrangement, hundred Wasta will come to convince us that the drivers are poor and they want to earn their bread and their work is so tiring, are poor and they want to earn their bread and their work is so tiring, so it is not easy to change it.so it is not easy to change it.

Wasta makes trouble for us. It do you mean include? embraced the Wasta makes trouble for us. It do you mean include? embraced the director of the centre and the GP ( SSP6)director of the centre and the GP ( SSP6)

Wasta plays a role, because some patients who make trouble have Wasta plays a role, because some patients who make trouble have relatives inside the centre and in order to keep good relations with relatives inside the centre and in order to keep good relations with your colleagues, you have to be tolerant (SSP1).your colleagues, you have to be tolerant (SSP1).

Regarding the children and like I said before any transfer, we have to Regarding the children and like I said before any transfer, we have to take an appointment. If you have a Wasta they might give you an take an appointment. If you have a Wasta they might give you an appointment after a week in the external clinics. I mean when I went appointment after a week in the external clinics. I mean when I went for the first time they told me 12 days or maybe a week (MACLM2)for the first time they told me 12 days or maybe a week (MACLM2)

Traditional medicineTraditional medicine• Most common herbal remedies used in Northern Most common herbal remedies used in Northern

Badia are: chamomile, thyme, sage, Badia are: chamomile, thyme, sage, شيحشيح sheehsheeh, , Jaadat el subianJaadat el subian الصبيان الصبيان جعدة جعدة

• Most of these herbal remedies used for stomach Most of these herbal remedies used for stomach cramps, nausea and common coldcramps, nausea and common cold

• In the Northern Badia there are other alternative In the Northern Badia there are other alternative therapies and healing practices such as using therapies and healing practices such as using cautery cautery الكيالكي for therapy, visiting the graves for for therapy, visiting the graves for therapy therapy القبور القبور زيارة and taking some soil and mixing and taking some soil and mixing زيارةit with olive oil and painting the skinit with olive oil and painting the skin

• In the past the role of the traditional healers in the In the past the role of the traditional healers in the Northern Badia was important, especially for born Northern Badia was important, especially for born the babiesthe babies

• Today, as the health care is widely available, the Today, as the health care is widely available, the role of the traditional healers dramatically role of the traditional healers dramatically decreased in the Badiadecreased in the Badia

ContinueContinue• The most common diseases are the diseases related to children, The most common diseases are the diseases related to children,

for example the disease that doctors call measles, we call it for example the disease that doctors call measles, we call it "Fushit Dam", and we give the child "sheep Magher" which is the "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 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 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 daya red dress, and with God's help he cures the next day (AZAH1). (AZAH1).

• We have a proverb which is "give a child Marmaka and Anzout We have a proverb which is "give a child Marmaka and Anzout (herbs) and through him away". It means when the child drink (herbs) and through him away". It means when the child drink from these herbs he will be recovered. We used to spread the 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 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 to sleep until he sweat. Then he will become fine. We use

Marmaka for diarrhoea Marmaka for diarrhoea (AZAH1).(AZAH1).

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

another herb. We boil the mix and ask her to drink itanother herb. We boil the mix and ask her to drink it (SAAH2).(SAAH2).

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

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

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

Use of Use of Traditional Medicine and Traditional Medicine and Herbs among BEDOUINHerbs among BEDOUIN• Measles= Fushit DamMeasles= Fushit Dam• The most common diseases are the diseases related to The most common diseases are the diseases related to

children, for example the disease that doctors call children, for example the disease that doctors call measles, we call it measles, we call it "Fushit Dam"Fushit Dam", and we give the child ", and we give the child ""sheep Magher"sheep Magher" which is the colouring on the sheep's which is the colouring on the sheep's back like red soil. We mix it with water and give it to 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 the child to drink, and then we dress the child with a

red dress, and with God's help he cures the next dayred dress, and with God's help he cures the next day (AH1)(AH1)

• Khaitah=red spots like ant Khaitah=red spots like ant bites on chest and backbites on chest and back

• Rx: sheep Magher and Rx: sheep Magher and dressing child in reddressing child in red

• RX:We give him herbs (RX:We give him herbs (WhiteWhite shohoutshohout, , Red shohout , White Red shohout , White Titwanah, Alhasan Alyousef, Titwanah, Alhasan Alyousef, Kaset Aloukht, eggKaset Aloukht, egg). ).

• Also a child might come with Also a child might come with KhaitahKhaitah which is red which is red spots like ant bites on his chest and back. We give spots like ant bites on his chest and back. We give him herbs (him herbs (WhiteWhite shohoutshohout, , Red shohout , White Red shohout , White Titwanah, Alhasan Alyousef, Kaset Aloukht, eggTitwanah, Alhasan Alyousef, Kaset Aloukht, egg ). We ). We mix them, and cook them, and then spread them on mix them, and cook them, and then spread them on the child's body, we also give the child a little bit of the child's body, we also give the child a little bit of coffee to drink, and after that, and with God's help, coffee to drink, and after that, and with God's help, he becomes better. (AH1)he becomes better. (AH1)

Traditional Medicine Traditional Medicine (continued)(continued)• DiarrheaDiarrhea• For For Ukht IlA'ielUkht IlA'iel, it's when the , it's when the

child stops eating, vomits and child stops eating, vomits and has diarrhoea. He eats food has diarrhoea. He eats food and after that he collapses, and after that he collapses, it's like he gets poisoned, and it's like he gets poisoned, and the child also suffers from the child also suffers from stomach aches.(AH4)stomach aches.(AH4)

• Post Delivery Post Delivery

• Frequent miscarriagesFrequent miscarriages

• Marmaka, Biradeh, Anbar & Za’utMarmaka, Biradeh, Anbar & Za’ut• We have a proverb which is "give a child We have a proverb which is "give a child

MarmakaMarmaka and and AnzoutAnzout (herbs) and through him (herbs) and through him away". It means when the child drink from these away". It means when the child drink from these herbs he will be recovered. We used to spread herbs he will be recovered. We used to spread the child body with the child body with MarwahaMarwaha (herbs) if he has (herbs) if he has sun stroke and ask him to sleep until he sweat. sun stroke and ask him to sleep until he sweat. Then he will become fine. We use Then he will become fine. We use MarmakaMarmaka for for diarrhoea. (AH1)diarrhoea. (AH1)

• Yes, Yes, Qasumeh, Shihah, Ja'det Alsubyan, Qasumeh, Shihah, Ja'det Alsubyan, Chamomile, Za'tarChamomile, Za'tar I get all these things from the I get all these things from the wild.(AH4)wild.(AH4)

• In this case we give the child a mix of honey and In this case we give the child a mix of honey and ((BiradehBiradeh) which is prepared by the herb seller ) which is prepared by the herb seller (AH2)(AH2)

• After I buy them I grind the ingredients and After I buy them I grind the ingredients and bring some incense and ember, I then put the bring some incense and ember, I then put the stuff on the stuff on the emberember. After that I bring some . After that I bring some Za'utZa'ut, , put some incense with it, and if a person is put some incense with it, and if a person is vomiting or has diarrhoea and you gave it to vomiting or has diarrhoea and you gave it to him, they become better immediately.(AH3)him, they become better immediately.(AH3)

• Khoulagan: We boil grape syrup and ginger and Khoulagan: We boil grape syrup and ginger and KhoulajanKhoulajan (herb) which allow the blood to come (herb) which allow the blood to come out and clean the woman. At present, women go out and clean the woman. At present, women go to doctors to give birth.(AH1) to doctors to give birth.(AH1)

• Je’edeh +Je’edeh +• Cauterization: but sometimes women come to Cauterization: but sometimes women come to

me after giving birth to a lot of children because me after giving birth to a lot of children because they keep miscarrying, so I cauterise her back, they keep miscarrying, so I cauterise her back, and she stops miscarrying after that.(AH2)and she stops miscarrying after that.(AH2)

• Yes, a lot, especially mobile Bedouin women Yes, a lot, especially mobile Bedouin women who carry heavy things while they are pregnant.who carry heavy things while they are pregnant.(AH2)(AH2)

Traditional Medicine Traditional Medicine (continued)(continued)• Tantuf (piece of flesh in child throat) Tantuf (piece of flesh in child throat)

and Abou Sufar (throat inflammation)and Abou Sufar (throat inflammation)• The most common disease I face with The most common disease I face with

children is children is TantufTantuf (A piece of flesh in a (A piece of flesh in a child's throat) child's throat) Abu SufarAbu Sufar (Throat (Throat inflammation) and dislocation, inflammation) and dislocation, especially dislocation in the shoulder. especially dislocation in the shoulder. (AH5)(AH5)

• Eye allergyEye allergy

• Nose bleeding, ear inflammationNose bleeding, ear inflammation

• We We DayahsDayahs don't do that, we do what don't do that, we do what we call it we call it KabsaKabsa (pressing the tonsils). I (pressing the tonsils). I first press it with salt, then with coffee, first press it with salt, then with coffee, the salt disinfects it and removes the the salt disinfects it and removes the fluids, and the coffee cools the tonsils fluids, and the coffee cools the tonsils down, after 2 or 3 days the child heals. down, after 2 or 3 days the child heals. (AH5)(AH5)

• As for Abu Sufar, we cauterise the As for Abu Sufar, we cauterise the baby behind his ear, and he screams. baby behind his ear, and he screams. (AH5)(AH5)

• Jasmine: If you have an allergy in the Jasmine: If you have an allergy in the eye, then Jasmine is the cure, it clears eye, then Jasmine is the cure, it clears the eye.(AH5) the eye.(AH5)

• The cure for nose bleeding is the shells The cure for nose bleeding is the shells of eggs, we toast them until they of eggs, we toast them until they become like Kohl. We also use it for become like Kohl. We also use it for the nose or ears if they hurt or there is the nose or ears if they hurt or there is ear inflammation. You can also put ear inflammation. You can also put apple vinegar in the ear and close it apple vinegar in the ear and close it with cotton (AH5)with cotton (AH5)

Chapter 5Chapter 5

Role of Women in Health Role of Women in Health Promotion among Bedouin in Promotion among Bedouin in

Northern BadiaNorthern Badia

OutlineOutline

• Intended Learning Outcomes (ILOs)Intended Learning Outcomes (ILOs)

• Introduction: Division of roles by genderIntroduction: Division of roles by gender

• Household Activities Household Activities

• Economic ActivitiesEconomic Activities

• Attitudes Toward Education Attitudes Toward Education

• Fertility and Attitudes Toward ChildrenFertility and Attitudes Toward Children

• MarriageMarriage

• Status of WomenStatus of Women

Intended Learning Outcomes Intended Learning Outcomes (ILOs)(ILOs)

At the end of this unit the student will be able to:At the end of this unit the student will be able to:Knowledge and understanding:Knowledge and understanding:• Classify different roles of women in household and Classify different roles of women in household and

economic activitieseconomic activities• Identify five role of Bedouin women in health promotion Identify five role of Bedouin women in health promotion • Define women attitudes towards education based on their Define women attitudes towards education based on their

lifestyle lifestyle Intellectual Skills: Intellectual Skills: • Relate how male prevalence affects reproductive behaviorRelate how male prevalence affects reproductive behavior• Explain Bedouin women attitudes towards children and Explain Bedouin women attitudes towards children and

relate them to fertility trends of women in Northern Badia relate them to fertility trends of women in Northern Badia • Predict status of women in Northern Badia based on project Predict status of women in Northern Badia based on project

findings findings Professional and transferable skills Professional and transferable skills • Involve women in local health provision and family health Involve women in local health provision and family health

plans plans • Relate status of women in Northern Badia to development Relate status of women in Northern Badia to development

strategies of the region strategies of the region

Introduction: Division of Roles by Introduction: Division of Roles by

GenderGender • In the Badia, there is a clear differentiation between In the Badia, there is a clear differentiation between

men’s work which takes place outside, and women’s men’s work which takes place outside, and women’s work which is largely concentrated in or near the work which is largely concentrated in or near the

dwellingsdwellings

• The man taking total responsibility for animal The man taking total responsibility for animal husbandry, cultivation and community relations husbandry, cultivation and community relations considered herding and agriculture his major and only considered herding and agriculture his major and only specialties and prided him self in associated tasksspecialties and prided him self in associated tasks

• Women's work was highly diversified and time Women's work was highly diversified and time consuming, her exclusive duties ranging from child consuming, her exclusive duties ranging from child rearing and routine housekeeping to more productive rearing and routine housekeeping to more productive taskstasks

Household ActivitiesHousehold Activities • Making Bread (pictures)Making Bread (pictures)

• CookingCooking

• Fetching WaterFetching Water

• Collecting FuelCollecting Fuel

• Milking and Milk ProcessingMilking and Milk Processing

• Spinning and WeavingSpinning and Weaving

• Other TasksOther Tasks

Economic ActivitiesEconomic Activities • The majority of women were not engaged enough The majority of women were not engaged enough

in economic activities in the academic sensein economic activities in the academic sense

• A considerable minority of women were putting A considerable minority of women were putting some effort into family farming and herding, some effort into family farming and herding, helping in harvesting andhelping in harvesting and grazing flocks grazing flocks

• Nowadays, a number of women in the North Nowadays, a number of women in the North Badia had a good level of education, therefore Badia had a good level of education, therefore most of these women are employed in the most of these women are employed in the Ministry of EducationMinistry of Education and Ministry of Health and Ministry of Health

Attitudes Toward EducationAttitudes Toward Education

• In the past women's educational achievement In the past women's educational achievement was nil (add references and new data with was nil (add references and new data with references)references)

• Data revealed that more than 90% of the women Data revealed that more than 90% of the women were illiterate andwere illiterate and as for the handful of women as for the handful of women who had had some education, that did not go who had had some education, that did not go much beyond the primary level and those women much beyond the primary level and those women were in the younger age groupswere in the younger age groups

• The problem was the lack of nearby schoolsThe problem was the lack of nearby schools• From Twenty years ago, most of the girls in the From Twenty years ago, most of the girls in the

North Badia have a good educated level in the North Badia have a good educated level in the schools, institutes and universities.schools, institutes and universities.

• Nowadays, most of the villages in North Badia Nowadays, most of the villages in North Badia have educated women, especially in the Ministry have educated women, especially in the Ministry of Educationof Education

Fertility and Attitudes Toward Fertility and Attitudes Toward ChildrenChildren• The prevailing levels of fertility appeared to be The prevailing levels of fertility appeared to be

quite high considering that this was a population quite high considering that this was a population characterized by moderate mortality, moderate to characterized by moderate mortality, moderate to poor levels of nutrition and probably quite long poor levels of nutrition and probably quite long periods of breastfeedingperiods of breastfeeding

• One of the principal factors responsible for the One of the principal factors responsible for the high level of fertility was the marriage patternhigh level of fertility was the marriage pattern

• In the Badia, only a small fraction of all women In the Badia, only a small fraction of all women never marriage and of those who did marry, their never marriage and of those who did marry, their mean age at first marriage was slightly over 18 mean age at first marriage was slightly over 18 yearsyears

• This pattern of early and almost universal This pattern of early and almost universal marriage, women were exposed to the risk of marriage, women were exposed to the risk of

becoming pregnant from an early agebecoming pregnant from an early age

MarriageMarriage

• Women in the Badia married at a fairly young ageWomen in the Badia married at a fairly young age

• In the Badia, endogamous marriage was In the Badia, endogamous marriage was universally approveduniversally approved

• As a rule, a women was married to her fathers As a rule, a women was married to her fathers brothers son who had first claim to her handbrothers son who had first claim to her hand

• She could not marry any other kin without his or She could not marry any other kin without his or his fathers consenthis fathers consent

Status of WomenStatus of Women

• In a traditional society, such as that in the Badia, In a traditional society, such as that in the Badia, preference for males was evident preference for males was evident

• Until she was married, a girl assisted her mother in Until she was married, a girl assisted her mother in almost all household activitiesalmost all household activities

• Women gained in status and their importance and Women gained in status and their importance and influence within the family circle increased influence within the family circle increased considerablyconsiderably with marriagewith marriage

• The women in the Badia is not veiled and is less The women in the Badia is not veiled and is less secluded than her peers in townssecluded than her peers in towns

• The women exercised considerable independence The women exercised considerable independence and influence in household matters, the women was and influence in household matters, the women was the one person upon whom household viability or the one person upon whom household viability or otherwise seemed to dependotherwise seemed to depend

Chapter 6Chapter 6

A Strategy for the Development of A Strategy for the Development of the Badia based on Findingsthe Badia based on Findings

OutlineOutline

• Intended Learning Outcomes (ILOs)Intended Learning Outcomes (ILOs)

• A Strategy for DevelopmentA Strategy for Development

• Possible project interventionsPossible project interventions

• Possible steps to remove service barriers in Possible steps to remove service barriers in health provisionhealth provision - Fees- Fees

- Childbirth- Childbirth

- Reproductive health- Reproductive health

- - System and Distribution of care in rural areasSystem and Distribution of care in rural areas

Intended Learning Outcomes Intended Learning Outcomes (ILOs)(ILOs)At the end of this unit the student will be able to:At the end of this unit the student will be able to:Knowledge and understanding:Knowledge and understanding:• Identify five strategies for the development of Northern Identify five strategies for the development of Northern

Badia based on project findings Badia based on project findings • List five steps to remove service barriers in health provision List five steps to remove service barriers in health provision

Intellectual Skills: Intellectual Skills: • Predict challenges in implementation of these strategies Predict challenges in implementation of these strategies

Professional and transferable skills Professional and transferable skills • Change student attitudes towards BedouinChange student attitudes towards Bedouin• Communicate with Bedouin in a respectful manner Communicate with Bedouin in a respectful manner • Act as an advocate for the Bedouin population in promoting Act as an advocate for the Bedouin population in promoting

health needs and development health needs and development

A Strategy for DevelopmentA Strategy for Development

• The development of the Badia is far from being as The development of the Badia is far from being as easy jobeasy job

• The ecology of the region coupled with a wide range The ecology of the region coupled with a wide range of human-related factors have confronted planners of human-related factors have confronted planners with difficult and limited choiceswith difficult and limited choices

• The strategy for development should allow for the The strategy for development should allow for the incorporation of three basic principles:incorporation of three basic principles:

- - The developmentThe development of the livestock industry as the of the livestock industry as the cornerstone for all development activities,cornerstone for all development activities,

- The integration of animal husbandry into dry and irrigated - The integration of animal husbandry into dry and irrigated farming within and without the region,farming within and without the region,

- The capitalization on existing natural and human resources in - The capitalization on existing natural and human resources in the areathe area

Possible project interventionsPossible project interventions

• Recruitment drive of Jordanian Nursing Recruitment drive of Jordanian Nursing Association in schools in Northeast BadiaAssociation in schools in Northeast Badia

• Training Bedouin staff – scholarships for Bedouin Training Bedouin staff – scholarships for Bedouin nursesnurses

• Orientation training for staff in clinics in the Orientation training for staff in clinics in the Northeast BadiaNortheast Badia

• More Health promotion in schools and well as in More Health promotion in schools and well as in the clinics on particular issuesthe clinics on particular issues

Possible stepsPossible steps

- - FeesFees Remove fees from attending a different clinicRemove fees from attending a different clinic

- - ChildbirthChildbirth• Nurses to act as midwives and have some training in IUD Nurses to act as midwives and have some training in IUD

insertioninsertion

• More ambulancesMore ambulances

• Staff to be ready to be on call at nightStaff to be ready to be on call at night

- - Reproductive HealthReproductive Health• Staff at primary care clinics to be trained in IUD insertion Staff at primary care clinics to be trained in IUD insertion

regularly to prevent lack of skills when staff leave regularly to prevent lack of skills when staff leave

• Clear protocols for post natal careClear protocols for post natal care

ContinueContinue

- System and Distribution of care in rural areas- System and Distribution of care in rural areas

• Close some sub-centres and re allocate resources Close some sub-centres and re allocate resources to primary health centres and comprehensive to primary health centres and comprehensive centres with the provision of better transport from centres with the provision of better transport from villages to these clinicsvillages to these clinics

• Educate the community concerning the decision re Educate the community concerning the decision re quality of care requires fewer better clinicsquality of care requires fewer better clinics

• Develop more strategic collaboration with the Develop more strategic collaboration with the military medical services who are planning a military medical services who are planning a hospital and with private and NGO providers.hospital and with private and NGO providers.

RecommendationsRecommendations

Need for specialist doctorsNeed for specialist doctors

• If you want to transfer the patient to Zarqa If you want to transfer the patient to Zarqa governmental hospital it's a burden to the centre. governmental hospital it's a burden to the centre. The money they pay for the petrol used for the The money they pay for the petrol used for the ambulance, they can use to get a specialist. ambulance, they can use to get a specialist. Everyday we go to Zarqa two or three times. They Everyday we go to Zarqa two or three times. They can just bring a specialist and it would save a lot can just bring a specialist and it would save a lot if there was a specialist here and he would take if there was a specialist here and he would take care of the broken bones here rather then go care of the broken bones here rather then go there.(AZCLP5)there.(AZCLP5)

• Another problem is the lack of medical staff.Another problem is the lack of medical staff.(AZCLP1)(AZCLP1)

• Providing specialists, and providing transport for Providing specialists, and providing transport for the employee.(AZCLP6)the employee.(AZCLP6)

• . There should be a gynaecologist. .(AZCLP4). There should be a gynaecologist. .(AZCLP4)

Need for equipment and tools and Need for equipment and tools and

staffstaff • I think the health needs are the staff, equipment, I think the health needs are the staff, equipment,

and tools that cause the lack of health services and tools that cause the lack of health services for the Bedouins. .(AZCLP6)for the Bedouins. .(AZCLP6)

• The biggest challenge I face is the shortage of The biggest challenge I face is the shortage of medicine. When this happens, people shout at me medicine. When this happens, people shout at me as if I am the Minister of Health. This is not my as if I am the Minister of Health. This is not my fault.(AZCLP7)fault.(AZCLP7)

• Sometimes there are one or two deliveries at Sometimes there are one or two deliveries at night and of course no sleep. How could I work in night and of course no sleep. How could I work in the morning?! Staffing should be improved. There the morning?! Staffing should be improved. There should be two doctors working in the morning and should be two doctors working in the morning and more nurses in the afternoon. .(AZCLP6)more nurses in the afternoon. .(AZCLP6)

ContinueContinue• Sometime the nurse has to work as an accountant or Sometime the nurse has to work as an accountant or

radiologist, if one of the employees has a vacation. The radiologist, if one of the employees has a vacation. The staff have to understand everything. A nurse might staff have to understand everything. A nurse might work at everything in the health centre. So we have a work at everything in the health centre. So we have a lack of staff and equipment in the centre which is a lack of staff and equipment in the centre which is a catastrophe. When a diabetic comes and you don't catastrophe. When a diabetic comes and you don't know whether his blood sugar is high or low. A simple know whether his blood sugar is high or low. A simple device like that should be available here. .(AZCLP4) device like that should be available here. .(AZCLP4)

• We don't have any registered nurses here. .(AZCLP3)We don't have any registered nurses here. .(AZCLP3)

• Increasing the staff would promote the self esteem of Increasing the staff would promote the self esteem of the staff and enhance performance. In addition, a the staff and enhance performance. In addition, a convenient number of staff must be available after 2:00 convenient number of staff must be available after 2:00 pm. If there is just a nurse and the doctor decides to pm. If there is just a nurse and the doctor decides to refer a case, the nurse and the driver will go with the refer a case, the nurse and the driver will go with the case and the doctor will stay alone.(AZCLP1)case and the doctor will stay alone.(AZCLP1)

ContinueContinue

• We have one midwife and giving birth doesn't have a We have one midwife and giving birth doesn't have a specific hour. I can't tell a woman to give birth between 8-specific hour. I can't tell a woman to give birth between 8-2 p.m only when there is a midwife. There should be at 2 p.m only when there is a midwife. There should be at least three midwives. .(AZCLP6)least three midwives. .(AZCLP6)

• Second problem, there are no tests and the Ultrasound Second problem, there are no tests and the Ultrasound machine is out of service. If you are pregnant you cannot machine is out of service. If you are pregnant you cannot check yourself. They send us to Zarqa or to D clinic who check yourself. They send us to Zarqa or to D clinic who charges us 5 JD. We cannot afford to go often to D clinic charges us 5 JD. We cannot afford to go often to D clinic and get tests there.and get tests there.

• Another problem is that we do not have a delivery section Another problem is that we do not have a delivery section here in the centre. The midwives do not know us and they here in the centre. The midwives do not know us and they refer us to Zarqa. So we have many problems here.refer us to Zarqa. So we have many problems here.(AZW4)(AZW4)

• In Azraq health centre they do not refer people, there is no In Azraq health centre they do not refer people, there is no medicine, and they ask us to buy medicine from medicine, and they ask us to buy medicine from pharmacies outside the centre.(AZW5)pharmacies outside the centre.(AZW5)

Need for transport for the Need for transport for the

staff and Bedouin local peoplestaff and Bedouin local people • Transport is the most important problem which faces us Transport is the most important problem which faces us

especially for girls and women because men can especially for girls and women because men can manage. The girls have a deal with a bus and pay 20- manage. The girls have a deal with a bus and pay 20- 30 JD monthly in order to come and reach the centre. .30 JD monthly in order to come and reach the centre. .(AZCLP1)(AZCLP1)

• The problem of the buses. All the lines are for the The problem of the buses. All the lines are for the northern Azraq. When they come here we have to wait northern Azraq. When they come here we have to wait three hours until they come. Our daughters go to the three hours until they come. Our daughters go to the university and study, but they miss their lectures while university and study, but they miss their lectures while they are standing on the street waiting,(AZW1)they are standing on the street waiting,(AZW1)

• The problem is, we have problems with transport. They The problem is, we have problems with transport. They don't come here although there are about 20 buses. ,don't come here although there are about 20 buses. ,(AZW2)(AZW2)

Need for accommodation for staff and Need for accommodation for staff and

familiesfamilies • In addition, the staff that are from outside the area should In addition, the staff that are from outside the area should

be provided with accommodation at a reasonable price, so be provided with accommodation at a reasonable price, so he and his family could move to the area instead of he and his family could move to the area instead of keeping coming and going every day and suffer from keeping coming and going every day and suffer from transport problems. I feel dizzy when I come and go every transport problems. I feel dizzy when I come and go every day and arrive late because of the transport. I swear to day and arrive late because of the transport. I swear to God I feel each day is like a month. AZCLP5:God I feel each day is like a month. AZCLP5:

• I don't have any comfort conditions and no I don't have any comfort conditions and no accommodation or transport although I'm from outside accommodation or transport although I'm from outside area. AZCLP3:area. AZCLP3:

• I'm renting a house here at my expense and the transport I'm renting a house here at my expense and the transport is at my expenses. There isn’t even any transport here is at my expenses. There isn’t even any transport here after 2 pm. There aren't any financial or emotional after 2 pm. There aren't any financial or emotional incentives and they wouldn't give or provide me with incentives and they wouldn't give or provide me with anything. I would go out at 7am without any incentives anything. I would go out at 7am without any incentives without anything added to my salary. So the last 2 years without anything added to my salary. So the last 2 years I've stopped it. They don't provide me with anything, not I've stopped it. They don't provide me with anything, not accommodation or transport, or even equipment. AZCLP3:accommodation or transport, or even equipment. AZCLP3:

Need for staff trainingNeed for staff training

• They should do more courses for us, I They should do more courses for us, I started working in 1999 at Prince Faisel started working in 1999 at Prince Faisel hospital in the obstetrics department. I hospital in the obstetrics department. I worked there for 3 months and they worked there for 3 months and they transferred me here. I used to learn from transferred me here. I used to learn from the people here like registered nurses who the people here like registered nurses who have been working in hospitals for 10-13 have been working in hospitals for 10-13 years. I learned a lot from them. But they years. I learned a lot from them. But they should teach us more and give us training, should teach us more and give us training, so that we become stronger in our field so that we become stronger in our field and provide people with better services. and provide people with better services. AZCLP4:AZCLP4:

Need for incentives for the staffNeed for incentives for the staff

• The financial incentives are the most important The financial incentives are the most important because the staff will feel comfortable, if they receive because the staff will feel comfortable, if they receive their rights they will perform the service in a better their rights they will perform the service in a better way.(AZCLP4) way.(AZCLP4)

• Fourthly, the staff should receive incentives especially Fourthly, the staff should receive incentives especially those who serve in remote areas. 6% (6 JD) or 10% is those who serve in remote areas. 6% (6 JD) or 10% is not a motivation to serve in these areas and does not not a motivation to serve in these areas and does not solve the problem. Nowadays the only psychological solve the problem. Nowadays the only psychological and personal motivation is the call of duty, it's the only and personal motivation is the call of duty, it's the only motivation the staff have. When a staff member sees a motivation the staff have. When a staff member sees a human suffering with pain in front of him, he will serve human suffering with pain in front of him, he will serve him whether there are incentives or not.(AZCLP1)him whether there are incentives or not.(AZCLP1)

• They should give incentives, I am not going to stay They should give incentives, I am not going to stay here, but my recommendation is to give my colleagues here, but my recommendation is to give my colleagues here incentives so they will feel satisfied. I recommend here incentives so they will feel satisfied. I recommend increasing their salaries and giving them incentives. increasing their salaries and giving them incentives. This is important for the rural areas.(AZCLP6)This is important for the rural areas.(AZCLP6)

Need for a hospitalNeed for a hospital

• Building a hospital is the another important thing .Building a hospital is the another important thing .(AZCLP3)(AZCLP3)

• The centre should have a delivery section. A pregnant The centre should have a delivery section. A pregnant woman who feels she needs to give birth, is usually woman who feels she needs to give birth, is usually stressed. Most of the pregnant women who feel they stressed. Most of the pregnant women who feel they are due, do not find transport to hospital. They gave are due, do not find transport to hospital. They gave birth in the ambulances. When the nurses in the centre birth in the ambulances. When the nurses in the centre check a pregnant woman, they usually say she is not check a pregnant woman, they usually say she is not due yet, and the midwife sometimes refuses to go with due yet, and the midwife sometimes refuses to go with the pregnant woman who want to give birth.(AZW5)the pregnant woman who want to give birth.(AZW5)

• I wish there would be a hospital for delivering babies.I wish there would be a hospital for delivering babies.(AZW6)(AZW6)

ContinueContinue

• I wish there is a big hospital or a big centre. .I wish there is a big hospital or a big centre. .(AZW5)(AZW5)

• We just want a large hospital.(AZW6)We just want a large hospital.(AZW6)

• We want a larger hospital then this, I mean the We want a larger hospital then this, I mean the hospital is small, and they don't listen to our hospital is small, and they don't listen to our demands. We want a hospital that we can give demands. We want a hospital that we can give birth in. .(AZW5)birth in. .(AZW5)

• They should bring a female doctor, a female They should bring a female doctor, a female obstetrician, and expand the centre. It is big but obstetrician, and expand the centre. It is big but there is a lack of doctors in it, and dentists. .there is a lack of doctors in it, and dentists. .(AZW1)(AZW1)

Need for centres for people Need for centres for people

with special needswith special needs

• There are some handicapped children. If There are some handicapped children. If they could have special centres for them they could have special centres for them rather then them staying at home all the rather then them staying at home all the time, I mean there are a lot of time, I mean there are a lot of handicapped here, and so we request a handicapped here, and so we request a centre for them. .(AZW6)centre for them. .(AZW6)

Need for family planning Need for family planning educationeducation

• I think we should educate the husband I think we should educate the husband because the woman is forced by her because the woman is forced by her husband who wants a number of children. husband who wants a number of children. So women are forced, we should educate So women are forced, we should educate their husbands. (AZCLP4)their husbands. (AZCLP4)

Thank you for your attentionThank you for your attention