An Interprofessional Educational Intervention: the Bedouin Health Module in Jordan

1. An Interprofessional Educational Intervention:the Bedouin Health Module in Jordan Fadia Hasna, PhD Mohammed Smairan, PhD Sahar Makhamreh, PhD Gillian Hundt, PhD Salah el Zaroo, PhD

2. Bedouin Health Project • EC funded through FP6 INCO DEV programme • Co-ordinated by the University of Warwick, UK • Partners – • Philadelphia University - Jordan • American University of Beirut - Lebanon • University of Stockholm - Sweden • University of Oxford - UK • CERMES, Inserm - France

3. Jordan Map

4. Bedouin Rural Health Project (BHP) Aims • Assess current health status, health seeking behaviour and current health service provision • Elicit the views of stakeholders-policy makers, health personnel and Bedouin • Develop model interventions in partnership with stakeholders • Evaluate and disseminate the interventions locally, nationally, regionally and internationally

6. Background • Bedouin • NE desert area of Jordan • Living in villages and encampments • Rural area, large distances, uneven health care provision

7. Educational Intervention in Jordan relating to Bedouin Health • Interviews with policymakers, health professionals and Bedouin in 2007-8 showed the need for an educational intervention • Educational intervention piloted in the autumn 2008

9. Bedouin in Jordan • 5%of total population • Today, 5-10% of Bedouin remains nomadic, traveling the area in their black goat hair tents called Beit Shaar or "hair tent". • Self-employment in herding or farming, Government is the largest single employer (Jordan Army and Ministry of Education) • Low standard of sanitation and hygiene, malnutrition and a harsh environment go together to make the Bedouin prone to various classes and types of diseases • Girls in the Badia married earlier than their counterparts elsewhere on the other parts of Jordan, higher fertility rates • Health issues: high fertility, respiratory diseases, Brucella (livestock raising and dairy products), gastro-intestinal, chest and skin conditions • Transport and distances to health services

10. Gradual Settlement of the Bedouin • Water is one of the most important factors for Bedouin settlement • Loss of much of the herds as a consequence of prolonged drought • Availability of services such as roads, telecommunications, electricity, schools are other factors responsible for Bedouin settlement • Despite government efforts aimed at providing the Badia with basic services, the quantity and quality of these services remain inadequate

11. Data Collection Methods

12. Data Collection Methods

13. Data Collection Methods (Continued)

14. Educational Intervention in Jordan relating to Bedouin Health • Interviews with policymakers, health professionals and Bedouin in 2007-8 showed the need for an educational intervention

15. Views of policymakers Data on cultural competence: “I say that if there is something missing in our staff it is the skill of communication. I always stress the importance of communication skills. It is important that when you work in an area you understand the culture. It is important that he speaks the same dialect of the people of the area. It is important to deal with them in the way they like. This is one of things that we miss if I want to send someone from Amman to Ruwaished area. It is possible that he doesn't know the habits and the customs of the people there”. (PM3).

16. Views of policymakers “Nurses and midwives are the first priority. We have problems in dealing with clients. We have some nurses who are rude to clients but if you meet them in another place they are different. Midwives know their jobs; they have experience in dealing with emergency situations and coil installation. We also have continual training courses…. Psychologically speaking, professional – patient interaction is very important not only in Zarqa but all over Jordan. I expect that there will be in- service training on this because it was neglected in the past. It is very important because when the patient comes to the health centre and is treated badly, he will leave unsatisfied even if he received all the health care that he wanted. The patient's satisfaction is an important dimension of the health system because all services are available to serve the patient. We try to talk about this issue in all the courses we do. There is no independent programme that focuses on this but it is a part of training that is delivered generally in workshops (PM8).

17. Views of health professionals “Many times, problems happen between doctors and the people of this area. They don't understand people or accept them. People here are simple and doctors know that they don’t know anything and their thoughts are narrow. I see them in the emergency room a lot. …. They complain against the general doctor and whether he is good or not. When a doctor comes from Amman, he feels proud and he doesn’t bother to answer greetings. He has his status. Then he adapts to the situation here”. NBCLP11 “When a Bedouin visits a clinic, everybody feels disgusted from him, so it's very important to educate the staff and give them training courses about how to receive a Bedouin although he is smelly. The relationship between the patient and his doctor or nurse is very important. Staff need to be qualified in order for them to really help Bedouins ….. If a patient distrusts the doctor who describes the medicine, the medicine will lose its value”(MFPD3).

18. Views of Bedouin men and women “The nurse started mocking me there. Every body did that even the people sweeping the floor, started mocking me. They asked me how many kids I had. If you tell them 4,5,6 they start mocking you again. When you call one of them and you ask them to check on you because you're about to give birth, they say no, go give birth on your own” (Bedouin woman). “The midwife in the health centre who is from Tafilah do not communicate with me as well, some times she see me in the centre and doesn't say hello, although she knew very well that I am the Mukhtar (chief of the tribe), I do not care about her behaviour because I have insurance for me and my family but I care about those who have no health insurance” (Bedouin Man).

19. Views of Bedouin men and women “Frankly, they are not good and they don’t benefit us. We want good doctors. The doctors here aren’t good. They don’t understand anything at all we want other doctors. ….We want doctors that understand, not any kind of doctor, the doctors who are here don't understand" (Bedouin Woman). “When we go to the doctor in the health centre in order to get treated. You sometimes want to talk to him privately and not in front of people but this doesn't happen because the female nurse, the two janitors, the male nurse and the pharmacist are all sitting there. If we say something, they become upset and don’t even leave. Imagine that the two janitors have chairs in the doctor's room and they remain sitting there when clients see the doctor” (Bedouin Woman).

20. Design and Preparation of Educational Intervention (June-Sept 2008) • When? June – Sept 08 • For who? Nursing and Social work fourth year students at Philadelphia (private) and Al Balqa Applied (public) universities. • How? Series of meetings then individual preparation and email, consultations with Vice Dean of Social Work • Behavioral objectives as well as module contents in units were prepared. • Contents writing including photos and references (Literature review) as well as based on findings collected (interview data, maps, observations, clinic records and statistics were used)

21. Implementation of Educational Intervention: the Bedouin Health Module (October-December 08) • Aim: To sensitize nursing, social work and medical students to the Bedouin culture and health needs in Northern Badia of Jordan making them more aware and culturally sensitive to this local population’s health, economic and psycho-social needs.

22. Structure of the Module Theoretical part: Integrated into community health nursing course (3 credit hours) and community health course for social work students. Duration: - Total of six lectures in Philadelphia for 145 nursing students - Two lectures at Al Balqa Applied University for social work students from October –December 08

23. Structure of the Module (Continued) Practical part: - Integrated into community health nursing practice (3 credit hours) course as well as community health course for social work students. Duration: - Seven weeks (Two times a week) - When? October-December 08 - Where? Sama el Serhan and Northern Badia CHCs, Elementary and Secondary schools in Sama el Serhan & Northern Badia as well as home visiting in both communities - Who? About 45 nursing students (2 sections and their faculty) and eight social work students and their facultyin collaborationwith the clinic staff.

24. Contents of the Module • Unit 1: The Badia of Jordan • Unit 2: Population Characteristics and Socio-economic Conditions in Northern Badia • Unit 3: Determinants of Health: Community Services and Facilities and their Impact on Badia Health • Unit 4: Health Services • Unit 5: Role of Women in Health Promotion among Bedouin in Northern Badia • Unit 6: A Strategy for the Development of the Badia based on Findings

25. Module Evaluation (December 08)

26. FG Discussion with Faculty Strengths - Faculty “They were very enthusiastic and committed to what they were doing but sometimes there were not enough patients to work with. The experience definitely changed their attitudes toward the Bedouin community and they learned how to communicate. Feedback from the students was very positive “SF2. “It was a very good practical experience for the students, the involvement of the students familiarised them with health services available to the community and developed networking between nurses, social workers and providers of health services” SF1. “Home visits were very useful with some students .The experience developed the abilities of students to solve complex situations” SF3.

27. Weaknesses- Faculty “ Inability to follow-up some cases and Limited time to provide better services” SF4. “Health education needs to be emphasized and needs better organization. More of social work involvement, many social problems need to be addressed” SF1. “there were difficulties to approach people beside the need to know more about tradition and culture before embarked on the project” SF3.

28. Strengths- Students “I feel that the project served the local people and identify the problems, there was a positive reaction from the local community” St3. “Sharing and cooperation with nursing student was great, the project joined both social and health worker to help the Bedouin” St2. “It gave us the opportunity to explore the social problem of the Bedouin which some time they do not talk about it such as domestic violence” St5. “The chance to give the right advice to the people” St1.

29. Weaknesses -Students • Objectives were not very clear • Transport and distances “Traveling and limited time to do the job properly” St 3. • Not enough time • Not enough supervisors • Access to unsettled Bedouins “some people show no trust in our work” St 1. “Families some time hesitates to invite us inside their home specially when there is female” St 6. “we participate in the immunization, but it was difficult to get permission to do our work and planning was not enough” St 2.

30. Lessons Learnt -Students “We had a good understanding of the health & social problems of Bedouin” St 13. “We found out that there is a shortage of health services in the area” St10. “There is not enough equipment available to them such as ECGs , emergency equipment” St8. “We understood what Badia meant and we had an idea how to approach people” St 6. “The experience changed our attitude toward the Badia; Bedouin can be sometimes very secretive about their health. In some cases,it was difficult to get information from them. One of the household refused to talk about his diabetes and he said he got a herb from the Sahara to take” . St 7 .

31. Challenges • Resistance of faculty: they wanted incentives • Expense: In Al Balqa university we had to rent a bus • Distances: 200 km per trip • Lack of motivation of providers to participate • Lack of commitment of the medical school • Sustainability - We are trying to replicate this intervention at Al Bayt and Al Hashemieh Universities (adjacent to Badia)

32. Lessons Learnt • More time is needed in preparation of staff and for the implementation of the module • Participatory approach in design and content preparation and not only findings • Incentives for faculty, and clinic staff would be helpful • BH module and pre and post test should be assessed within the curriculum • Resources are required (buses, money to pay clowns) • Evaluation and monitoring necessary when replicated in other universities

33. Thank you