Philadelphia University Faculty of Nursing

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Philadelphia UniversityFaculty of Nursing

• Bedouin Health Project
• Badia Health Education Module
• Prepared by
• Dr. Fadia Hasna
• Philadelphia University, Faculty of Nursing
• Dr. Mohammad Al-Smairan
• Jordan Badia Research and Development Centre

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Background

• This Bedouin Health module is one of the proposed
  interventions of the Bedouin Health Project and
  it utilizes findings of the data collected in
  Northern Badia during the years 2007-2008 which
  builds on policy makers, health providers in
  Northern Badia, alternative healers and Bedouin
  men and women interviews in the Northern Badia.
• Aim
• The aim of this module is 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 populations
  health, economic and psycho-social needs it was
  found out that many clinic staff interviewed
  during our field research work had little
  knowledge about the Bedouins culture or way of
  life.

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Chapter 1

• The Badia of Jordan

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Outline

• Intended Learning Outcomes (ILOs)
• The Badia
• Population Change in lifestyle
• Physical Characteristics
• Badia Resources
• Some Touristic Sites in the Northern East Badia
• Strengths of the Badia

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Intended Learning Outcomes (ILOs)

• At the end of this unit the student will be able
  to
• Knowledge and understanding
• Define Badia
• List seven important tribes in Northern Badia
• Discuss five physical characteristics in Northern
  Badia of Jordan
• Intellectual Skills
• Differentiate between Asheera ????? and Hamoula
  ????? in Northern Badia
• Relate five major strengths in the Northern Badia
  to future strategic developments
• Explain resources of Badia and relate them to the
  opportunities for development
• Professional and Transferable Skills
• Communicate with Bedouin in a respectful style
  based on the challenges in the Northern Badia
  context
• Change attitudes towards Bedouin by refuting
  misconceptions

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The Badia

• - Badia is a classical Arabic word used to
  describe arid to semi- arid regions of the
  middle east, where rainfall averages less than
  200mm, which today makes-up part of Jordan,
  Syria, Saudi Arabia and Iraq.
• - In Jordan, the Badia extends from north to
  south along the eastern portion covering about
  80 of the country's total area.
• - At present it is home to about only 5 of the
  Jordanian population.
• - Desertification is a common fear, which
  threatens that region, causing degradation of
  resources and most painfully demographic
  displacement.
• - Desertification and wise use of natural
  resources is a shared concern in the Middle East
  and throughout the world.

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Population Change in lifestyle

• The total population of the Badia represents
  about 5 of the whole population of the country.
• Today, an estimated 5-10 of the population
  remains nomadic, traveling the area in their
  black goat hair tents called beit shaar or "hair
  tent".
• The majority of the population is now permanently
  settled in villages.
• The Badia is home to numerous Bedouin tribes
  whose history lays at the foundation of western
  civilization.
• At present, the most important tribes live in
  Northern Badia are Al- Maasaeed, Bani Khalid,
  Al- Serhan, Al- Shurufat, Al- Sardyih, Al-
  Adamat, Al- Essa, Zubaid and Al- Ghiath.
• Any one of the a above tribes composed of more
  than one Hamouleh.

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Physical Characteristics

• The Badia experiences huge seasonal temperature
  fluctuations.
• In winter, the minimum mean temperatures may drop
  to 2o-9o degrees C and snowfall and sub-zero
  temperatures may occur.
• The summer maximum mean temperature is around 35
  -38 C. Low humidity causes high levels of
  evaporation.
• Rainfall between December and March, with great
  differences in the intensity of showers and
  storms.
• The region is subdivided into three main
  geographical areas, as follows 
• -The northern Badia, comprising 26,000 km. (
  shown in green )
• -The middle Badia, comprising 10,000 km. (
  shown in light blue )
• -The southern Badia, comprising 38,000 km. (
  shown in white )

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Badia Resources

• The Badia holds numerous and rich natural
  resources in quantities adequate for overall
  development requirements.
• Besides the vast area available for development,
  resources include mineral deposits, surface and
  groundwater, tourism sites, sunny weather,
  renewable natural range and cultivated land
  suitable for improved agriculture and livestock
  breeding.
• The area also has the potential for the
  development of non-pollutant renewable energy
  sources, namely, solar and wind energy.
• As the Badia extends into the borders of
  neighboring countries, there is the additional
  benefit of its being a junction for export-import
  activities at the regional level

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• The Badia represents a strategic depth for the
  country because it provides Jordan with 
• - 60 of groundwater needs.
•  
• - 90 of rangelands.
•  
• - 10 of conventional energy.
•  
• - 70 of the red meat needs. 
• - 24.36 of GDP

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Some Touristic Sites in the Northern East Badia
ASEIKHIM

• Um Al Jimal

Qasr Burqu
JAWA
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Strengths of the Badia

• Northern Badia is a priority on political agenda
• New mobile military field hospital established
  and operating
• Hashemite fund for Badia Development
• Jordan Badia Research and Development Centre
• MOH High coordination amongst MOH, Military and
  local institutes
• Existence of Network of health centers at three
  different levels across a large rural area
• - CHC
• - Primary health centre
• - Village center

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Chapter 2

• Population Characteristics and Socio-economic
  Conditions in Northern Badia

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Outline

• Intended Learning Outcomes (ILOs)
• Introduction Transition in lifestyle in the
  Badia
• Educational Levels
• Marital Status
• Fertility and Mortality
• Causes of high Mortality
• Morbidity
• Employment
• - Sectors
• - Challenges

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Intended Learning Outcomes (ILOs)

• At the end of this unit the student will be able
  to
• Knowledge and understanding
• Describe kinship relationships in the Badia and
  relate the to fertility behaviours
• Describe four marital status characteristics in
  Northern Badia
• Explore important Bedouin lifestyle habits
• List common misconceptions about Bedouin
• Identify main nutritional components of Bedouin
  diet in Northern Badia
• List five most important health needs of the
  following Bedouin population groups women,
  children, pregnant women, older age group
• Describe housing pattern in Northern Badia

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• Intellectual Skills
• Relate current Bedouin lifestyle challenges to
  health status of Bedouin in Northern Badia
• Discuss how nutritional status in the Badia
  affects the health of the local population
• Relate how male preference affects reproductive
  behavior in Northern Badia
• State fertility, morbidity and mortality trends
  in Northern Badia
• Explain causes of high mortality in Badia
• Explain educational level of Bedouin and relate
  it to their lifestyle challenges
• Identify employment challenges in Northern Badia
• List household facilities and relate them to
  socio-economic challenges in Northern Badia
• Professional and transferable skills
• Communicate with Bedouin in a respectful manner
  based on an appreciation of their local context
• Provide culturally-sensitive attitude towards
  Bedouin (stigma free)
• Act as a health promotion advocate for the
  Bedouin population in Northern Badia

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Introduction Transition in Lifestyle in the
Badia

• Life in the desert has always depended on
  striking a balance between human and animal
  populations and the natural environment
• In general, the Badia has developed and changed
  in step with the rest of the urban-based economy
• The government has provided roads, health
  clinics, water supplies, schools and other
  services which has directly raised living
  standards in the Badia, but at the same time may
  have made an indirect contribution to the loss of
  go-ahead individuals.
• Return flows of the earnings of migrants,
  especially those in the army and the police
  force, undoubtedly make a significant
  contribution to the support of the families
  remaining in the Badia.

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Educational Levels

• The level of education in the Northern Badia were
  slightly below the national average and even
  below those for the settled population in rural
  areas of Jordan,
• A number of factors was responsible for these low
  educational levels which in turn had a bearing on
  the welfare and economic opportunities open to
  the population of the Badia,
• - First, the Badia population being only a
  small fraction of the total population, seemed to
  have received less than their fair share of
  attention from the educational planners,
• - A second factor related to educational levels
  and school attendance figures was that the kind
  of work available in the Badia did not require
  the kind of skills which could be obtained in
  schools

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Marital Status

• The Marriage was almost universal and began at an
  early age for females
• The mean age at marriage for females around 18
  years compared to an age around 24 years for
  males (Abu Jaber and Gharaibeh)
• Girls in the Badia married earlier than their
  counterparts elsewhere on the other parts of
  Jordan
• In general, it seems that a more traditional
  marriage pattern prevails in the Badia with girls
  marrying early and very few remaining single
• The marriage of widowers and of divorcees is
  easily accomplished since the bridge price for
  second marriages is lower and the marriage
  ceremonies much simpler.

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Fertility and Mortality

• It seems that fertility in the Badia is high,
  higher than the other parts of Jordan, where the
  total fertility rate of 7.8,
• Plainly, fertility in the Badia is uncontrolled
  and close to a natural regime in which the
  duration of post-partum amenorrhea is the
  principle factor affecting the length of
  inter-birth intervals,
• In Northern Badia, some direct evidence of a slow
  decline in mortality over the last twenty years,
  but the overall mortality levels are still
  slightly high by national standards.

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Causes of high Mortality

• The high infant mortality rate in the Badia is a
  result of several sets of factors
• - Some of the babies in the Badia are still born
  at home especially for nomadic Bedouins
• - The short supply of clean and reliable sources
  of water
• - The lack of specialist health clinics and
  hospitals, especially in the remote areas
• - Poor diet which leaves people exposed to
  infection especially during the damp cold winters

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Morbidity

• 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
• The most common of which are internal and
  respiratory diseases, such as chest conditions,
  brucella, hypertension, kidney diseases, dental
  caries and diabetes
• Ailments such as hepatitis and dysentery are
  widely reported
• Other intestinal afflictions such as worms of
  various types are also prevalent
• Respiratory diseases especially inflammation of
  the eyes is even more common among children than
  among adults
• Milk may also be a health hazard in the region.
  One of the major products consumed raw and
  unprocessed

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Employment

• Sectors
• - Aside from self-employment in herding or
  farming, work opportunities in the Badia are
  indeed very scarce
• - Government is the largest single employer
  followed by farming
• - Government sector include Jordan army mainly,
  Ministry of education
• - Farming sector include herding, planting
  vegetables and fruits, etc.
• - Private sector composed a small portion of the
  employment in Northern Badia and include, trading
  in shops, livestock, land and other small business

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• Challenges
• Bedouin economy revoled around the occupation
  of camel, sheep and goat husbandry. In such an
  economy, livestock is considered the principal
  asset, hence, wealth as well as status were
  judged by the size of the animal herd.
• The size and composition of the herd has
  recently undergone considerable changes
• - The size of the herd has decreased
  substantially due to severe livestock losses and
  liquidation,
• - Many Bedouin have taken to settled life in
  order to profit from the services provided in
  their habitat

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• - Manpower shortages in the region resulting
  from adult out-migration to urban centers for
  employment has forced herd owners to reduce the
  number of animals
• - The lack of industrial projects
• - The lack of manpower training
• - Drought years

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Chapter 3

• Determinants of Health Community Services and
  Facilities and their Impact on Badia Health

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Outline

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

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Intended Learning Outcomes (ILOs)

• At the end of this unit the student will be able
  to
• Knowledge and understanding
• Explain five main strengths in health provision
  in the Northern Badia
• Differentiate and explain the various services in
  Northern Badia schools, water and electricity,
  communication and agriculture
• List the determinants of health in Northern Badia
• Intellectual Skills
• Relate the determinants of health to the various
  services in Northern Badia
• Professional and transferable skills
• Provide culturally-sensitive attitude towards
  Bedouin (stigma free)
• Act as a health promotion advocate for the
  Bedouin population in Northern Badia

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Introduction Gradual Settlement of the Bedouin

• A host of factors appears responsible for Bedouin
  settlement.
• Water is one of the most important factors
  underscoring Bedouin settlement
• Other factor play varying role in Bedouin
  settlement is the 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 are judged inadequate.

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Determinants of Health

• Lifestyle and Behavior
• - Some of babies in the Badia are still born at
  home. The midwife (daya) or an elder women often
  use procedures during and after delivery (e.g.
  wrapping a new baby in a cloth sprinkled with
  dung to deceive the evil eye) which are
  inherently unhealthy
• - A baby girl is universally less welcome than
  a boy, she gets less attention and more work even
  at an early age
• - The boy eats with the men, but the girl and
  her mother often eat what is left of the meal
• - Also, some of the lifestyle habits specific
  to Bedouin that increase communicable health
  disease incidence in the Northern Badia are
  Raising livestock, drinking unpasteurized milk
  and milk products, drinking from rain water in
  the ponds and some times drinking and eating from
  the same cub and the same dish

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Environment

• Environmental Health
• There were a number of concerns and these
  varied according to area.
• The ecology of the region (dust and the average
  of the temperature in summer and winter), poor
  living conditions and low living standards are
  some of the factors affecting health in the
  Northern Badia
• There were concerns expressed about the quality
  of water, water being brackish with too much
  fluoride, and having a high dust content.
• Sewage disposal and Solid waste management was a
  concern as in many of these encampments and
  villages.
• there is a lack of infrastructure and this is a
  public health concern.

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• 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 water is polluted,
  if you come and test the water you'll find that
  it's not suitable for human consumption and
  everyone suffers from this problem (NBM2)
• We have a lot of flies and mosquitoes and the
  percentage of chlorine and not chloral is high in
  the area. We want something to fight all this..
  Once I went to buy some bread from the bakery
  which was full of flies. The bread was full of
  flies. The MoH must inspect the bakeries (NBM4).

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• 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 line has sediments from
  the past time... This is the main thing.. The
  main point is establishing a hospital for North
  Badia. It is a very wide area and it needs a
  hospital. The second point, we need sewage
  system, because the sewage is polluting the area.
  The whole sewage system needs changing (NBM3).
• The sewage pits in the area. We don't have a
  sewage system, instead we have sewage pits all
  over the village. When it's summer and the
  weather is hot and dry with no wind, the
  mosquitoes appear (RHCLM5).

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Services in the Badia

• The distribution and quality of services in the
  Badia as of early 1976
• Schools
• - Everywhere you go in the Badia, you find
  schools, primary, elementary and secondary for
  boys and girls
• - The geographic distribution is adequate, the
  quality of physical facilities and teachers is
  often not very good
• - The educational apparatus in the Badia is far
  from satisfactory and suffers from two cases of
  problems, physical plant and staff
• - The severe shortage of trained staff is a
  major problem. Teachers, male and female are hard
  to recruit for the Badia, especially for the
  remote areas.

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Disability services in North Badia

• The disability in Northern Badia is slightly high
  because of the relatives marriage
• The disabilities concentrated in the field of
  mental, hearing and movement disability
• Most of these disabilities are concentrated in
  male, but may be covered disability in females
• In Northern Badia, there is just one society that
  deals with this group of community
• Child Caring Society is the only one that is
  found in Northern Badia at Al-Saydiya village, 25
  kilometer east of Mafraq

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Water and Electricity

• The Badia draws its water supplies from
  multiplicity of sources
• Piped water systems are found in about 95 of the
  villages
• Groundwater are used for human uses where the
  service water resources are used for animals and
  other uses
• These sources, however are inadequate leaving the
  water supply situation critical in most of the
  Badia
• Since the Badia is an arid region with scarce and
  undependable water resources, most of the
  population relies on rainwater collecting schemes
  for their supplies especially for those that have
  animals.
• In his modern day counterpart seems helpless and
  since he has practically settled down he has lost
  his traditional independence and initiative

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• Electricity is universally available in the Badia
• About 99 of the villages in North Badia are
  offered electricity
• In the North Badia a single company monopolizes
  electricity generation for the whole governorate
  (Irbid Governorate Electricity Company)
• There are some small settlement in the
  Northeastern part of the Badia near Ruwashid uses
  Renewable Energy (Photovoltaic solar energy
  systems) for electrification

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Housing

• The proportion of true nomads had steadily
  declined and the proportion of tent-dwellers also
  declined,
• Nowadays, a small figure of households were still
  to live in the hair tent (bait shaar)
• The typical tent was rectangular in shape and
  made of black goat-hair and divided by a screen
  into two quarters, one for men and one for women
• Like the rest of the population, the residents of
  the Badia now live in stone or concrete houses,
• Almost all the dwellings were owner-occupied
• House furnishing was sparse and limited to basic
  necessities, but however, a few modern pieces of
  furniture in the form of steel, bedsteads, chairs
  and tables appeared in the houses of income
  families

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Household Facilities

• Most of the population in the Badia have piped
  water either in their homes or at a stand-pipe,
• As expected in a comparatively poor population,
  possession of household facilities is slightly
  restricted,
• Electricity is widely available except in a very
  small groups of households with their own
  generators or stand-alone photovoltaic solar
  energy systems,
• The most common domestic appliances are radio,
  TV, Refrigerator and washing machine.

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Communications

• Most villages in North Badia are connected to a
  main highway by a secondary road
• These secondary roads are characteristically
  asphalted, and wide enough to accommodate a two
  motor vehicle comfortably
• In addition, most of these villages are connected
  to each other with a road and these roads are in
  a good condition in most cases
• Telephone services is widely available in North
  Badia, fixed or mobile, also internet services is
  available in some villages in North Badia, where
  the first IT center in Jordan was established in
  Safawi village in 2000
• The post office is one of the most effective form
  of long-distance communication in the Badia

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Communications

• Picture

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Agricultural Services

• Agricultural Services in the Badia such as
  cooperative, savings and credit societies,
  extension and veterinarian services are not
  widely available
• Social Welfare Services
• - Most of the social welfare services performed
  in the Badia have been initiated by organizations
  from outside the region such as
• Royal Court
• Jordan Army
• Public sector Ministry of Planning
• Hashemite fund
• Jordan Badia Research and Development Centre
• NGOs Noor Al-Hussain Foundation and Jordan River
  Foundation
• - These social services in the region have had
  a positive effective and raising the living
  standards of the Bedouin community

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Diet

• For the Badia population, food consumption
  patterns have changed somewhat during the past
  few decades
• The Bedouin of the past ate less and with less
  variety
• Their meals used to consist of milk and milk
  products, they hardly ever consumed vegetables
  and meat was limited to festive occasions
• Now when the Bedouin took to a settled way of
  life, and especially for those who live in towns,
  vegetables are consumed
• Today, milk and milk products like Yoghurt,
  Labneh and ghee, burghul, vegetables, bread, meat
  and sometimes fruit are consumed
• The most important health conditions relating to
  diet among Bedouin are Anemia, stunting and
  osteoporosis among older women,

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Nutritional Status

• The average Bedouin calorie is to be below the
  national average
• This situation is a reflection of the low living
  standards among the population
• The Bedouin diet is monotonous, insufficient,
  unbalanced and seriously deficient in animal
  protein
• For girls and women the food consumption is below
  that of the average male because of the
  prevailing traditions
• Cultural habits relating to beliefs, attitudes
  and practices affect the nutritional status
  especially among females
• Female early marriage and multiple pregnancies
  continue to act as a further drain on their
  health status

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Chapter 4

• Health Services

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Outline

• Intended Learning Outcomes (ILOs)
• Health Care Systems
• - Primary health care services
• - Differentiate between village, primary and
  CHCenters
• - Referral system
• - Network and coordination among the sectors
  providing health services
• Health Services
• - Availability of health insurance
• - Availability of RH
• - Availability of dental health
• - Availability of doctors, dentists and nurses
• Strengths of the system

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• Issues
• 1- Centralisation of health care system
• 2- Staff morale
• 3- Views of staff on Bedouins
• 4- Staff training needs
• 5- Reproductive Health
• 6- Immunizations
• 7- Outreach Services
• Views of Bedouin on Service Provision
• 1- Communication
• 2- Payment policy and emergency services
• 3- Views of Bedouin on their situation
• - Wasta A common barrier for providers and the
  community of Bedouin
• - Traditional medicine

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Intended Learning Outcomes (ILOs)

• At the end of this unit the student will be able
  to
• Knowledge and understanding
• List five environmental factors affecting health
  in the Northern
• Recall important Bedouin lifestyle habits
• List three determinants of health affecting
  Bedouin in Northern Badia housing , poverty,
  health behaviors, occupation etc
• List five communicable diseases found in Northern
  Badia
• List five chronic conditions found in the
  Northern Badia Diabetes, hypertension, chest
  conditions, skin conditions etc
• List five most common herbal remedies used in the
  Northern Badia
• List other alternative therapies and healing
  practices in the Northern Badia
• List five most important health challenges found
  in the Northern Badia
• Discuss three types of health centers found in
  Northern Badia village centers, primary health
  centers, comprehensive health centers
• Describe the most important challenges met by
  Bedouin to access health services in Northern
  Badia
• List unmet health needs of the following Bedouin
  population groups women, children, elderly and
  pregnant women
• Analyze ten issues in health service provision in
  Northern Badia

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• Intellectual Skills
• Explain how these environmental factors impact
  health
• Relate these communicable diseases to lifestyle
  and the environment
• Explain conditions for which these herbal
  remedies are used in Northern Badia
• Explain the difference between comprehensive
  health center, primary and village health centers
  
• Professional and transferable skills
• Explain role of traditional healers in the
  Northern Badia
• List most important service barriers met by
  Bedouins in the health centers
• Propose strategic solutions to the challenges in
  service provision
• Provide culturally-sensitive attitude towards
  Bedouin (stigma free)
• Act as a health promotion advocate for the
  Bedouin population in Northern Badia
• Propose strategic solutions to the challenges in
  service provision

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Health Care Systems

• Primary Health Care Services
• The national system of three levels of primary
  health care clinics may not necessarily be the
  most suitable for this large rural area that is
  sparsely populated with huge distances.
• Owing to the presence of sub-centres, there is a
  problem of expectations alongside quality of
  care.
• The community have unrealistic expectations of
  round the clock excellent primary health care
  close to home, which is not possible to provide
  within the constraints and resources of the MoH
  budget for primary health care.

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• Differentiate between village, primary and
  CHCenters
• - Village center, mostly composed of two to
  three rooms and rented in the small villages,
  have a nurse and visited by doctor two to three
  times a week and opened three to four hour a day
• - Primary Health Center, this is larger than
  the village center, good infrastructure, have the
  primary requirement like GP, lab, pharmacy,
  dental, emergency, immunization and ambulance and
  opened from eight to three evening
• - Comprehensive Health Center, this is larger
  than the above two, good infrastructure, have the
  primary requirement like GP, lab, pharmacy,
  dental, emergency, x-ray, immunization,
  ambulances and visited by specialist doctors two
  to three times a week and opened from eight to
  three evening and twenty four hours for emergency

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The Main Key Indicators of the Area Population,
Comprehensive Health Centers
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• Referral system
• - The referral system in the health caring
  system in Northern Badia is depend on the
  available of the health center, and the distance
  between the villages
• - in general, when the patient visit the
  village center and he have the solution of his
  problem, then he does not need to visit other
  clinic
• - If no, the GP referral him to the nearest
  primary health center
• - The primary health center referral the
  patient to the comprehensive health center for
  more check if the patient required that

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

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Health Services

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

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

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

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• Availability of dental health
• The dental medicine is available in this
  remote area other clinics which are 200 KM away
  from here like the Irbid clinic offer the same
  services (RUP6).
• Availability of doctors, dentists and nurses
• All things are available, Pharmacy, medical
  secretary, laboratory if there is one at the
  health centre, a dental clinic, and a medical
  clinic, etc (PM4).
• Of course services are available until 2 pm,
  full services from nursing to MCH and delivery,
  laboratory, pharmacy, X-ray department,
  accountants, doctors and dentists. All of that is
  available.(AZCLP6 ).

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Strengths of the System

• Availability of a database
• We now have a database that we have created
  to capture the pattern of settlement and movement
  (PM2)
• I think the strongest point is that we know
  Bedouins places and we can follow them. We have
  enough knowledge about their places and we have
  outreach clinics and outreach teams who go out
  and reach them (PM3).
• Outreach activities
• There is health education especially during
  vaccinations and outreach vaccination campaigns.
  We go out with a midwife or a nurse. We also have
  vaccination campaigns in schools, and we do
  environmental inspections at schools regarding
  the quality of drinking water. We also visit
  citizens outside the centre and give them health
  education (AZCLP1).

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Tally Sheet of Monthly Reports Used In Northern
Badia Comprehensive Health Centres
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Tally Sheet of Monthly Reports Used In Northern
Badia Comprehensive Health Centres (Cont.)
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• National Immunization campaign
• we have the national official programme which
  contains different kinds of vaccines against
  polio, DT (Diphtheria Tetanus), measles and the
  package of 5 vaccines (DPT H. InflHBV
  Diphtheria, Pertussis, Tetanus, Influenza and
  Hepatitis B virus). These vaccines are provided
  through a planned programme that starts from
  three months old and above.
• We have mobile immunization teams that work
  in the field in the whole Ruwaished area. They
  move from tent to tent in encampments in the
  desert. Every year we have an immunization
  campaign against polio. The campaign continues
  for 4-5 days with two doses of polio vaccine. The
  campaigns include providing one dose of vaccine
  and another dose a month later. We do a
  comprehensive field survey and we vaccinate all
  children who are under five years of age (PM5)

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• Availability of health insurance
• Health insurance is one of the problems that
  confront us nowadays. Many people ask for it and
  they ask for comprehensive health insurance. The
  MOH of course aims to implement comprehensive
  health insurance and we could say that we already
  have a comprehensive health insurance because the
  MOH covers 70 of the cost and the people - even
  those who can pay- cover the rest (30) of the
  cost only (PM3).
• Availability of dental health
• The dental medicine is available in this
  remote area other clinics which are 200 KM away
  from here like the Irbid clinic offer the same
  services (RUP6).
• Availability of doctors, dentists and nurses
• All things are available, Pharmacy, medical
  secretary, laboratory if there is one at the
  health centre, a dental clinic, and a medical
  clinic, etc (PM4).
• Of course services are available until 2 pm,
  full services from nursing to MCH and delivery,
  laboratory, pharmacy, X-ray department,
  accountants, doctors and dentists. All of that is
  available.(AZCLP6)

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• Availability of RH
• For the pregnancies and health care, we have
  a maternity section in the health centre. The
  obstetrician checks the female clients, and gives
  them advice, vaccines and contraception. The
  contraception could be through the rhythm method,
  the pills injections or by IUDs. Pregnant women
  are checked from the beginning of pregnancy by an
  obstetrician. It is free of charge Each case has
  a file, we have midwives who weigh the pregnant
  women and monitor her during the pregnancy till
  she gives birth, These services are free of
  charge including contraception. We also have
  coils for those women who do not want children or
  for spacing between pregnancies. All these
  services are free of charge (PM5).
• The MoH provides postnatal care however,
  the problem is that women after delivery do not
  visit the clinic. This is a problem and we need
  health education in this area. We should teach
  them that you should not care about your health
  only when you feel you are ill. You should
  maintain your body because your body is like a
  machine which needs regular maintenance. You need
  immediate intervention to fix a problem. Sometime
  you need to do preventive care before any
  complications for example dental check ups (PM6).

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Issues

• 1- Centralisation of health care system
• Whilst it is strength for training staff, and
  providing national care, local directors are
  limited in their ability to act
• "We dont buy anything directly. We do not
  have the authority to spend.
• There is central control (PM8)
• Within the MOH there is no decentralization.
  The Director in the health directorate does not
  have the power to decide on expenditure or on
  appointing staff.. We do not deal with financial
  resources as we do not have the authority. We
  have something called financial income (that is
  the budget we are allocated). As a directorate we
  have shortages in equipment and supplies of
  medicines and technical staff. But the Director
  has no power to control it . There is shortage in
  the supply of almost 200 medicines (PM8).

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• We face problems in remote areas such as Azraq.
  The ministry is centralized in its structure and
  organization and provides the staff. If there was
  decentralization, the work in the health centers
  would be better, and administratively there would
  be more delegated power of decision making in the
  areas of finance, administration and appointing
  staff. There would be no problems. Currently when
  the director faces problems, these are referred
  to the central offices of the Ministry (PM8).
• For example if there are maintenance problems
  which requiring financial expenditure, we have a
  problem of purchasing if there is technical or
  electrical defect, and similarly if we need to
  fix machines, equipment and vehicles. This is
  centralization and is not within the authority of
  the director. It would be better if there was
  more decentralization. There was a study done on
  this. They gave two hospitals some kind of
  decentralized powers and they were well
  administered. The project is over"(PM8).

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• 2- Staff morale
• Staff feel isolated and often are living far
  away from their families, working long hours with
  little time off and feel not valued and
  underpaid.
• no extra fuel allowances and few incentives for
  working in these areas.
• The accommodation is often of poor quality.
• Rural Population very doctor focused and lack of
  awareness to what nurses can provide.
• Qualified doctors are reluctant to serve in rural
  areas.

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• Other challenges are pertinent to the best use of
  the resources some times we face some problem
  such as the brain drain. For instance, if we have
  a vacancy for a physician to serve in an urban
  area, 30 doctors might 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
  go there. There are qualified people in Amman but
  they refuse to serve in the rural areas (PM3).
• We have a kitchen but it is empty. The staffs
  after 24 hours of work have to cook for
  themselves. There should be meals for the staff
  that are on duty (NBCLP3).
• 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 hours but they don't
  care about our suffering (NBCLP12).

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• 3- Views of staff on Bedouins
• Many staff interviewed had little knowledge about
  the Bedouins culture or way of life
• The majority of Bedouins live in the desert.
  This type of Bedouin is not interested in
  education, health or drinking 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 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 unclean. He will
  draw water from wherever he found water in the
  desert to irrigate his sheep and himself. He does
  not care about other things, he does not care
  about having health awareness, or social
  awareness, watching TV and seeing the world or
  civilization. He will be away from the wider the
  world without water or electricity or anything as
  long as he keeps staying in the desert. He
  depends on the resources which exist in the land
  around him. If he finds pasture he will bring his
  herd to graze. If he finds water he will collect
  it with his vehicle and drink it. (PM5)

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• 4- Staff training needs
• Staff are not from the area and lack knowledge
  about the local population.
• Lack of Bedouin staff.
• Lack of communication skills.
• Staff would like more pre and in- service
  training.
• They should do more courses for us. They
  should teach us more and give us training, so
  that we become stronger in our field and provide
  people with better services. (AZCLP4)
• The department is equipped but it needs
  medical staff. We have a lack of medical staff
  here, especially nurses. Unfortunately all the
  appointments here in the centre are people who
  have a lack of experience. I mean they graduate
  from college or university and then they directly
  start working here in Ruwaished. So what we have
  here is a lack of practical experience ( RUP4)

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• The MoH do not pay attention to the Badia.
  For example 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 remind us of the
  things that we studied. They honestly don't do
  anything like that at all. (NBCLP3)
• My recommendations are to enhance the health
  services in the area and provide pre-service
  training for the staff in the art of
  communication with people NBCLP7.
• We should organize training courses for staff
  even in the field of culture, education,
  awareness raising, updating, etc. . We have some
  courses but they are limited and we do not
  participate because our MoH does not participate
  and rejects covering any financial fees. We need
  continuous education and awareness. .The
  equipment is available but becomes out of service
  because the staff are not trained to use them
  (NBCLP6).

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• 5- Reproductive Health
• Postnatal services are not systematic or regular.
  
• Family planning services are varying from area to
  another.
• Family planning in relation to Intra-uterine
  devices are not always available owing to staff
  not being trained to insert them.
• There is a need for more female staff.
• They are in a hurry. Most women dont wait
  five minutes only when they come for
  immunization. They ask me to queue them because
  they have children at home waiting. Sometimes
  they dont come and they send their mums, their
  sisters or their aunts. The habits and the
  customs also play a role in this matter. It is
  difficult for women to come out of their houses
  before 40 days of delivery (SSP4).
• They come for immunization or for family
  planning. These things are more important to them
  than the puerperium period (SSP4)

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• 6- Immunizations
• Immunization services are available at the
  clinics and through outreach with regular
  campaigns but sometimes they are unable to reach
  all of children of families that are nomadic or
  semi-nomadic to ensure complete coverage.
• The Bedouins are more distant than us from
  civilization. We have to take the information to
  them. The last time we did a vaccination campaign
  we were searching for them because they wouldn't
  receive us. We would tell them that the
  vaccination is good for you and immunizes you
  from diseases. They would say no either because
  they were afraid or because they were far from
  civilization. That is what we face (AZCLP4).
• In Azraq the citizens hear that there is a
  vaccination campaign and it's not even for them,
  but they come to get vaccinated although the
  campaign isn't for them. Since they are near in
  this area they come. As for the tents that are
  30-40 km, if we can reach them, we vaccinate
  them, but if we don't reach them and the
  information about the campaign didn't reach them
  they don't get vaccinated in our last
  immunization campaign three weeks ago people ran
  off and refused to be immunized (AZCLP3).

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• 7- Outreach Services
• Outreach faces a plethora of obstacles such as
• Lack of awareness among Bedouin that drives some
  of them to escape the immunization campaigns
• The coverage of outreach is not comprehensive due
  to staff, facilities and equipment shortages
• Mobility of Bedouins disturbs the comprehensive
  coverage of immunization.
• Mobile clinics are not cost- effective
• "They are more distant than us from civilization.
  We have to take the information to them. The last
  time we did a vaccination campaign we were
  searching for them because they wouldn't receive
  us. We would tell them that the vaccination is
  good for you and immunizes you from diseases.
  They would say no either because they were afraid
  or because they were far from civilization. That
  is what we face." (AZCLP4).

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• There are a lot of mobile Bedouins here, they
  live in an area and then they move to another
  one. We even found this problem in schools some
  students repeat the same classes because of the
  absence. They live here for a year and next year
  they decide to live in another place. This is the
  problem we face with vaccination, its hard to
  know 100 (RUP1).
• We thought a lot about the provision of
  mobile clinics and sometimes with help from the
  private sector we make a mobile clinic for eye
  examinations or for other things. But this is
  not easy and it costs a lot without any profit.
  We think that these clinics cost a lot of money
  however the number of people who are served is
  little. We study both sides of this issue (PM3).

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Views of Bedouin on Service Provision

• Communication
• The attitudes of some staff as well as their lack
  of knowledge about Bedouins impairs the quality
  of care owing to poor communication.
• The lack of understanding of primary health care
  amongst the community also means that their
  demands may be unreasonable and their use of the
  health care system not optimal.
• The nurses' treatment of people is very bad.
  They don't treat us kindly, and honestly there
  aren't any services. So I prefer to borrow money
  from someone to go to a private doctor rather
  than go to the health centre..They don't treat
  us well. We complained to the district chief, but
  everything stayed the same. Nobody listens. Where
  are we supposed to go?!(AZW3).

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• The treatment in Mafraq hospital is not good
  at all. I will never go there for delivery if I
  am pregnant now. I decided not to have more
  children after my last delivery in Mafraq
  hospital. They sent me home the next day of
  delivery at midnight. They did not look after
  patients properly. In delivery, you become sick,
  fed up, and you are bleeding but they do not care
  about you!
• The Refa'eat Health centre is pointless. I
  had fights with the GP and the pharmacist who
  works there. I always tell them that we come at
  600 am and keep on waiting till 1100 AM and
  the doctor doesn't arrive (MACLW8).
• There isn't an otolaryngologist at the
  centre, or a cardiologist, or an ophthalmologist,
  or dermatologist. Also we don't have a female
  gynaecologist here. We have a male gynaecologist
  but you know it's a sensitive issue to people
  here. I complained more than one time about it,
  but they told me that no female doctor would come
  and work 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 committed to, the
  government can make her go to the end of the
  world. We used to have a female doctor here in
  the end they transferred her (RUM3)

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• Payment policy and emergency services
• Bedouin who move seasonally and then attend a
  clinic other than where they are registered are
  charged an additional fee. This is deterrent to
  completing immunizations.
• Attending the clinics in the afternoon is
  sometimes necessary owing to an emergency or to
  transport only being available in the afternoon.
  Fees are charged.
• When drugs are not available, people are referred
  to private pharmacies.
• Fees are higher if people are not insured and
  this excludes those who are more marginal.
• Another problem is that although there is a
  decision to cure who are less than six years old
  free of charge, they still ask us to pay for
  those who are under six. They ask us to pay even
  if they are 10 tablets of Aspirin (AZM1).

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• They use another manoeuvre they ask us to
  pay 25p for the drug, but the drug is nothing, it
  is just two suppositories or some tablets of
  Revanin (painkiller) and they register them. ..I
  have Asthma but I do not have insurance. I have
  only the white card. I havent got insurance
  although I am 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 sick and
  unemployed. I have asthma and I want inhaler but
  they refuse to prescribe medicine for me (AZM4).
• The first problem with the Health Centre is
  related to fee. They charge us more after working
  hours. They have two different rates one for the
  working hours and the other for the afternoon.
  Not only the fee but also the medicine becomes
  more expensive, almost like the regular prices
  outside the center's pharmacy. As a consequence,
  some patients prefer to delay their visit to the
  next day, and visit the centre in working hours
  to avoid paying extra fee (NBM2).

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Views of Bedouin on their situation

• Bedouin felt that their community is neglected.
• There were some issues in particular in Azraq at
  the clinic owing to the mixed population of the
  town and the clinic staff being solely Druze.
• They dont care about Bedouins in the eastern
  parts of the country. We feel we havent got
  anything (MACLW7).
• There is a lot of neglect at the health
  centre in Ruba'a (SSW5).
• The GP just asks you and writes the
  prescription which is mostly pain killers or
  aspirin or whatever is available. He tells you
  "this is what I have here". There is no test or
  check. We are disconnected and isolated here
  (SAM5)

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Wasta A common barrier for providers and the
community of Bedouin

• 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 exert
  pressure on staff when faced with requests as
  well as result in resentment amongst patients.
• 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 are
  poor and they want to earn their bread and their
  work is so tiring, so it is not easy to change
  it.
• Wasta makes trouble for us. It do you mean
  include? embraced the director of the centre and
  the GP ( SSP6)
• Wasta plays a role, because some patients
  who make trouble have relatives inside the centre
  and in order to keep good relations with your
  colleagues, you have to be tolerant (SSP1).
• 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
  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)

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Traditional medicine

• Most common herbal remedies used in Northern
  Badia are chamomile, thyme, sage, ??? sheeh,
  Jaadat el subian???? ???????
• Most of these herbal remedies used for stomach
  cramps, nausea and common cold
• In the Northern Badia there are other alternative
  therapies and healing practices such as using
  cautery ???? for therapy, visiting the graves for
  therapy ????? ?????? and taking some soil and
  mixing it with olive oil and painting the skin
• In the past the role of the traditional healers
  in the Northern Badia was important, especially
  for born the babies
• Today, as the health care is widely available,
  the role of the traditional healers dramatically
  decreased in the Badia

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• The most common diseases are the diseases related
  to children, for example the disease that doctors
  call measles, we call it "Fushit Dam", and we
  give the child "sheep Magher" which is the
  colouring on the sheep's back like red soil. We
  mix it with water and give it to the child to
  drink, and then we dress the child with a red
  dress, and with God's help he cures the next day
  (AZAH1).
• We have a proverb which is "give a child Marmaka
  and Anzout (herbs) and through him away". It
  means when the child drink from these herbs he
  will be recovered. We used to spread the child
  body with Marwaha (herbs) if he has sun stroke
  and ask him to sleep until he sweat. Then he will
  become fine. We use Marmaka for diarrhoea
  (AZAH1).
• I order the things from herb seller. They are
  expensive, for instance, if a mother became
  pregnant while she is breastfeeding a previous
  child, her child will suffer from severe
  diarrhoea. In this case we give the child a mix
  of honey and (Biradeh) which is prepared by the
  herb seller. Another example, we cauterise the
  woman who has repeated miscarriages, and give her
  Ja'edeh and another herb. We boil the mix and ask
  her to drink it (SAAH2).

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• I buy the stuff I need from a herb seller in
  Mafraq. After I buy them I grind the ingredients
  and bring some incense and ember, I then put the
  stuff on the ember. After that I bring some
  Za'ut, put some incense with it, and if a person
  is vomiting or has diarrhoea and you gave it to
  him, they become better immediately (NBAH3).
• For Ukht IlA'iel, it's when the child stops
  eating, vomits and has diarrhoea. He eats food
  and after that he collapses, it's like he gets
  poisoned, and the child also suffers from stomach
  aches (NBAH4).
• After the hospital opened I stopped delivering
  babies. They bring children to me as to treat
  them. Dr.A (a doctor who used to work in the
  hospital) used to send women to me to treat their
  children. Doctors have science, while we Dayahs
  have life experience. I used to go with my mother
  and see how women give birth. I helped women
  deliver their babies two times on my own, one of
  those times a woman gave birth to twins (RUAH5).

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Use of Traditional Medicine and Herbs among
BEDOUIN

• Measles Fushit Dam
• The most common diseases are the diseases related
  to children, for example the disease that doctors
  call measles, we call it "Fushit Dam", and we
  give the child "sheep Magher" which is the
  colouring on the sheep's back like red soil. We
  mix it with water and give it to the child to
  drink, and then we dress the child with a red
  dress, and with God's help he cures the next day
  (AH1)
• Khaitahred spots like ant bites on chest and back

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

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Traditional Medicine (continued)

• Diarrhea
• For Ukht IlA'iel, it's when the child stops
  eating, vomits and has diarrhoea. He eats food
  and after that he collapses, it's like he gets
  poisoned, and the child also suffers from stomach
  aches.(AH4)
• Post Delivery
• Frequent miscarriages

• Marmaka, Biradeh, Anbar Zaut
• We have a proverb which is "give a child Marmaka
  and Anzout (herbs) and through him away". It
  means when the child drink from these herbs he
  will be recovered. We used to spread the child
  body with Marwaha (herbs) if he has sun stroke
  and ask him to sleep until he sweat. Then he will
  become fine. We use Marmaka for diarrhoea. (AH1)
• Yes, Qasumeh, Shihah, Ja'det Alsubyan, Chamomile,
  Za'tar I get all these things from the wild.(AH4)
• In this case we g