Assessment of SocialDeterminants

of Health in Selected Slum Areasin Jordan: Amman and Aqaba

Dr. Musa AjlouniApril, 2013

Why treat people’s illnesses without changingthe conditions that made them sick? (WHOCommission on Social Determinants of Health, 2008)

The social determinates of health (SDH)have been described as:

‘The causes of the causes' they arethe social, economic andenvironmental conditions thatinfluence the health of communitiesfrom birth to the death; and thatpotentially can be altered by informedaction.

Socioeconomic Indicators

• Jordan is a middle income country.

• Annual per capita income: US$2,746.

• Expenditure on health: about 9.05% of GDP (about

US$250 per person per year).

Health Indicators

• Life expectancy: 73 years.

• Crude death rate: 7 per 1000: the leading cause of

death is cardiovascular followed by cancer.

• Infant mortality: 23 per 1000 Live Births and child

mortality 28 per 1000 Live Births

• Maternal mortality: 19.1 per 100,000Live Births

Slums and Informal Settlements

• Rapid unplanned urbanization createssocial stratification manifested by slumsand informal settlements. According to the2003 Global Report on HumanSettlements, 43 per cent of the urbanpopulation in developing countries lives in“slums”; in the least developing countries,the figure rises to 78 per cent

Percentage of Urban Population Living In“Slums” In Different Countries

Source: WHO Centre for Health Development, Kobe, Japan (2007). Our Cities, Our Health, Our Future: Acting On SocialDeterminants for Health Equity In Urban Settings.

Urbanization and InformalSettlements in Jordan

• 6.4 million people in 2011.• Quarter of the total population growth is

attributed to in-migration• Population growth rate 2.2 %.• Population will double within the next 30• 82.6% of population is urban• 50% lives in Amman• 940147 housing units(2004)• 10539 houses not suitable for human housing

Objectives of the Study

• Assess the social determinants of health(SDH) in selected slum areas in Ammanand Aqaba to:1.Highlight the most common challengesrelated to social determinants of health inthese areas.2.Suggest policy directions andinterventions to meet these challenges.

Conceptual Framework

Source: WHO, Commission on Social Determinants of Health (2010), A Conceptual Framework for Action on theSocial Determinants of Health, Geneva 2010.

METHODOLOGY• Inclusion Criteria:

The slum household to be included in the study isdefined as a group of individuals living under the sameroof in an urban area who lack one or more of thefollowing:

1. Durable housing of a permanent nature.2. Sufficient living space (not more than 3 people/room3. Easy access to safe water.4. Access to adequate sanitation (private or public toilet).5. Security of tenure that prevents forced evictions.

Source: UN–HABITAT (2007), State of the World Cities, 2006/7, United Nations Centre forHuman Settlements.

Study SitesAmman Slums at Adan Area/Alnasir District

Amman Slums

Study Sites

• Aqaba Slums at Khazan Area

Data Collection• Socioeconomic data collection sheet for

each household :For each member( wherever applicable):

Age, sex, marital status, education level, job,monthly income, diseases and disabilities.

For each household:•Number of children died before age of 5.•Number of children who dropped out of schoolbefore completing tenth class.•Health insurance status.•Number of people supported by the householdhead other than children and wife.

Focus group meetings: Objectives• To find how residents perceive the structural

determinants of health (income, education,occupation, occupation, ethnicity, social class).

• To find how residents perceive the intermediarydeterminants of health (material circumstances,social-environmental or psychosocial circumstances,behavioral and biological factors, the health system).

• To obtain their opinions on major health andsocio economic issues .

• To gather local community suggestions forfurther improvements of SDH.

Participants in the Focus groupmeetings(13-15 people):

• Two community leaders (one Sheik)• One widow• Two senior/old residents (> 65 years old)/male and female.• Two school students (girl and boy)• Two housewives.• One unemployed.• One self employed.• One employed resident.• Two youth residents (male and female)/18-25 years of age

one (university or college graduate, if available).

Ethical issues

• Verbal consents were taken from participants tocollect data, conduct the focus group meetingsand perform the audiovisual recording.

• Their rights to withdraw anytime and not to berecorded or pictured were explained for them.

• They were assured that all documents andrecordings related to this study will be used forstudy purposes and official uses by WHO andMOH.

RESLUTS: Quantitative

RESLUTS: Quantitative

RESLUTS: Quantitative

RESLUTS: Participants’ Perceptions

• Structural Determinants of HealthEconomic Situation

Participants in both slum areas in Amman andAqaba stated that they all suffer from lowincome and low wage earning, poverty,unemployment and job insecurity, and highdependency ratios.

Structural Determinants of HealthEducation

High rates of illiteracy especially amongmothers;High percentage of school dropouts beforethe tenth class especially girls;Children have difficulties in accessingschools.Participants express their regard foreducation and foresee upward social mobilityfor their children by educating their offspringas much as possible.

Structural Determinants of HealthOccupation

A significant number of households inAmman and Aqaba slums raise sheep toearn income or at least to secure basicfood requirements .In Amman most of the employed work asdrivers, while in Aqaba most of theemployed work in unskilled jobs in the port.

Structural Determinants of HealthGender

• Gender issues in the two study sites do not varysignificantly from the general prevailing situation inJordan (The Gender Inequality Index value is 0.456placing Jordan at 83 out of 146 countries).

• Gender inequity : women are oppressed andmaltreated by their husbands.

• Many families are female headed.• Children of a Jordanian mother are denied

citizenship because their dead father is notJordanian.

Structural Determinants of HealthEthnicity and Social Exclusion

• Almost all of the families are of well knownJordanians clans and tribes , they are not living inthe slums for ethnical reasons.

• Many families living in Aqaba slums claim thattheir grandfathers were among the first people tolive in Aqaba .

• Residents don’t feel of significant social exclusionfrom urban people living in neighborhoods near tothem.

• They feel that officials don’t deal with themrespectfully; they claim that they are victims of“official exclusion”

Intermediary Determinants of HealthMaterial Circumstances

• Slum shelters are built of cardboards andmangled zinc and tin, and worn wood.

• Residents suffer from harsh cold in winter andscorching summer sun.

• Lacking the minimum necessities of life such assewage system, electricity, or clean drinkingwater, and paved roads and lanes.

• Puddles and slush are common-place afterevery rain shower .

Intermediary Determinants of HealthPsychosocial Circumstances

• Residents suffer from stressful livingcircumstances, psychosocial stressors andsocial exclusion and neglect.

• Many have mental stress related to uncertaintyabout the financial situation, insecurity, andstressful events.

• Social solidarity among slum residents andcommunity spirit are the main drivers for theabsence of violence in the two slumsettlements .

Intermediary Determinants of HealthBehavioral , Biological Issues

The participants reported that due povertyand unemployment almost all householdsliving in the two slum settlements sufferfrom poor diet and low protein intake.They declared that they do not havenegative behavioral threats as substanceabuse and moral misconduct.

Intermediary Determinants of HealthThe Healthcare System

• The slum inhabitants have many healthproblems as kidney diseases, respiratorydiseases (asthma, respiratory tractinfections), mental and psychologicaldisorders, diabetic, high blood pressure,arthritis, osteoporosis, urinary tractinfections.

• Some of them also have physicaldisabilities and can’t support themselves.

The Healthcare System

• Most of slum residents at Amman site claim thatthey do not have health insurance.

• At Aqaba, though most slum residents arecovered by the government health insuranceplan for vulnerable and poor people, they claimthat they are not given equal opportunities asother patients.

• All participants in the two slum locationsreported that local health authorities have nevervisited their premises or provided them with anyhealth services in the field.

Recommendations

Seeing

“Seeing is of course very much amatter of verbalization. Unless I callmy attention to what passes beforemy eyes, I simply won’t see it.”

--Annie Dillard, Pilgrim at Tinker Creek

Three Pillars for Addressing SocialDeterminants

1. Social protection for thepoor

- Distributive policies, living conditions,stress

2. Social Inclusion- Supportive ties, Bridging social capital

3. Empowerment- Control over conditions in work and

life

(Marmot, Lancet, 2006; WHO Commission Report on SDOH, 2008)

2.Social inclusion 3. Empowerment

1.Social protection

1.Social protection• Developing strategies to house the

existing slum residents andprevent the formation of new slums.

• Developing and adopting clearly-defined area specific povertyreduction interventions with cleargoals to achieve specific outcomesduring a limited time frame.Giving slum residents employmentpriority ,especially in Aqaba.

1.Social protection• Expanding the social protection to target

slum residents according to well definedpriority criteria:Portable drinking waterTemporary housing units (i.e. caravans) with basicsanitation facilities.Health servicesGarbage collectorsElectricity generatorNutritionVeterinary services

2.Social Inclusion• Removing financial burdens incurred as a result

of enrolment children in primary education atpublic schools, including school donation fees.

• Offering financial incentives for families that failto enroll their children as a result of their pooreconomic status.

• Encouraging pre-school programmes byopening kindergartens in slum areas or nearthese areas.

2.Social Inclusion

• Rules and regulations should be reviewedto give the right for women to confercitizenship to children born to a non-Jordanian father.

3.Empowerment• Supporting and enhancing the

programmes designed to habilitate andtrain productive households in slum areas.

• Adopting a community-based model toeliminate illiteracy in slum residential areasin collaboration with local authorities.

3.Empowerment

• Development of community based womenempowerment programs for slum areas inorder to assist women in making informedchoices in all aspects related to their lives;develop their capacities to communicateeffectively with other community members,and to initiate actions and projects toimprove their lives.

3.EmpowermentDesignating specificzone in urban areas forlivestock raising withthe appropriateinfrastructure andhousing units.Providing slumlivestock keepers bywater supply, veterinaryservices and basicenvironmental healthservices.Providing livestockkeepers with micro-financing.

ConclusionProviding slum residents with adequatehousing units, equitable work opportunities,and proper protection against poverty andsocial exclusion is the main avenue for ahealthy physical, social and mental well-being of those vulnerable people.

Like our Children… Amal HasA Smile and A Dream……

Look into her Eyes ,you can see the Dream!