Girl child marriage and the social context of displacement: a qualitative comparative exploration of Syrian refugees in Jordan and Rohingya refugees in Bangladesh.

BACKGROUND: There is growing global evidence that girl child marriage (CM) increases during humanitarian crises. Norms, attitudes, and policies that sustain CM are deeply entrenched within families and communities, and may be further exacerbated by conflict and displacement. The purpose of this study is to understand how the social and normative environment influences attitudes and practices related to CM in two diverse humanitarian settings. METHODS: We held a total of eight focus group discussions, four in each country, with Syrian refugees in Jordan and Rohingya Refugees in Bangladesh. FGDs were conducted with fathers, mothers, and adolescent boys and girls. RESULTS: Similar themes emerged from both settings. Participants discussed a desire to hold onto tradition in displacement and how norms are reinforced across generations. Social influence emerged in positive and negative ways, including peer pressure and conformity and the positive influence of host communities. In both settings, girls themselves described having little agency. Participants described resistance to change, which was exacerbated by conflict and displacement, though they discussed how social influence could be an effective way to challenge existing norms that drive the practice of girl child marriage. CONCLUSIONS: Our findings represent a more robust understanding of how norms operate within the social ecological system, and how they are reinforced across social relationships, offering an opportunity to more effectively challenge norms that sustain the practice of girl child marriage.

Measuring health service providers' attitudes towards the provision of youth-friendly sexual and reproductive health services: a psychometric study to develop and validate a scale in Jordan.

OBJECTIVES: The aim of this study is to develop and validate a scale to measure provider attitudes towards provision of youth-friendly sexual and reproductive health (SRH) services in a conservative setting in the Middle East. DESIGN: Cross-sectional, psychometric validation study. SETTING: Public health facilities in Amman, Irbid, Mafraq and Zarqa in Jordan. PARTICIPANTS: 552 healthcare providers were recruited by convenience. Providers were eligible if they were a practising midwife, nurse or physician in one of the selected health facilities. METHODS: An initial pool of 52 items was generated using theory and local expert input. We evaluated the psychometric properties of the scale using factor analysis. We assessed internal consistency reliability by calculating Cronbach's alpha and convergent construct validity using linear regression to assess the association between a provider's score on the scale and whether they had ever received training on SRH issues. RESULTS: Our final scale consisted of 3 dimensions and 29 items corresponding to the constructs of: (1) Attitudes towards Information and Services Offered to Youth (11 items) (2) norms and personal beliefs (10 items) and (3) attitudes towards the service delivery environment (8 items). Cronbach's alpha was estimated at 0.72 for the full scale, and between 0.70 and 0.73 for each subscale. The scale demonstrated high construct validity. The results of the linear regression analysis suggest that respondents who had received SRH training had a mean score that was 16% higher (0.64 points; 95% CI 0.2 to 11.2; p<0.01) on the full attitudes scale compared with those who did not. CONCLUSIONS: This paper describes a study to formally develop and validate a scale to measure healthcare provider attitudes in support of youth-friendly SRH services, thus providing an important tool to identify areas for improvement of youth SRH programmes in the Middle East and globally.

Understanding attitudes and norms related to sexual and gender-based violence among youth in Jordan: an egocentric social network study protocol.

INTRODUCTION: Sexual and gender-based violence (SGBV) is a major public health concern in Jordan, especially among youth. Social acceptance of SGBV is alarmingly high, including among youth. Refugee populations may be at particular risk given limited social support and access to health services combined with increased social and economic pressure and vulnerability. Further research is needed to understand how norms are embodied and reproduced at individual, interpersonal and community levels through relationships between partners, families, peers and community leaders. This study seeks to provide data on attitudes and norms in communities and across youth social networks in order to support gender transformative approaches that seek to change harmful social norms that perpetuate acceptance of SGBV. METHODS AND ANALYSIS: This study will collect egocentric data from 960 youth in Jordan (480 men and 480 women) aged between 18 years and 24 years. Individuals will be asked about their perceptions of norms relating to SGBV in their community as well as their perceptions of the attitudes held by up to 15 individuals within their social network. Data will also be collected on the social, economic and demographic variables, refugee status, experience of depression and anxiety, and social support. We will use multilevel analysis to examine individual and group-level associations. We will also assess other network attributes, such as homophily, the role of social engagement, social learning and social support in the transmission of norms and attitudes. ETHICS AND DISSEMINATION: Ethical approval was obtained from the Institutional Review Boards of the Harvard T.H. Chan School of Public Health and the University of Jordan. Rigorous ethical protections will be followed with regard to confidentiality and respondent safety. We intend to publish peer-reviewed papers of our findings in addition to a variety of tools and resources targeting diverse audiences, including policy and technical briefs.

Health care professionals' attitudes towards youth-friendly sexual and reproductive health services in Jordan: a cross-sectional study of physicians, midwives and nurses.

BACKGROUND: Youth-friendly sexual and reproductive health (SRH) services are thought to make such services for adolescents more accessible and acceptable; however, provider attitudes may still present an important barrier. Improving youth SRH service utilization has been recognized as a national priority in Jordan; however, existing services remain underutilized. Previous studies found that youth perceive SRH services to be inadequate and that providers are not supportive of their needs. The purpose of this study is measure provider attitudes towards youth-friendly SRH services and explore their variation according to individual characteristics among health care professionals in Jordan. METHODS: We measured provider attitudes towards youth-friendly SRH services using a scale that was developed and validated in Jordan. The scale consists of three subscales: (1) Attitudes towards SRH information and services offered to youth, (2) Norms and personal beliefs, and (3) Attitudes towards the policy and clinical environment. Possible scores range between 1 and 4, with higher scores reflecting more youth-friendly attitudes. Physicians, midwives and nurses working at either primary health centers, comprehensive care centers, or women's and children's health centers where services to adolescents are or should be offered were recruited from four governorates in Jordan using a two-stage, cluster sampling scheme. Differences in attitudes were assessed using simple and multivariable linear regression analysis. RESULTS: The sample consisted of 510 providers from four governorates in Jordan. The mean provider score on the full scale was 2.7, with a range of 2.0 to 3.8. On Subscales 1 and 2, physicians exhibited significantly more youth-friendly attitudes than nurses by scoring 0.17 points higher than nurses on Subscale 1 (95% CI: 0.02-0.32; p < 0.05) in adjusted analyses. Providers who had been previously trained in SRH issues scored 0.10 points higher (95% CI: 0.00-0.20; p < 0.05) than those who had not on Subscale 3. No differences were found according to provider characteristics on Subscale 2. Providers exhibited the lowest scores related to items referencing youth sexual behavior. CONCLUSIONS: Provider attitudes towards youth-friendly SRH service delivery highlight context-specific, cultural concerns. The limited variation in attitudes related to norms and personal beliefs may be a reflection that such beliefs are deeply held across Jordanian society. Last, as past training on SRH was significantly associated with higher scores, our results suggest opportunity for intervention to improve providers' confidence and knowledge.

Making sexual and reproductive (SRH) services easier for youth to access, organizing service delivery in a way that meets youth's needs, and supporting health care professionals to interact with youth in a friendly manner can make SRH services more youth-friendly. If SRH services are more youth-friendly, more youth may use them. In Jordan, steps have been taken to make SRH services more youth-friendly, but youth still do not believe that providers are supportive of their needs. This study aims to measure physician's, nurse's, and midwives' attitudes towards youth-friendly SRH services in Jordan. We also look at whether certain individual characteristics, such as age, type of service provider, etc. are related to provider attitudes We used a scale that tested in Jordan to measure provider attitudes. The scale focuses on three domains: (1) Attitudes towards SRH information and services offered to youth, (2) Norms and personal beliefs, and (3) Attitudes towards the policy and clinical environment. Possible scores range between 1 and 4, with higher scores reflecting more youth-friendly attitudes. Our sample includes 510 health care providers from four regions in Jordan. We used descriptive statistics and regression analysis to conduct our analysis. Our results show that physicians had more supportive attitudes than nurses or midwives on Subscales 1 and 3. Providers who reported having been trained in SRH issues in the past had higher scores on Subscale 3. No individual characteristics were related to Subscale 2. We find that in Jordan, provider attitudes may reflect deeply rooted cultural norms.

How Jordanian and Syrian youth conceptualise their sexual and reproductive health needs: a visual exploration using concept mapping.

Young people in Jordan are caught between the rapid social change that has encompassed the Middle East and the pressure to adhere to the strict norms and values that have defined previous generations, especially with regard to sexual and reproductive health. This study seeks to understand how Jordanian and Syrian adolescents conceptualise their concerns, needs and challenges with respect to their developing sexuality and reproductive health, while offering a comparative perspective by nationality and gender. Study participants were 271 young people aged 15-19. Data were generated using an interactive concept mapping approach. Data collection included brainstorming, pile sorting and rating to create a visual map that was interpreted by the participants. The results of this study show that both Jordanian and Syrian adolescents have a complex understanding of sex, sexuality and reproductive health that they define through broad conceptual spheres which include health, economic and social issues. Differences by gender highlight the conflict between traditional norms and changing social expectations. Both Jordanian and Syrian participants identified the need for diverse informational resources. For Syrians, the results emphasise how the hardship has influenced sexual and reproductive health through a focus on early marriage and need for economic stability.

Landscape analysis of family planning research, programmes and policies targeting young people in Jordan: stakeholder assessment and systematic review.

BACKGROUND: Reaching married and unmarried young people in Jordan with family planning information and services is a priority, especially considering Jordan's large refugee populations. To date, dissemination of family planning research and programmatic experience targeting young people in Jordan has been limited. AIMS: This study aimed to provide in-depth information on family planning intervention programmes, research and policies in Jordan that focus on young people aged 10-24 years. METHODS: Data were gathered through a systematic review of peer-reviewed and grey literature related to reproductive health of young people, and focus groups discussions with stakeholders from 18 relevant governmental and nongovernmental organizations. RESULTS: The literature review included 37 documents produced since 2008, which provide information at the individual, family/community, service delivery and policy levels. Young people in Jordan have limited knowledge of family planning methods and where to obtain family planning services. Little information is available on the availability of family planning services for young people. Several policy documents discuss family planning and reproductive health of young people in Jordan. Focus group discussions identified opportunities to integrate services and strengthen the development of future policies. CONCLUSIONS: The results of this study highlight key lessons learnt, opportunities for interventions and research gaps related to family planning among young people in Jordan. More attention should be paid to understanding and meeting the needs of Jordan's most vulnerable populations of young people, including urban refugees and married adolescents, especially as these populations continue to grow. Future programmes should build from past evidence and explore new areas and interventions.

A social-ecological examination into the research, policy and health service delivery environment related to early marriage and sexual and gender-based violence among youth in Jordan.

BACKGROUND: The determinants of sexual- and gender-based violence (SGBV) and early marriage are embedded across different levels of the social ecological system, including at the individual, family, community, and policy levels. In Jordan and the Middle East, SGBV, honor killing, and early marriage are priority public health and human rights issues that often overlap, and affect a significant percentage of youth. Jordan is home to a large number of refugees from across the Middle East, who may be even more vulnerable to these forms of violence than the local youth. The purpose of this analysis is to 1) synthesize the existing literature and 2) present the perspectives of key stakeholders to identify research gaps, programmatic lessons learned, and opportunities for policy change from an ecological perspective at the individual, community, health-system, and policy/legal levels. METHODS: This study includes 1) a systematic literature review of both published and unpublished literature since 2008 and 2) focus group discussions (FGDs) with key stakeholders representing 18 international and local governmental and non-governmental organizations. RESULTS: The literature review included 27 documents. Stakeholder discussions highlighted important research and policy gaps. Prevalence estimates of SGBV, honor killing, and early marriage vary across sources; however, all of them indicate that they remain important issues for youth in Jordan. Several sources indicate that early marriage has been increasing in Jordan since the beginning of the war in Syria, especially among Syrian refugees. Refugee youth are particularly vulnerable to SGBV and early marriage given the worsening economic situation in Jordan. The norms, attitudes, and practices that support SGBV in Jordan appear to be reinforced within families and communities. Despite ongoing programs, SGBV services are limited, especially for youth, and there is little awareness of service availability amongst target populations. Laws and policies continue to offer legal justification for SGBV, honor killing, and early marriage. DISCUSSION: As countries across the Middle East face instability and continue to struggle with the urgent health needs of large refugee and youth populations, this review provides valuable insight relevant to research, programs, and policy in Jordan and across the region.

Parent-child communication about sexual and reproductive health: perspectives of Jordanian and Syrian parents.

Young people throughout the world face considerable challenges related to their sexual and reproductive health (SRH). The parent-child relationship is fundamental to shaping children's trajectories through adolescence and suggests considerable potential to improve youth SRH knowledge. Lack of parent-child sexual communication (PCSC) may cause youth to turn instead to questionable information sources, such as peers, the internet and social media. The limited research in this area, and specifically in the Middle East, led us to explore how parents discuss SRH issues with their children and pinpointed the potential role for parents in supporting their children's SRH needs. A qualitative research approach was used, with 20 focus groups stratified by nationality and sex of participants from four major communities in Jordan. Thematic coding and analysis was used. Parents described their willingness to "break the culture of shame." Three primary strategies emerged: (1) the gender match, (2) mothers as a safe space and (3) seeking help from others, which included two sub-themes: incorporating others, and relying on the delivery of SRH information in schools. Strengths and challenges were inherent within each strategy, and discussion topics varied according to the strategy used. Evidence from this study provides an opportunity for future research and programming to improve adolescent health outcomes within conservative milieus to break the intergenerational cycle of shame. Interventions are suggested to target parents' knowledge and self-confidence to help youth achieve their sexual development. Using gender-matched PCSC strategies, school-based platforms and religious institutions are ways to destigmatise such topics.

How do Jordanian and Syrian youth living in Jordan envision their sexual and reproductive health needs? A concept mapping study protocol.

INTRODUCTION: Youth in Jordan constitute 20.4% of the population, and many face considerable challenges in addressing their sexual and reproductive health (SRH) needs, such as those related to the prevention of unintended pregnancy and sexually transmitted infections, early marriage and sexual coercion and violence. The findings of previous studies indicate that Jordanian youth require reproductive health-related support, information and services; however, there remains very limited data as to how youth envision their SRH challenges and needs. This protocol outlines the design of a qualitative study using a participatory research methodology called concept mapping. This methodology enables participants to develop a conceptual framework for how they envision their sexual and reproductive health needs. METHODS AND ANALYSIS: This study will use concept mapping, which consists of a structured and iterative participatory research process that engages participants over three data collection sessions in order to generate the information needed to create a visual display of their ideas pertaining their SRH needs, issues and concerns, and how these ideas relate to each other. Each data collection session focuses on a different activity, including brainstorming, pile sorting and interpretation of the results. Data will be analysed using hierarchical cluster analysis and multidimensional scaling. Transcriptions of group discussions will be coded and analysed to add depth to the study results. Two hundred and eighty-eight males and females of Jordanian or Syrian descent living in Jordan will be recruited from four communities across Jordan. ETHICS AND DISSEMINATION: This study meets the requirements of the Declaration of Helsinki and has been approved by the Institutional Review Boards at the Harvard T.H. Chan School of Public Health and the University of Jordan. Study findings will be presented in peer-reviewed, international journals and made available to local programme managers, policy-makers and stakeholders through local dissemination efforts.