This presentation summaries the main findings of a study which was performed to asses the Social Determinants of Health (SDH) in selected slum Areas in Jordan and suggest some policy directions to deal with the challenges related to these SDH.

1. Assessment of Social
Determinants
of Health in Selected Slum Areas
in Jordan: Amman and Aqaba
Dr. Musa Ajlouni
April, 2013

2. Why treat people’s illnesses without changing
the conditions that made them sick? (WHO
Commission on Social Determinants of Health, 2008)

3. The social determinates of health (SDH)
have been described as:
‘The causes of the causes' they are
the social, economic and
environmental conditions that
influence the health of communities
from birth to the death; and that
potentially can be altered by informed
action.

5. 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).

6. 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

7. Slums and Informal Settlements
• Rapid unplanned urbanization creates
social stratification manifested by slums
and informal settlements. According to the
2003 Global Report on Human
Settlements, 43 per cent of the urban
population in developing countries lives in
“slums”; in the least developing countries,
the figure rises to 78 per cent

8. 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 Social
Determinants for Health Equity In Urban Settings.

9. Urbanization and Informal
Settlements 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

10. Objectives of the Study
• Assess the social determinants of health
(SDH) in selected slum areas in Amman
and Aqaba to:
1.Highlight the most common challenges
related to social determinants of health in
these areas.
2.Suggest policy directions and
interventions to meet these challenges.

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

12. METHODOLOGY
• Inclusion Criteria:
The slum household to be included in the study is
defined as a group of individuals living under the same
roof in an urban area who lack one or more of the
following:
1. Durable housing of a permanent nature.
2. Sufficient living space (not more than 3 people/room
3. 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 for
Human Settlements.

13. Study Sites
Amman Slums at Adan Area/Alnasir District

14. Amman Slums

15. Study Sites
• Aqaba Slums at Khazan Area

16. 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 school
before completing tenth class.
•Health insurance status.
•Number of people supported by the household
head other than children and wife.

17. 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 intermediary
determinants of health (material circumstances,
social-environmental or psychosocial circumstances,
behavioral and biological factors, the health system).
• To obtain their opinions on major health and
socio economic issues .
• To gather local community suggestions for
further improvements of SDH.

18. Participants in the Focus group
meetings(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).

19. Ethical issues
• Verbal consents were taken from participants to
collect data, conduct the focus group meetings
and perform the audiovisual recording.
• Their rights to withdraw anytime and not to be
recorded or pictured were explained for them.
• They were assured that all documents and
recordings related to this study will be used for
study purposes and official uses by WHO and
MOH.

20. RESLUTS: Quantitative

21. RESLUTS: Quantitative

22. RESLUTS: Quantitative

23. RESLUTS: Participants’ Perceptions
• Structural Determinants of Health
Economic Situation
Participants in both slum areas in Amman and
Aqaba stated that they all suffer from low
income and low wage earning, poverty,
unemployment and job insecurity, and high
dependency ratios.

24. Structural Determinants of Health
Education
High rates of illiteracy especially among
mothers;
High percentage of school dropouts before
the tenth class especially girls;
Children have difficulties in accessing
schools.
Participants express their regard for
education and foresee upward social mobility
for their children by educating their offspring
as much as possible.

25. Structural Determinants of Health
Occupation
A significant number of households in
Amman and Aqaba slums raise sheep to
earn income or at least to secure basic
food requirements .
In Amman most of the employed work as
drivers, while in Aqaba most of the
employed work in unskilled jobs in the port.

26. Structural Determinants of Health
Gender
• Gender issues in the two study sites do not vary
significantly from the general prevailing situation in
Jordan (The Gender Inequality Index value is 0.456
placing Jordan at 83 out of 146 countries).
• Gender inequity : women are oppressed and
maltreated by their husbands.
• Many families are female headed.
• Children of a Jordanian mother are denied
citizenship because their dead father is not
Jordanian.

27. Structural Determinants of Health
Ethnicity and Social Exclusion
• Almost all of the families are of well known
Jordanians clans and tribes , they are not living in
the slums for ethnical reasons.
• Many families living in Aqaba slums claim that
their grandfathers were among the first people to
live in Aqaba .
• Residents don’t feel of significant social exclusion
from urban people living in neighborhoods near to
them.
• They feel that officials don’t deal with them
respectfully; they claim that they are victims of
“official exclusion”

28. Intermediary Determinants of Health
Material Circumstances
• Slum shelters are built of cardboards and
mangled zinc and tin, and worn wood.
• Residents suffer from harsh cold in winter and
scorching summer sun.
• Lacking the minimum necessities of life such as
sewage system, electricity, or clean drinking
water, and paved roads and lanes.
• Puddles and slush are common-place after
every rain shower .

29. Intermediary Determinants of Health
Psychosocial Circumstances
• Residents suffer from stressful living
circumstances, psychosocial stressors and
social exclusion and neglect.
• Many have mental stress related to uncertainty
about the financial situation, insecurity, and
stressful events.
• Social solidarity among slum residents and
community spirit are the main drivers for the
absence of violence in the two slum
settlements .

30. Intermediary Determinants of Health
Behavioral , Biological Issues
The participants reported that due poverty
and unemployment almost all households
living in the two slum settlements suffer
from poor diet and low protein intake.
They declared that they do not have
negative behavioral threats as substance
abuse and moral misconduct.

31. Intermediary Determinants of Health
The Healthcare System
• The slum inhabitants have many health
problems as kidney diseases, respiratory
diseases (asthma, respiratory tract
infections), mental and psychological
disorders, diabetic, high blood pressure,
arthritis, osteoporosis, urinary tract
infections.
• Some of them also have physical
disabilities and can’t support themselves.

32. The Healthcare System
• Most of slum residents at Amman site claim that
they do not have health insurance.
• At Aqaba, though most slum residents are
covered by the government health insurance
plan for vulnerable and poor people, they claim
that they are not given equal opportunities as
other patients.
• All participants in the two slum locations
reported that local health authorities have never
visited their premises or provided them with any
health services in the field.

33. Recommendations

34. Seeing
“Seeing is of course very much a
matter of verbalization. Unless I call
my attention to what passes before
my eyes, I simply won’t see it.”
--Annie Dillard, Pilgrim at Tinker Creek

35. Three Pillars for Addressing Social
Determinants
1. Social protection for the
poor
- 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

36. 1.Social protection
• Developing strategies to house the
existing slum residents and
prevent the formation of new slums.
• Developing and adopting clearly-
defined area specific poverty
reduction interventions with clear
goals to achieve specific outcomes
during a limited time frame.
Giving slum residents employment
priority ,especially in Aqaba.

37. 1.Social protection
• Expanding the social protection to target
slum residents according to well defined
priority criteria:
Portable drinking water
Temporary housing units (i.e. caravans) with basic
sanitation facilities.
Health services
Garbage collectors
Electricity generator
Nutrition
Veterinary services

38. 2.Social Inclusion
• Removing financial burdens incurred as a result
of enrolment children in primary education at
public schools, including school donation fees.
• Offering financial incentives for families that fail
to enroll their children as a result of their poor
economic status.
• Encouraging pre-school programmes by
opening kindergartens in slum areas or near
these areas.

39. 2.Social Inclusion
• Rules and regulations should be reviewed
to give the right for women to confer
citizenship to children born to a non-
Jordanian father.

40. 3.Empowerment
• Supporting and enhancing the
programmes designed to habilitate and
train productive households in slum areas.
• Adopting a community-based model to
eliminate illiteracy in slum residential areas
in collaboration with local authorities.

41. 3.Empowerment
• Development of community based women
empowerment programs for slum areas in
order to assist women in making informed
choices in all aspects related to their lives;
develop their capacities to communicate
effectively with other community members,
and to initiate actions and projects to
improve their lives.

42. 3.Empowerment
Designating specific
zone in urban areas for
livestock raising with
the appropriate
infrastructure and
housing units.
Providing slum
livestock keepers by
water supply, veterinary
services and basic
environmental health
services.
Providing livestock
keepers with micro-
financing.

43. Conclusion
Providing slum residents with adequate
housing units, equitable work opportunities,
and proper protection against poverty and
social exclusion is the main avenue for a
healthy physical, social and mental well-
being of those vulnerable people.

44. Like our Children… Amal Has
A Smile and A Dream……
Look into her Eyes ,you can see the Dream!