A presentation by Bassam Abu Hamad, Dr Nicola Jones, Agnieszka Malachowska and Professor Sarah Baird to the 3rd Regional Conference: Investing in Healthier Generations in Amman, Amman, Jordan, December 2019

1. ©
Water distribution in ITS in Karak © Herwig / UNICEF 2019
Exploring health-related challenges facing adolescents in
humanitarian contexts: Findings from the GAGE baseline research in
Jordan
Bassam Abu Hamad, Nicola Jones, Agnieszka Malachowska and Sarah Baird
Amman, December 2019

2. Outline of presentation
1
• Overview: GAGE research
2
• Research methodology
3
• Key findings
4
• Implications for policy and practice

3. Gender and Adolescence: Global Evidence (GAGE):
The largest longitudinal research programme on adolescents in the Global South (2015-2024)
By finding out ‘what works,’ for whom, where
and why, we can better support adolescent girls
and boys to maximise their capabilities now and
in the future.
We are following the largest cohort of adolescents in the Global South

4. Why adolescence?
An age of opportunity The demographic imperative
% total population 10-24 years in 2013
In Jordan, in 2015,
20% of the population
are adolescents
1-in-5 of Jordan’s children,
3.2 million individuals, are
multidimensionally poor
ADOLESCENCE
10-19 years
Rapid neuro-
development
changes Growing
adoption of
adult-like
roles, e.g.
work, intimate
relationships
Development
of healthy
versus risky
long term
behavioursIncreased
interaction
with peers vs
parents
Psycho-
emotional
and self-
identity
changes
Physical and
reproductive
changes with
associated
gender norms
Most physical and mental disorders begin
in adolescence

5. GAGE 3Cs Conceptual Framework

6. Context in Jordan
 Jordan’s population, nearly 10 million, has almost doubled in the last decade, 30% are
refugees; over 1.2 million Syrians living in Jordan—nearly 660,000 are registered refugees
 Jordan is deeply constrained by agro-climate conditions, 90% is desert
 A country ranked as "high human development" with an "upper middle income" economy.
 Economic growth has almost flat-lined since 2011, at only 2.3% in 2016.
 Around 86% of Syrian refugees lived below the poverty line.
 Refugee households have a high burden of chronic illness and disability—35% and 7%
respectively.
 More than half of HHs experiencing food shortage in last month
 Since health care user-fees were imposed by the GoJ, refugees’ access to care has been sharply
limited.
 71% of adolescents are enrolled in school, enrolment is inversely
correlated with age.

7. 1. How do adolescent girls and boys in diverse low- and middle-income countries
(LMICs) experience transitions from childhood to adulthood? How do these differ
by age, gender, disability, geographic location, and displacement?
Stemming from our conceptual framework, GAGE addresses three core sets of questions:
2. What effects do adolescent-
focused programme interventions
have on adolescent capabilities in the
short and longer-term?
3. What programme design and
implementation characteristics matter
for effective delivery and scalability?
GAGE Core Research Questions

8. GAGE longitudinal research methodology and sample
8
Jordan 4000 Jordan 220 Jordan 100

9. Vaccinating in Azraq Hospital: © Herwig/UNICEF/2019
Key Findings
Please note that the photographs of
adolescents DO NOT capture GAGE research
participants and consent was gained from
their guardians for the photographs to be
used for GAGE communications purposes.

10. Adolescents are generally healthy—but remain vulnerable
82% of all GAGE adolescents
report good health
 Syrians (80%) are less healthy
than Palestinians (90%) and
Jordanians (88%)
Gender matters
 Boys are far more likely to smoke cigarettes (34% versus
5%)
 Boys are at higher risk of serious illness or accident (17%
versus 11%), likely due to gender norms that keep girls
home.
‘When my son was shot, he was with 19 other people, I
thanked God 100 times, 1,000 times that none of the women
were shot. Because really, how difficult would that be.
Because if we wanted to treat her, and she would need to
come and go all the time, that would have been a big
problem.’ (Syrian father of an 18-year-old son with a physical
impairment)
Adolescents with disabilities
are more at risk
 Only 64% report good health
 23% have been seriously ill in
the last year (versus 13%)

11. Adolescent ill-health has multiple reasons
 Child labourers are prone to work-related injuries
‘We had many cases of children going outdoors
instead of the toilets. There’s sharing of the toilets…
Some people feel the toilet is not clean, and
outdoors is better.’ (Key informant, Azraq)
 Many illnesses result from overcrowding, poor
sanitation, poor nutrition, stress, isolation, risky
behaviors and substance abuse
‘There are girls who work over their ability. For
example, in their work, they carry the cartons and
they transfer them so that their backs and legs pain
them. They have varicose veins in their legs from
standing still all day. (17-year-old Jordanian girl)Father with his son in Azraq Camp: ©Herwig/UNICEF/2019

12. Both under- and over-medicalisation are concerns
 65% of recently ill GAGE adolescents
sought treatment—sometimes for minor
complaints such as headache
 There is a widespread belief that more
care is always better care.
 Costs are an issue for the poorest—
especially refugees living in host
communities and ITS where service
access is more limited compared to
camps.
 Limited preventive services/information
 Discrimination can be an issue for
refugees.
’Now we have to pay for the transportation, then
pay to have an appointment to see the doctor,
then pay to buy the medication.’
(Syrian father, ITS)
‘The doctor treats the patient based on their own
description of what they feel. The doctor does
not make any medical tests for the patient.’
(Palestinian father, Gaza camp)
‘My parents noticed that something was wrong, but the
doctors were telling them the opposite to what I told
them… The doctor told my parents that I was mentally ill...
that what I had was a mental illness, not physical.’
(16-year old Syrian girl hospitalized with severe fibrosis)

13. 17% of GAGE adolescents
reported going hungry in the
last month.
‘I mean if there is a coupon there
will be food, if the coupon is
finished there is no food at all.’
(Syrian mother, ITS)
Food security is better in camps
than host communities and ITS,
due to free bread distribution
and school feeding.
Adolescents with disabilities
are more likely to report hunger
(28% versus 16%) than those
without, due to the added costs
of disability.
Diet quality is an
issue—there are too many
carbohydrates and too few
micronutrients.
‘Most of them (young mothers)
suffer from Iron deficiency,
because she has two challenges;
the first that she is a pregnant
and the other challenge that she
is still developing.’
(Health care provider, Zaatari)
Food insecurity is the norm—and hunger is relatively common

14. Overweight and obesity are on the rise
• Over two-thirds of adult Jordanians are now overweight (Mokdad et al., 2014)
Shifting diets are fueling epidemics of obesity, diabetes, and tooth
decay.
Adolescents prefer chips, biscuits, juice and soda—despite good
knowledge about nutrition.
School canteens serve junk food, not healthy food.
• ‘I used to play football…Then they started convincing my mom to change her
mind. They’d tried before with my father but he didn't listen to them and said
"it's her choice, this is what she wants". So they tried with my mother until she
made me stop playing.’ (16-year-old girl, Zaatari)
Exercise for adolescent girls is often discouraged due to conservative
social norms

15. Older adolescents have information about puberty—but…
Girls were more likely to
have a source of
information than boys
(92% versus 79%)—
though most did not know
about menstruation until
after it began.
‘I feel shy to tell him, but I
can tell my daughter
without shyness.’
(Mother, Zaatari)
Adolescents in host
communities were
advantaged (88%) over those
in formal camps (82%) and
ITS (76%).
‘I did not tell her about
periods, this generation is
taught by themselves, they
teach each other. Aren’t they
working together? They know
more than me’
(Mother, ITS)
Adolescents reported
learning about puberty from
their mothers and aunts, at
school, and through Makani
classes:
‘My aunt told me… I feel like
my aunt is more like a friend
of mine.’
(17-year-old Palestinian girl,
Gaza camp)

16. Knowledge about SRH is very limited
‘I worked with some children
who were pregnant and they
found that they’re pregnant
in their like sixth
month…because these
children they do not know
that sexual relations makes
women pregnant.’
(Key informant, host
community)
Due to cultural norms, sexuality is rarely discussed
prior to marriage.
There are barriers even for married girls.
Some married girls reported that they were
not told about sex itself until the day of
marriage.
Some young mothers do not understand the
link between sex and pregnancy.
Only 43% of married girls could identify a form
of contraception when present with a list.
Married girls reported that their husbands will not
allow them to use contraception.

17. Girls and boys face different health risks…
Married girls
Unmarried girls
Recognise a form of contraception Percent already married
‘The girl is 13 years old and
was pulled out of school. She
ran away from home as she
did not want to get married
so young.
Now she stands by the
window and thinks of
suicide. She does not leave
the house. She has a
psychological illness.’
(15-year-old married Syrian
girl, Amman)

18. Boys are at greater risk of substance abuse
Smoke cigarettes Smoke shisha
Older boys
Older Jordanian boys

19. Resilience is the norm, but emotional distress is common
One-third of adolescents had scores that demonstrated emotional distress:
• Adolescents with disabilities are 71% more likely to exhibit distress
• Older girls are 11% more likely to be distressed than older boys
• Those in ITS (40%) are more distressed than those in host communities (33%)
and camps (29%)
• Nationality differences were relatively small
‘Depression… comes from very severe poverty… it has a high effect on adolescents as all their
needs aren’t complete, they have only one club and it doesn’t accept everyone - only those who
have talent, the rest are marginalized… So they spend their time in the street or the girls at
home home in their room… and we know of suicide attempts… families may try to hide it but
it’s happening’. (Social worker in Gaza Camp)
Our survey included the General Health Questionnaire-12 and the Child and Youth
Resilience Measure-28 and found that most adolescents are not psychologically
distressed and are emotionally resilient:

20. Positive experiences: Makani impacts wellbeing
• Older boys who attend Makani are 19% less likely to smoke cigarettes.
Makani contributes to a reduction in substance abuse through life skills messages
and by mentorship
• Older girls who attend Makani are twice as likely to play a sport (25% versus 12%).
Makani provides opportunities for girls to participate in sport as part of its activity
package
• ‘I took a course at the Makani centre, called The Woman and The Girl, and they got us
a female doctor so we could ask her anything.’ (14-year-old Syrian girl, Azraq)
Makani increases girls' access to information about puberty changes through life
skills and child protection messages.
• Adolescents who attend Makani demonstrate better knowledge of nutrition.
Makani contributes to improved understanding of good nutrition through science
and life skills classes

21. Priority actions to enhance adolescent health
Priority health challenges facing adolescents are nutritional problems (obesity and food insecurity),
sanitary related diseases, psychological distress, risky behaviours and substance abuse, lack of
awareness about puberty and SRHR related issues inappropriate
Strategies should address the key social and contextual determinants of physical and mental
wellbeing including food security, WASH. Integrated, intersectoral interventions to address the
multiple vulnerabilities adolescents face are essential (e.g Makani initiatives).
Promote adolescents' access and utilization of age and gender sensitive health services and
information through investments in adolescents’ friendly health services, outreach services,
school health, better utilization of school counsellors and social workers and awareness-raising
Design age-tailored health awareness activities using different outlets e.g mass media, school,
community centres, social media and websites focusing on healthy life style, self-care, puberty, sex
education exercising, combating smoking and substance abuse, and health seeking behaviours
Policies to prevent substance abuse and to support adolescent drug users should be implemented
include psychosocial support, awareness and introduction of rehabilitation programmes

22. Contact Us
Dr Nicola Jones, GAGE Director
n.jones@odi.org.uk
Dr Bassam Abu Hamad , GAGE MENA
Associate Director
ghsrcb@gmail.com
Agnieszka Malachowska, GAGE MENA
Manager
a.malachowska@odi.org.uk
www.gage.odi.org
@GAGE_programme
GenderandAdolescence
About GAGE:
 Gender and Adolescence: Global Evidence
(GAGE) is a nine-year (2015-2024) mixed-
methods longitudinal research programme
focused on what works to support adolescent
girls’ and boys’ capabilities in the second
decade of life and beyond.
 We are following the lives of 18,000
adolescents in six focal countries in Africa,
Asia and the Middle East.