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

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Jewel Gausman,1 Areej Othman,2 Abeer Dababneh,3 Iqbal Hamad,4 Maysoon Dabobe,4 Insaf Daas3 and Ana Langer1

1Women and Health Initiative, Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston (MA), United States of America. 2Maternal and Child Health Nursing Department, School of Nursing, University of Jordan, Amman, Jordan. 3Center for Women’s Studies, University of Jordan, Amman, Jordan. 4Jordanian Hashemite Fund for Human Development, Amman, Jordan. (Correspondence to: Jewel Gausman: This e-mail address is being protected from spambots. You need JavaScript enabled to view it ).

Abstract

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.

Keywords: adolescents, youth, reproductive health, family planning services, Jordan

Citation: Gausman J; Othman A; Dababneh A; Hamad I; Dabobe M; Daas I; Langer A. Landscape analysis of family planning research, programmes and policies targeting young people in Jordan: stakeholder assessment and systematic review. East Mediterr Health J. 2020;26(x):xxx–xxx. https://doi.org/10.26719/emhj.20.018

Received: 10/01/19; accepted: 13/08/19

Copyright © World Health Organization (WHO) 2020. Open Access. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo)

Introduction

Preventing unintended pregnancy among young people is a global priority. Targeting young people in Jordan with family planning information and services is complicated by the conservative social context that prohibits sexual activity outside of marriage; however, many young women in Jordan remain at risk of early and unintended pregnancy (1,2). While most sexual activity occurs within marriage, a study in Jordan found that 7% of university students reported premarital sexual activity, although data are limited (3). In recent years, marriage of women younger than 18 years has increased in Jordan from 13.7% to 18.1% (4). High pregnancy rates have been seen in married adolescents (5), and sexual assault and rape are a concern, especially among refugees (6).

The large influx of refugees in Jordan has stretched its limited health resources. Young people constitute large proportions of Jordan’s refugee populations. About 30% of Jordan’s population is non-Jordanian and includes populations from across the Middle East. Only 16% of the 1.2 million Syrian refugees in Jordan live in official camps (7); those outside of camps are younger, poorer and less educated (8). More than 2 million registered Palestinians and 66 000 to 150 000 Iraqi refugees live in Jordan (9,10).

To date, there has been limited dissemination and collation of existing family planning research and programmatic experience among young people in Jordan between the ages of 10 and 24 years. Therefore, we aimed to (i): review and synthesize information from existing research and programmatic experiences that address family planning in young people in Jordan; (ii) examine which existing policies facilitate the provision of youth-friendly family planning services and which produce barriers, and; (iii) identify gaps in the research, policy and programmatic environments that could strengthen the provision of youth-friendly family planning services in Jordan and increase family planning use among young people.

Our findings will serve as a resource for policy-makers and programme managers in Jordan and elsewhere in the Middle East in order to inform programme design and strategy development by documenting the current evidence base, past programmatic experiences, and existing policy environment, while identifying key gaps and opportunities.

Methods

We undertook a literature review of published and unpublished research, programmatic reports, and policy papers that address family planning in young people in Jordan, and conducted focus group discussions with key informants in the fields of research, policy and practice related to young people.

Systematic literature review

Academic and peer-reviewed documents were obtained through structured searches on PubMed®, JSTOR, Embase, MEDLINE®, Web of Science, CINAHL and Google Scholar. Our search terms included combinations of the following terms: family planning, reproductive health, birth spacing, contraceptive, fertility, unmet need and Jordan. We did not include terms related to youth because we wanted to find all studies that had our age range of interest regardless of whether the authors identified youth as a focus, given the sensitivity of the topic.

We accessed non-academic literature using four approaches: (i) searches of grey literature databases (OpenGrey, PopLine, USAID Development Experience Clearing House and Knowledge4Health), (ii) Internet searches, (iii) website review and (iv) consultation with experts. Hard-copy only documents were obtained by personal contact with organizations active in family planning in Jordan.

Documents were included if they focused on young people aged 10–24 years and on family planning, were published after 2008 in Arabic or English, and were conducted in Jordan. The year 2008 was selected as the cut-off to ensure current contextual relevance. Two researchers screened and reviewed each record for eligibility. Consensus was reached to identify a final list of relevant documents.

Focus group discussions

Four focus group discussions were conducted with key informants representing 18 organizations between August and September 2018. Key informants were identified through consultation with local experts and snowball sampling. Selection criteria for participation was based on an individual’s expertise in the topic and/or experience working on family planning- or youth-related issues. The following organizations were represented: Ministry of Education, Ministry of Youth, National Council for Family Affairs, National Committee for Women’s Affairs, Ministry of Health, Higher Population Council, Higher Health Council, United Nations High Commissioner for Refugees (UNHCR), United Nations Population Fund (UNFPA), United States Agency for International Development (USAID), Institute for Family Health, Royal Health Awareness Society, Jordanian Association for Family Planning and Protection, Jordanian Communication, Advocacy and Policy Project, Health Service Delivery Project, Women Helping Women, Jordan Hashemite Charity Organization, and National Women’s Comprehensive Health Centre. Discussion centred on past programmatic experience, existing policies, barriers and challenges to providing services for young people, and recommendations to strengthen existing policies and programmes.

Data analysis

The social ecological model was used as a guiding framework for this analysis (11). Data from the literature review were abstracted and synthesized as being either directly pertinent to youth, indirectly relevant to youth (i.e. youth were included as part of the overall study population, but not considered a specific target population), or applicable to the supportive environment, which included peers, family, school, community, and the service delivery, policy, and legal environments. For the analysis of qualitative data from the focus group discussions, the discussions were recorded, transcribed and thematically coded by two coders. Data were coded according to a priori themes based on the focus group discussion guide at the different levels of the ecological model (individual, family/community, service delivery and policy levels). The coders then inductively examined each level for emergent subthemes.

Ethical considerations

This study was approved by the institutional review boards of Harvard T.H. Chan School of Public Health (approval number: 18-0427) and University of Jordan School of Nursing.

Results

Literature review

We identified 1049 records, of which 37 documents were included as shown in the flow chart (Figure 1). Fourteen of the 37 documents were in peer-reviewed journals and 23 were retrieved from the grey literature (Table 1, available online at: ….). Fifteen documents specifically focused on young people, 16 included young people within the overall study population, programme or policy, and 15 documents targeted other levels of the ecological model in ways that were relevant to young people. Based on ecological level, the themes derived from the literature review include knowledge, attitudes and practices related to family planning in young people within a social context, the health service delivery environment and the policy landscape. Box 1 gives a summary of the key findings and recommendations from the literature review to improve family planning programming targeting young people in Jordan.

Family planning: knowledge, attitudes and practices

Most of the research related to the family planning knowledge, attitudes and practices of young people in Jordan comes from secondary analysis of existing datasets (i.e. the Jordan Population and Family Health Surveys), relatively small project-based surveys and qualitative data from focus group discussions that are integrated in service delivery programmes. Few studies include unmarried young people and refugee young people outside of camps.

Jordanian, Syrian and Iraqi young people living in Jordan have limited knowledge of contraceptives (5,18,48), especially younger adolescents. In one study, nearly half of the women aged 15–19 years and 15.9% of women between 20 and 24 years did not know if modern or traditional family planning methods, such as withdrawal or periodic abstinence, were more effective (5). A study in Syrian refugees and two studies in Iraqi refugees found that knowledge of specific methods of family planning was almost non-existent among the young people in both populations (2,18,48).

Misinformation and concerns over negative side-effects of using family planning are especially prominent among younger women. Married women between 15 and 24 years reported that concern about future fertility was one of the main reasons for not using a method (5,21,42). Similar concerns have been found among young Iraqi and Syrian refugees in Jordan (48,23).

Contraceptive use in young people in Jordan is low. Analysis of data from the 2012 Jordan Population and Family Health Survey found that 72.5% of married adolescents between 15 and 19 years were not using contraception (21). Unmet need for family planning was high; of the 40% of married adolescent girls who did not want a child in the next 2 years, only 35.2% were using a contraceptive (21). Pills and the lactational amenorrhoea method were the most commonly used modern methods among adolescent girls aged 15–19 years (11.4% and 4.1% of users, respectively). Half of all users in this age group were using a traditional method (21). Use of family planning was lower in married adolescents than older young people; 18.3% of women between 15 and 19 years used contraception compared with 40.1% of women aged 20–24 years (5). One study found that 6.5% of married Iraqi adolescents living in Amman between 15 and 24 years were using a method of contraception (2). Many young people indicated that social pressure to begin childbearing immediately after marriage is one of their main reasons for not using family planning (5,42).

Social expectations limit the role of men in family planning. One survey found that 70% of women aged 15–19 years had not discussed family planning with their husband in the previous 6 months compared with 50.2% of women aged 20–24 years (5). In addition, cultural values and shame limit the degree to which men participate in decisions on reproductive health (18). Despite the restrictive gender norms, many unmarried Jordanian and Syrian young women want their partners involved in family planning, and some young men believe that discussing family planning between partners can strengthen marital relationships (4,18,40).

Other women, television, community events and radio are common sources of family planning information for young Jordanian women (5,40). While many adolescents use the Internet as a primary source of information, they do not think that online sources, including social media, are trustworthy (5,40). Unmarried Iraqi boys and girls aged 15–19 years said they would first approach their mother (for girls) or father (for boys) if they had a question about their reproductive health before turning to other sources (2).

In general, young people in Jordan have limited information on where to obtain family planning services and are concerned over the quality of care. According to data from the 2012 Jordan Population and Family Health Survey, most adolescent girls aged 15–19 years obtained family planning services from the private sector (38%) or pharmacy (32%) (21). A study conducted in Jordanian adolescents aged 12–18 years found that most of them did not know where to obtain family planning services or they believed that such services were only available for pregnant women (40). Syrian refugees living in camps also had limited knowledge about family planning services available for young people (23). Young people expressed concerns over privacy and confidentiality because of strict social norms governing the sexual behaviour of adolescents. In Zaatri camp, young Syrian women spoke about embarrassment in asking for condoms and feared being overheard by men (23). Jordanian young people are concerned about long waiting times, poorly staffed clinics and poor quality of care. They believe that providers do not take them seriously, do not know what information they need and view their questions as inappropriate (40). A study that included urban Syrian refugees between 12 and 24 years found that poor treatment by health care workers was one of the biggest disincentives to seeking reproductive health services (16).

Health service delivery environment

Little information is available on the availability of family planning services for young people. While a few facility-based assessments included data on aspects of service delivery pertinent to young people, this research did not have a specific focus on service delivery to young people. The Ministry of Health is piloting youth-oriented services in some women and child health centres, but implementation is not systematic, and the criteria for youth-friendly are still undefined (13). Reproductive health services provided in schools are limited to medical examinations, referrals and awareness-raising campaigns (13). Results from a health facility assessment in Zaatri and Irbid camps found that in Zaatri camp, health facilities were open and services were said to be available to adolescent females, while in Irbid, unmarried women could attend clinics but they would not be provided with contraceptives (23).

A few studies have assessed the quality of family planning services offered to young people in Jordan. An evaluation of family planning counselling at selected public and private clinics noted that many government-run facilities lacked private rooms to offer confidential services (49). Other studies found widespread misconceptions among health professionals about the side-effects of family planning methods used by young people (50). A study of private-sector providers in Jordan found that poor knowledge about the use of combined oral contraceptives by young people negatively influenced prescribing practices, especially among male providers (39).

Policy landscape

Several policy documents discussed family planning and reproductive health of young people in Jordan. The national reproductive health policy refers to young people as a cross-cutting priority and seeks to raise young people’s awareness of services and policies on reproductive health (1); however, the policy lacks specific indicators and age-disaggregated data (13). The national youth strategy from 2005 to 2009 focused on improving reproductive health services for young people, especially through information dissemination, premarital medical examination and the provision of youth-friendly services (47). A more recent youth strategy has not been approved, but is currently under development for 2018–2025 (13). A 2008 assessment that focused on the reproductive health policy environment in Jordan highlighted concerns about: legal and regulatory restrictions on what family planning services can be provided to young people; inadequate provider training on how to counsel youth; limited availability of family planning methods; and lack of routine research and data pertaining to young people (41).

Many of the same policy constraints affecting Jordanian young people also apply to young refugees; however, some issues are unique to refugees. A study in 2016 among Syrian refugees in urban areas found that young people between 12 and 24 years reported that a requirement to have an identification card substantially limited their ability to access reproductive health services (16) because most Syrian refugees are still unregistered in Jordan. Syrian refugees are also required to have a health services card to access services at Ministry of Health facilities. In late 2015, the Ministry of Health reduced the fee to obtain a health services card for registered Syrian refugees over 12 years from 30 to 5 Jordanian dinars (equivalent to about US$ 42 and US$ 7, respectively) (17). Recent changes in the policy on out-of-pocket payments for health services by refugees have led to confusion and reduced service utilization. Before 2014, registered Syrian refugees were provided with free primary health care at Ministry of Health facilities, including family planning; however, a policy change required that Syrians pay the same rates as uninsured Jordanians. Although family planning services are exempted from charge for uninsured Jordanians, the policy is inconsistently applied to Syrian refugees (17).

Focus group discussions

Analysis of the focus group discussions revealed three key themes: (i) a lack of youth-friendly services increases barriers to health services at the individual level, (ii) integration of services may improve social acceptability of family planning services and (iii) policy changes to make services more accessible for youth as well as the consistent implementation of policies are needed.

Theme 1: lack of youth-friendly services

<body1>During focus group discussions, stakeholders emphasized that family planning for young people is a priority, especially to support married adolescents in delaying and spacing births. Stakeholders also agreed that the existing environment for delivery of reproductive health services is not adequately youth-friendly. A participant from a nongovernmental organization indicated that in recent years there had been a shift away from the provision of youth-friendly services and identifying young people as specific target population for reproductive health services at the policy level: “Ten years ago, there was a ‘youth sector’ that is not there anymore, and part of its [role] was to train health workers in providing youth friendly services.” A Jordanian government official mentioned that the lack of a youth-friendly environment for delivery of services led to low utilization of health services by young people: “When youth want to go to health centres to acquire information related to reproductive health, they shy away from asking due to the fact that we don’t have a friendly environment [for youth] within health centres, this could be a priority… for youth to feel more comfortable”. Another Jordanian government official mentioned that the existing environment for delivery of services created even greater challenges for young men who wanted to obtain reproductive health services: “Even though female youth are shy to go…we only see female youth attending maternity and family planning centres. Male youth are even less willing to attend these centres”.

Theme 2: integration of services

Several participants mentioned that the strong donor-driven emphasis on family planning had caused communities to equate family planning with a foreign agenda. For example, a representative from a United Nations agency mentioned that, “Unfortunately, when we say family planning they attack us on religious basis and say that there are external agendas being forced upon us”. Another participant representing an international donor agency added that, “[family planning programmes] first appeared under the name of birth limitation, and due to social and cultural customs, they have been doubted, refused, and looked at as foreign policies”. Participants suggested that beginning with less controversial reproductive health topics, such as women’s perinatal physical and mental health, before including more sensitive topics such as family planning, may be a better strategy than focusing on family planning alone, especially to build acceptance of programmes targeting younger adolescents. However, a government representative mentioned, “we [should] start with 15 years olds about sexual education, psychological health, family planning, looking after women’s health even before marriage, and the same for males… It all must be in line with each other; you cannot focus on one topic and skip the other because people will attack the project… especially in rural areas”

In order to make family planning services more acceptable to communities, several participants described past success in integrating family planning into other programmes targeting young people. A participant from a local nongovernmental organization indicated that including reproductive health information into a life-skills programme made parents more supportive of the content: “We were afraid that parents wouldn’t allow their kids to come. Actually, it was the opposite. Parents were happy that someone was telling the truth to their children”. Participants also emphasized the importance of compulsory sexual education at the university level and integrating family planning into premarital counselling and preconception care; however, one nongovernmental organization participant mentioned that, “it’s [not] a very optimistic environment for sex education, and focusing on extracurricular activities may be a better strategy to reach more young people before compulsory programmes can be established”. Efforts to engage parents and build their capacity in discussing reproductive health information with their children was also discussed as a priority, given the cultural importance of parent–child relationships. A nongovernmental organization participant mentioned that, “mothers avoid answering their children’s questions as children or teenagers,” and there was agreement by participants that engaging adult figures in reproductive health topics was critical to overcoming the shame associated with reproductive health. As a representative from the Ministry of Youth said, “we need to build the capacity of parents, schools, teachers, and counsellors”.

Theme 3: policy change and consistent implementation

Stakeholders identified several policy-related challenges that make access to family planning services more difficult for young people. A government official mentioned that, “there are laws and regulations…that forbid young people between the ages of 10 to 24 from accessing such information and services if not accompanied by a parent”. Furthermore, participants from nongovernmental organization indicted that an existing policy that prohibits pregnant women from accessing reproductive services without a marriage licence is problematic for women married outside the formal legal system. This situation is most common among refugees and adolescent girls, and results in these women becoming pregnant at an early age and not receiving adequate maternal care. In addition, the confusion over the fee structure for reproductive health services at government facilities for Syrian refugees was identified as an important barrier. In addition, focus group participants indicated that there was currently an ongoing debate over another policy change to the fees charged for Syrian refugees accessing health services in the public sector.

Several policy-related opportunities to make services more youth-friendly were identified by focus group participants. One participant indicated that while the new reproductive health policy for young people is believed to include criteria for youth-friendly services, it had not yet been adopted. Furthermore, a national-level monitoring and evaluation plan needs to be implemented at the same time to ensure that the services are being offered according to agreed standards and that their delivery is sustained. A participant from the government mentioned that while the recently-drafted, youth-friendly service guidelines are expected to be adopted, “Until now, we don’t have any national standards related to a youth-friendly health environment...and we need support from a strong national body… to sustain [them]”. Participants also emphasized the need for a strong, government-wide body to coordinate activities related to young people across sectors to ensure a unified approach and to maximize impact. While participants praised current efforts to build a platform to document, collect and disseminate past experiences and evidence from research and programmes that target young people in Jordan, they indicated that such efforts were still just starting.

Discussion

The purpose of our review was to consolidate and synthesize the results and lessons learnt from research, programmes and policies targeting family planning in young people in Jordan at different ecological levels (individual, family/community, service delivery and policy levels). Our results highlight several key lessons learnt and opportunities for interventions on family planning for young people in Jordan at the individual, service delivery and policy levels. In addition, we identified several important research gaps on family planning in young people in Jordan that, if filled, could improve future, evidence-based interventions. A summary of these gaps is given in Box 2.

The results of our literature review and focus group discussions emphasize that young people in Jordan face many barriers to accessing reproductive health and family planning information and services. At the individual level, despite ongoing efforts, misinformation about family planning is widespread among young people and utilization of family planning services remains low. Furthermore, young people do not trust existing sources of information. The conservative social environment tends to cause young people to feel ashamed of accessing information related to reproductive health or family planning, so they have few resources they can rely on. To date, both programming and research focused on the unique needs of young people in Jordan have been limited. In particular, little information on the sexual behaviour of unmarried young people, especially young men, means that they are often overlooked in family planning programmes and policies, as the results of our literature review and focus group discussions indicate. As most existing research is based on relatively small sample sizes, larger studies that focus specifically on the reproductive health needs and behaviour of young people, including unmarried young people are needed to improve the evidence base on the family planning and reproductive health services needed by young people in Jordan. With changing demographics and normative shifts, more young people may engage in premarital sexual activity in the future, thus emphasizing the need for research on the reproductive health needs and behaviour of young people. Recent trends in other Arab countries suggest that increases in the age of marriage may be coupled with increases in premarital sexual activity, although data are limited (52). Increased attention should be also paid to understanding and meeting the needs of Jordan’s most vulnerable young populations, including urban refugees and married adolescents, especially as these populations continue to grow. Research focused on these populations may be of regional significance and help other countries with large refugee populations to better serve young people.

At the service delivery level, data from the focus group discussions emphasized the need for reproductive health and family planning services to be more youth-friendly. However, the literature review provided very limited information on how young people interact with the service delivery environment, and few specific initiatives to address the needs of young people exist. Both the literature review and the focus group discussions highlighted that the gender-related social norms that limit male involvement in reproductive health and family planning issues, and the fact that reproductive health and family planning services are typically provided at maternity and family planning centres, combine to exclude young men from using such services. As suggested in the focus group discussions, in order to ensure that any expanded implementation of youth-friendly services adequately meets the needs of young people, more research is needed to: understand how young people themselves envision a youth-friendly service delivery environment; identify gaps in current services and how they are organized; and explore supply-side barriers to providing high-quality services for young people.

At the policy level, our results highlight the need for improved policies to better support the consistent provision of good-quality youth-friendly reproductive health and family planning services. Often, not only is there inconsistency in what reproductive health and family planning services are available to young people and under what conditions, but consistent awareness is lacking of what policies exist for young people. This is because our focus group participants were inconsistent in the policies that they described pertaining to parental permission and marriage requirements, and such policies were not discussed in the literature. Such inconsistency may contribute to the low rates of utilization of reproductive health and family planning services by young people in an environment where they are already apprehensive about seeking care. Changes in policy that affect service availability for Syrian refugees discussed in the literature and in the focus group discussions may be particularly hard on already vulnerable populations of married adolescents, especially as this population is thought to have the highest rate of child marriage.

To better support policies, improved monitoring and evaluation of services offered at facilities is needed to ensure consistent implementation of standards. In addition, a more robust, nationwide, data collection platform is needed that includes age-disaggregated indicators relevant to the specific reproductive health needs of young people. The ongoing development of a national reproductive health strategy for young people signals important progress; however, the exclusion of the sexual and reproductive health of young people from previous national policy documents appears to reflect Jordan’s conservative cultural climate, and work in this area will likely continue to be contentious.

The results of our review should be considered in light of a few limitations. While every attempt was made to be exhaustive in the literature review, some studies or documents may have been unintentionally excluded in the analysis because they did not appear in the search results, or did not appear to have a youth-specific focus. This may be especially true with the grey literature search, as many organizations’ reports are unpublished. Furthermore, while the participants included in the focus group discussions represented a wide range of stakeholders, not all organizations were represented. Furthermore, as participants were representing their organizations, discussions may have been constrained as they may not have wanted to appear too critical of governmental policy or their organization’s challenges. Nevertheless, the participants openly discussed critical areas for improvement within policies and programmes, which may indicate the reliability of the data. We were not able to draw any conclusions about differences in trends according to stakeholder type.

Our study provides a consolidated picture of the state of research, programmes and policies targeting family planning in Jordan for young people between 10 and 24 years since 2008. Future programmes should build on past evidence in order scale up promising interventions while exploring new areas for research and programmes based on local needs. Results from our study may be applicable across the Middle East, as many other countries are dealing with similar populations because of displacement, a conservative programmatic environment and policy-related challenges.

Funding: This work is part of the Sexual and Reproductive Health Research Programme (project number W 08.560.012), which is financed by the WOTRO Science for Global Development of the Netherlands Organisation for Scientific Research.

Competing interests: None declared.

References

  1. Higher Population Council. National Reproductive Health/Family Planning Strategy 2013–2017. Amman: Higher Population Council; 2013. (http://www.hpc.org.jo/sites/default/files/EN-National%20FP-RH%20Strategy%202013-2017.pdf, accessed 29 February 2020).
  2. Connelly M. Baseline study: Documenting knowledge attitudes and practices of Iraqi refugees and the status of family planning services in UNHCRs operations in Amman, Jordan. New York, NY: UNHCR, Women’s Refugee Commission; 2011. (https://www.unhcr.org/protection/health/4e8c0c419/baseline-study-documenting-knowledge-attitudes-practices-iraqi-refugees.html, accessed 29 February 2020).
  3. DeJong J, El-Khoury G. Reproductive health of Arab young people. BMJ. 2006;333(7573):849–51. https://doi.org/10.1136/bmj.38993.460197.68
  4. Hikmat R. A study on child marriage in Jordan. Amman: Higher Population Council; 2017 (http://www.hpc.org.jo/sites/default/files/HPC%20Child%20Marriage%20Eng.pdf, accessed 29 February 2020).
  5. Jordan Communication Advocacy and Policy Activity. Knowledge attitudes and practices toward family planning and reproductive health among married women of reproductive age in selected districts in Jordan. Amman: US Agency for International Development; 2015 (https://jordankmportal.com/resources/knowledge-attitudes-and-practices-toward-family-planning-and-reproductive-health-among-married-women-of-reproductive-age-in-selected-districts-in-jordan, accessed 29 February 2020).
  6. Samari G. Syrian refugee women’s health in Lebanon, Turkey, and Jordan and recommendations for improved practice. World Med Health Policy. 2017;9(2):255–74. https://doi.org/10.1002/wmh3.231
  7. Doocy S, Lyles E, Roberton T, Akhu-Zaheya L, Oweis A, Burnham G. Prevalence and care-seeking for chronic diseases among Syrian refugees in Jordan. BMC Public Health. 2015;15(1):1097. https://doi.org/10.1186/s12889-015-2429-3
  8. Health access and utilization survey among non-camp refugees in Jordan final report. Geneva: UNHCR – The UN Refugee Agency; 2015 (https://data2.unhcr.org/en/documents/download/68539, accessed 29 February 2020).
  9. Where we work. United Nations Relief and Works Agency for Palestine Refugees (UNRWA) [webpage] (https://www.unrwa.org/where-we-work/jordan, accessed 29 February 2020).
  10. UNHCR Fact sheet. Jordan – February 2018. Geneva: UNHCR – The UN Refugee Agency; 2018 (https://data2.unhcr.org/en/documents/download/62241, accessed 29 February 2020).
  11. McLeroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Educ Behav. 1988;15(4):351–77. https://doi.org/10.1177/109019818801500401
  12. Akour A, Bardaweel S, Awwad O, Al-Muhaissen S, Hussein R. Impact of a pharmacist-provided information booklet on knowledge and attitudes towards oral contraception among Jordanian women: an interventional study. Eur J Contracept Reprod Health Care. 2017;22(6):459–64. https://doi.org/10.1080/13625187.2017.1412425
  13. OECD Development Centre. Youth well-being policy review of Jordan. Paris: European Union/Organisation for Economic Co-operation and Development Youth Inclusion Project; 2018 (https://data2.unhcr.org/en/documents/download/69257, accessed 29 February 2020).
  14. Clark CJ, Spencer RA, Khalaf IA, Gilbert L, El-Bassel N, Silverman JG, et al. The influence of family violence and child marriage on unmet need for family planning in Jordan. J Fam Plann Reprod Health Care. 2016;43(2):105–12. https://doi.org/10.1136/jfprhc-2014-101122
  15. Spindler E, Bitar N, Solo J, Menstell E, Shattuck D. Jordan’s 2002 to 2012 fertility stall and parallel USAID investments in family planning: lessons from an assessment to guide future programming. Glob Health Sci Pract 2017;5(4):617–29. https://doi.org/10.9745/GHSP-D-17-00191
  16. Reproductive health services for Syrians living outside of camps in Jordan. Amman: Higher Population Council; 2016 (http://www.hpc.org.jo/sites/default/files/Reproductive%20Health%20Services%20for%20Syrians%20Living%20Outside%20Camps%20in%20Jordan.pdf, accessed 28 March 2020).
  17. Jordan Communication Advocacy and Policy Activity. Family planning among Syrian refugees living in Jordan. Amman: US Agency for International Development; 2016 (https://jordankmportal.com/resources/family-planning-among-syrian-refugees-in-jordan, accessed 29 February 2020).
  18. Jordan Communication Advocacy and Policy Activity. Exploring gender norms and family planning in Jordan: a qualitative study. Amman: US Agency for International Development; 2016 (https://jordankmportal.com/resources/exploring-gender-norms-and-family-planning-in-jordan, accessed 29 February 2020).
  19. Jordan Evidence-Based Medicine/Reproductive Health Group. The best evidence on family planning methods and practices. Jordan Pharmacists Association; 2015 (http://pop.jpa.org.jo/news/best-evidence-family-planning-methods-and-practices, accessed 7 November 2018).
  20. West L, Isotta-Day H, Ba-Break M, Morgan R.Factors in use of family planning services by Syrian women in a refugee camp in Jordan. J Fam Plann Reprod Health Care. 2016;73(2):96–102. https://doi.org/10.1136/jfprhc-2014-101026
  21. Adolescent contraceptive use: data from the Jordan population and family health survey (JPFHS), 2012. Geneva: World Health Organization; 2016 (https://www.rhsupplies.org/uploads/tx_rhscpublications/Hashemite_Kingfom_of_Jordan_-_Adolescent_contraceptive_use__data_from_2012_.pdf, accessed 28 March 2020).
  22. Underwood CR, Kamhawi SS. Friday sermons, family planning and gender equity attitudes and actions: Evidence from Jordan. J Public Health. 2015;37(4):641–8. https://doi.org/10.1093/pubmed/fdu090
  23. Krause S, Williams H, Onyango MA, Sami S, Doedens W, Giga N, et al. Reproductive health services for Syrian refugees in Zaatri refugee camp and Irbid City Jordan: an evaluation of the minimum initial service package. Confl Health. 2015;9(Suppl 1):S4. https://doi.org/10.1186/1752-1505-9-S1-S4
  24. Kamhawi S, Underwood C, Murad H, Jabre B. Client-centered counseling improves client satisfaction with family planning visits: evidence from Irbid, Jordan. Glob Health Sci Pract. 2013;1(2):180–92. https://doi.org/10.9745/GHSP-D-12-00051
  25. O’Hara K, Tsai L. C, Carlson CE, Haidar YM. Experiences of intimate-partner violence and contraception use among ever-married women in Jordan. East Mediterr Health J. 2013;19(10):876–82.
  26. Underwood C, Kamhawi S, Nofal A. Religious leaders gain ground in the Jordanian family planning movement. Int J Gynecol Obstet. 2013;123(Suppl 1):e33–7. https://doi.org/10.1016/j.ijgo.2013.07.006
  27. Cetorelli V, Leone T. Is fertility stalling in Jordan? Demogr Res. 2012;26:293–318. https://doi.org/10.4054/DemRes.2012.26.13
  28. Hamza SM. Long acting hormonal contraceptives: without them, Jordan will not meet the population development goals. Int J Gynecol Obstet. 2012;119(S3):S364. https://doi.org/10.1016/S0020-7292(12)60725-5
  29. Jordan Health Communication Partnership. Evaluation of the Arab women speak out (AWSO) initiative – 2nd Tier (Phase I) – in Irbid Governorate, Jordan, 2011. Baltimore, MD: Johns Hopkins Bloomberg School of Public Health Center for Communication Programs, JHUCCP, 2012.
  30. Jordan Health Communication Partnership. Evaluation of the Arab women speak out (AWSO) initiative – 2nd Tier (Phase II) – in Irbid Governorate, Jordan, 2012. Baltimore, MD: Johns Hopkins Bloomberg School of Public Health Center for Communication Programs; 2012.
  31. Jordan Health Communication Partnership. Evaluation of the “hayati ahla” film in the Civil Status and Passports Department (CSPD) Offices Jordan 2012. Baltimore, MD: Johns Hopkins Bloomberg School of Public Health Center for Communication Programs; 2012.
  32. Lilleston P. Planning for life phase 2: evaluation report. Baltimore, MD: International Youth Foundation; 2012 (https://pdf.usaid.gov/pdf_docs/PDACU513.pdf, accessed 29 February 2020).
  33. Shakhatreh FMN. Family planning in women of childbearing age in disadvantaged south Jordan. Eur J Contracept Reprod Health Care. 2012;17(Suppl 1): S72. https://doi.org/10.3109/13625187.2012.673963
  34. Jordan Health Communication Partnership. Evaluation of the consult and choose initiative in Zarqa Governorate, Jordan – 2011. Baltimore, MD: Johns Hopkins Bloomberg School of Public Health Center for Communication Programs; 2011.
  35. Jordan Health Communication Partnership. Evaluation of the Arab women speak out (AWSO) initiative in Irbid Governorate. Baltimore, MD: Johns Hopkins Bloomberg School of Public Health Center for Communication Programs; 2011.
  36. Jordan Health Communication Partnership. Evaluation of the consult and choose initiative in Irbid Governorate, Jordan – 2011. Baltimore, MD: Johns Hopkins Bloomberg School of Public Health Center for Communication Programs; 2011.
  37. Jordan Health Communication Partnership. Evaluation of the Arab women speak out (AWSO) initiative in Zarqa Governorate, Jordan, 2009–2010. Baltimore, MD: Johns Hopkins Bloomberg School of Public Health Center for Communication Programs; 2011.
  38. Jordan Health Communication Partnership. Evaluation of the “mabrouk II: you’ve become a mother and a father” initiative. Baltimore, MD: Johns Hopkins Bloomberg School of Public Health Center for Communication Programs; 2010.
  39. Al-Awaki N. Private sector project for women’s health evaluation report: evidence-based medicine (EBM) for family planning program. Amman: US Agency for International Development; 2010 (https://www.shopsplusproject.org/sites/default/files/resources/12%20PSP-Jordan%20Evaluation%20Report%2C%20EBM%20Approach%2C%20Dec.%2020https://doi.org/10.pdf, accessed 29 February 2020).
  40. Khalaf I, Moghli FA, Froelicher ES. youth‐friendly reproductive health services in Jordan from the perspective of the youth: a descriptive qualitative study. Scand J Caring Sci. 2010;24(2):321–31. https://doi.org/10.1111/j.1471-6712.2009.00723.x
  41. Abel E. Jordan’s reproductive health policy environment score: measuring the degree to which the policy environment in Jordan supports effective policies and programs for reproductive health. Amman: US Agency for International Development; 2009 (http://www.healthpolicyplus.com/archive/ns/pubs/hpi/834_1_Jordan_PES_2008_FINAL_acc.pdf, accessed 29 February 2020).
  42. Health Communication Partnership. Motivating healthy timing and spacing of pregnancies – lessons from the field. Baltimore, MD: Johns Hopkins Bloomberg School of Public Health/ Center for Communication Programs; 2008. (https://pdfs.semanticscholar.org/f6e5/300b1a9f764fc276789c53d69750a648aa82.pdf; accessed 6 April 2020).
  43. Jurdi R. Unintended pregnancies remain high in Jordan. Washington, DC: Population Reference Bureau; 2008 (https://u.demog.berkeley.edu/~jrw/Biblio/Eprints/PRB/files/MENAWorkingPaper1.pdf, accessed 28 March 2020).
  44. Khalaf IA, Abu-Moghli F, Callister LC, Rasheed R. Jordanian women’s experiences with the use of traditional family planning. Health Care Women Int. 2008;29(5):527–38. https://doi.org/10.1080/07399330801949632
  45. DeJong J, Shepard B, Roudi-Fahimi F, Ashford L. Young people’s sexual and reproductive health in the Middle East and North Africa. Washington, DC: Population Reference Bureau; 2007 (https://www.researchgate.net/publication/237641810_Young_people’s_sexual_and_reproductive_health_in_the_Middle_East_and_North_Africa, accessed 28 March 2020).
  46. Committee on the Rights of the Child. Concluding observations on the consolidated fourth and fifth periodic reports of Jordan. New York, NY: United Nations Convention of on the Rights of the Child; 2014 (CRC/C/JOR/CO/4-5; https://undocs.org/en/CRC/C/JOR/CO/4-5, accessed 29 February 2020).
  47. Policies, legislation and strategies related to family planning in Jordan: review and recommendations. Amman: Jordan Communication Advocacy and Policy; 2015. (http://www.tawasol-jo.org/sites/default/files/policies_legistlations_and_stratgies_related_to_family_planning_in_jordan_review_and_recommendations.pdf, accessed 17 February 2019).
  48. Sinha R, Goyal N, Sirois A, Valeeva N, Doocy S. Family planning in displaced populations: an unmet need among Iraqis in Amman, Jordan. Am J Disaster Med. 2008;3(5):295–300.
  49. Okour AM, Saadeh RA, Zaqoul M. Evaluation of family planning counselling in north Jordan. Sultan Qaboos Univ Med J. 2017;17(4):e436–43. https://doi.org/10.18295/squmj.2017.17.04.010
  50. El-Khoury MT, Rebecca; Chatterji, Minki; Choi, Soon Kyu. Effectiveness of evidence-based medicine on knowledge, attitudes, and practices of family planning providers: a randomized experiment in Jordan. BMC Health Serv Res. 2015;15(1):449. https://doi.org/10.1186/s12913-015-1101-z
  51. Department of Statistics [Jordan] and ICF International. Jordan Population and Family Health Survey 2012. Calverton (MD): Department of Statistics and ICF International; 2013 (https://dhsprogram.com/pubs/pdf/FR282/FR282.pdf, accessed 29 February 2020).
  52. Obermeyer CM, Bott S, Sassine AJ. Arab adolescents: health, gender, and social context. J Adolesc Health. 2015;57(3):252–62. https://doi.org/10.1016/j.jadohealth.2015.01.002