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The World At Large
The Forgotten Few: The Social Context of Ageing and Alzheimer’s Disease in Jordan

Introduction

According to the UN (2009) 5.5% of Jordan's current 6 million inhabitants are over the age of 60, and this is expected to increase dramatically by 2050. We estimate that there are currently 16,500 people with clinically significant Alzheimer's disease and this will increase over the next forty years during which time the availability of younger people to care for them decreases. This demographic revolution has important implications socially, politically, culturally and in terms of the demands made upon formal (and informal) social institutions that provide care and support for older people. The care of older people with dementia is particularly current given the various social changes in Jordan that are impacting on the ability of the family and religious leaders to meet the needs of individuals with complex needs, and challenging long-established views regarding when and how to engage others in private matters (Sullivan et al., 2010).

The purpose of this paper is to introduce some of the implications of an ageing population in Jordan, including attention to issues relevant to the provision of social work, medical and nursing services. In doing so, the paper draws attention to Alzheimer’s disease and related dementias as a key consideration for policy and service development. The paper also introduces issues pertaining to health and social inequalities in the Jordanian context and their impact on healthy ageing.

The Ageing Population in Jordan

Older people in Jordan will continue to grow at a rate of 4.1%, from 220,000 to half million by 2030 and to 1.25 million by 2050 (see Figures 1 & 2). The dependency ratio for older people over 64 years of age is expected to increase from 6 to 16. The child dependency ratio is expected to decline from 60 to 34 in a declining fertility scenario (Mahasneh, 2000).


Figure 1
Figure 1


Figure 2
Figure 2

(Source: PRB WPDS, 2010)


Table 1 provides a description of family status among all older people (Masarweh, 2010). There is a striking difference between the number of married men versus the number of married women. According to the National Strategy for Senior Citizens (2008) and Mahasneh (2000), it was reported that 50.7% of all older people are illiterate and 30.2% have less than high school education. It is also reported that the majority of older people, 79.7%, live in urban areas.
Table 1
 Family Status  Males  Females
 Married 92.6%     49.4% 
Widowed   6.1%  47.0% 
 Single   0.7%    2.2%

The National Jordanian Strategy for Senior Citizens

Published in 2008, the National Council for Family Affairs (NCFA), in cooperation with the Ministries of Health and Social Development, the Jordanian Nursing Council, the World Health Organization (WHO), and experts in the field from the various Jordanian universities and non-governmental organizations, developed a comprehensive national strategy for senior citizens. This is considered to be the first document concerned with drafting policies for senior citizens to be presented to decision-makers.

The vision of the strategy was aimed at a society that improves the quality of life for its senior citizens, and ensures their ongoing and efficient participation in their communities. While its mission focused on enhancing the status of well-being at health, social, developmental, environmental and spiritual levels, recommendations were based on demographic changes particular to Jordan and by utilizing international standards (Hasna, 2010). The strategy directives focused on the following:

1. Senior citizens and development;
2. Health care;
3. A physical environment that enables senior citizens;
4. Social welfare;
5. Scientific studies, research and databases to inform decision-making; and
6. Legislative developments.

Health and Health Care in Jordan

In 2007 in Jordan, senior citizens were included in the civil health insurance program, however, to date, there are no specific services catering to the older age group within Ministry of Health services or mental health services. Therefore, older people usually receive care within the chronic diseases services of the public sector. There remains an urgent need to assess the unmet services for this age group
based on the following:

• Hypertension ranks as the most common chronic problem affecting 53% of all older people;
• 40% of all newly diagnosed cancer (all forms) is in older people;
• Cost of health care for individuals over 60 years of age and above was found to be about JD 599 million, or 74% of the total expenditure on curative services;
• Only a small portion of expenditure (26%) of health care spending was allocated to preventative services;
• Between 2000-2006 there were eighteen cases of suicide among senior citizens;
• Highest pattern of disabilities among older people (60 years of age and older) are physical/motor problems (43.2%);
• 16.1% of older people experience visual problems, 15.8% with speech and hearing problems, 10.5% with paralysis as a result of stroke, 3.7% with developmental disabilities, and 7.2% with other chronic diseases.
(Shishani, 2007)

The number of older people living with Alzheimer’s disease or other dementias is unavailable (Masarweh, 2010), and the number requiring long term care due to disability or illnesses is unknown (Shishani, 2007). According to some regional studies, however, the rates of dementia are varied. In Egypt, for example, 4.5% of older people have a diagnosis of dementia and 2.2% a diagnosis of Alzheimer’s disease. In the United Arab Emirates, 3.6% of older people have dementia and in Wadi Ara, 20.5%. Jordan’s circumstances closely resemble that of the region, so palpably the percentage with dementia will be more or less around what suggested in the other regions (Al Khateeb, 2009; Ghubash et al. 2004; Lindsay et al., 2003; Farrag et al., 1998).

According to Mahasneh (2000) common psycho-social problems among Jordan’s older people include relationship issues with family, lack of interest in social activities, loneliness, sleep disorders, anxiety and depression, and neglect and insufficient care. In this study, health and social care professionals also noted gender issues with men, more than women, reporting to have more health and psycho-social problems, to take more medication, to be living alone and needing assistance with activities of daily living, and to feeling unsafe. Older men also reported to be working (even if just part-time) more than women.

The number of older women living alone is actually significantly greater than men, and more women reported problems with anxiety and depression than men (Mahasneh, 2000). Attalah (1998) reported that older women experienced significantly more psycho-social problems than older men. According to Attalah (1998), the older a woman got, the lesser she agreed with members of her family and the more she feared loneliness. This may relate to Arab culture where, in general, the idea of a good, well behaved young woman is one who does not object family decisions made by men. However, age and marital status grant status, and for some, empower women to discuss their opinion without fear of stigma and promote their own independence (Al-Makhamreh, 2005 & 2008). This same study revealed that older women who chose who they married suffered less difficulties than those women whose husbands were chosen for them.

Given the range of health and social problems experienced by Jordan’s older population, Hasna (2010) has highlighted the need for multidisciplinary geriatric health services for older people rather than care being delivered solely within chronic disease and mental health clinics. The lack of training of health care providers in the field of geriatric medical sciences has been acknowledged, and the introduction of geriatric medicine as a specialization has been approved by the Jordanian Medical Council. Gerontology courses are typically not available in the Schools of Nursing, Social Work or Medicine. Following a WHO directive, however, Philadelphia University is now teaching a specialized course for nursing students in their senior fourth year of study, and there is an elective gerontology course at Al-Balqa Applied University. And more recently, the Board of Trustees at Philadelphia University approved the establishment of the new Centre for Ageing Studies in the Faculty of Nursing.

Family Caregivers

Family is still the most important unit in Jordanian society, and ageing parents and other relatives gain a high status within the family structure. Receiving care within the family is also a fundamental characteristic of both the culture and religion in Jordan. If any family member is sick or in need it will be a family matter, and therefore carers will most likely be one or more members of a family (Al-Makhamreh, 2005 & 2008). However, socio-economic changes are having an impact in Jordan as any other society. For example, children who would normally live close to their parents are now working abroad leaving some older people to manage on their own. Only recently have nursing homes been accepted by communities, and there are now 15 registered homes in Jordan, but not all working to full capacity. Dar-Aldhiyafa, for example, is the largest home (346 residents) and between 2006-2009 worked at full capacity, and is currently expanding their building to accommodate more residents.

Recently, informal discussions were held with family carers for relatives with dementia. The following findings were reported:

• Feelings of isolation, stigma, fatigue, loss, and guilt;
• More than 7 hours of care estimated per day;
• Family caregivers felt confrontational and frustrated at times, and strained and stressed at other times; and they felt that they had not yet adjusted socially and emotionally; and
• Positive aspects of care included companionship and personal fulfillment (Al-Makhamreh, 2010).

In Arab culture it is still typically expected that the eldest son will take care of his parents. However, care is actually provided by women, usually the son’s wife, or other female family members. Importantly, Jordanian society does not have sufficient awareness nor the resources to face some of the health and social care issues associated with population ageing (Al Khateeb, 2009).

Social Policy, Social Care and Home Care Services

Current social policy in Jordan contains laws, rules and instructions regarding civil and military retirement and social security. For example, social security pays a salary for men at age 60 and at age 50 for women. New legislation was formulated in 2005 to include support for older people, however, it was only meant to be for poor people based on the Charity or Zakat funds. In 2006, professionals at the first National Conference on Social Work advocated for organizing the work of supporting older people at home care institutions and day care clubs, but it is yet to be discussed at the national level.

Overall social care aims at supporting good quality service delivery to older people and their carers. In addition, it encourages older people to participate in social activities, works to prevent domestic violence and abuse, and raises society awareness towards the positive contribution that older people make to families and communities. Social care programmes also work to strengthen networking between services and institutions that care for older people.

There are 18 officially registered nursing homes and day care centers in Jordan. In 2009, Al-Khateeb conducted a study to examine some of these homes and day care centres. The study revealed that the Ministry of Social Development (MOSD) paid for all services and covered the expenses of some residents who could not afford to pay for their care. Some of these nursing homes and day centres are sponsored by nonprofit charity organizations with very limited financial recourses, and others are operated by the private sector.

The day care centers in Jordan consist of clubs where old age people can meet, socialize and enjoy entertainment. The health status of their members usually is very good. Most of these clubs are located in and around the city centers, which leaves some older people unable to access them. At the time of the study, there were 346 nursing home residents, most of them experiencing dementia but not diagnosed with an illness such as Alzheimer’s disease. There were also more female residents than male. Like the day care centers, nursing homes were mainly established in the larger cities.

Mahasneh’s study (2000) discussed the fact that older people usually rejected the idea of going to a nursing home. The few that accepted this level of care was necessary had severe physical disabilities and/or were neglected by their children. In addition, Mahasneh (2000) reported that those in nursing homes had higher levels of depression than older people living with their family. It is worth mentioning that all nursing home residents are not poor or displaced due to family problems. Residents in some of Jordan’s more prestigious homes are typically rich and have high care needs, and are placed there so families can take advantage of some of specialist services offered within these facilities.

Implications for Social Work, Medical and Nursing Practice

The priorities identified by the authors include localising gerontological/geriatric social work, medical and nursing knowledge, service development and multi-disciplinary practice for an ageing population in Jordan. As an understanding of the needs of older people in Jordan continues to develop, strategies that address high quality care and equal access to this care become paramount in our joint efforts. Thus, we argue that care at home and care by families is essential, and that outreach service development must target various supports to achieve this goal. In addition, service development must take into account how culture, religion and informal relationships shape the care that is provided. Finally, to ensure equity of access, services must benefit all people regardless of gender, wealth, disability and place of residence.

Other priorities include:

Geriatric/gerontology education and training – Joint education and training for social work, medical and nursing students, as well as practice learning within multi-disciplinary teams, must be developed at undergraduate and graduate levels. Ongoing professional development post-graduation is also required.

Research development – The new Centre for Ageing Studies at Philadelphia University aims to collect a rich data base on the size and needs of the older population. It is anticipated that this information will have important policy implications with respect to health and social care service delivery, as well further policy formulation to achieve well-being among Jordan’s older population. The capacity to conduct gerontological research also needs to be increased.

Public awareness – There remains an urgent need to increase public awareness by organizing national campaigns among all sectors (public and NGO) regarding the importance of the older age group, their needs and services required to meet them (decreasing economic burden and enhancing health status), and the promotion of their engagement in civic life.

Conclusion

Older people in Jordan represent an important and overlooked group that now requires strategic attention all at levels within society. Their human and civil rights demand that consideration be focused on improving their health and social circumstances to minimize burden on family and state care, reduce poverty and marginalization, improve participation in family and community life (including stigma campaigns), and address overall well-being. These efforts are required to feed into sustainable development in Jordan.



References

Al-Makhamreh S. (2005) Social work as an emerging profession in the Middle East: an ethnographic case study of Jordanian hospital social work. Unpublished PhD Thesis, University of Warwick, UK.

Al-Makhamreh S. and Lewadno-Hundt G. (2008) Researching ‘at home’ as an insider/outsider gender and culture in an ethnographic study of social work practice in an Arab society. Qualitative Social Work, 7(1): 9-23.

Al-Makahmreh S. (2010) The forgotten few: How can social work impact on the well- being of elderly people with dementia in Jordan? Presentation at Ageing and Alzheimer’s Disease Workshop, Philadelphia University, 3 October.

Al-Khateeb E. (2009) The study of dementia in Jordan. Presented to the 5th International Conference on Alzheimer’s Disease and Related Disordered in the Middle East. Limassol, Cyprus, 15-17 May.

Al-Kateeb E. (2010) A Study of Dementia in Jordan. Presentation at Ageing and Alzheimer’s Disease Workshop, Philadelphia University, 3 October.

Attalah K. (1998) The situation of elderly women in a changing Jordanian society. Unpublished MA Thesis, University of Jordan, Jordan.

Alzheimer’s Disease International (2009) World Alzheimer Report: The Global Economic Impact of Dementia: Executive Summary. London: ADI. Available at: http://www.alz.co.uk/research/files/WorldAlzheimerReport2010ExecutiveSummary.pdf [Accessed 22 October 2010]

Farrag A., Farwiz H.M., Khedr E.H., Mahfouz R.M. and Omran S.M. (1998) Prevalence of Alzheimer's disease and other dementing disorders: Assiut-Upper Egypt study. Dementia and and Geriatric Cognitive Disorders, 9(6), 323-328.

Ghubash R., El-Rufaie O., Zoubeidi T., Al-Shboul Q. and Sabri S.M. (2004) Profile of mental disorders among the elderly United Arab Emirates population: socio-demographic correlates. International Journal of Geriatric Psychiatry, 19(4), 344-351.

Hasna F. (2010) Policies, Services and Education for Older Age Group: A GAP Analysis. Presentation at Ageing and Alzheimer’s Disease Workshop, Philadelphia University, 3 October.

Lindsay A.F., Abdalla B., Freidland R.P., Waraska K., Korczyn A.D. and Baldwin C.T.( 2003) Identification of multiple loci for Alzheimer’s disease in a consanguineous Israeli-Arab community. Human Molecular Genetics, 12(4), 415-422.

Mahasneh S.M. (2000) Survey of the Health of the Elderly in Jordan. Medical Journal of Islamic Academy of Sciences, 13(1), 39-48.

Masarweh E. (2010) The Prospect of Elderly People in Jordan: 2010-2030 and Beyond. Presentation at Ageing and Alzheimer’s Disease Workshop, Philadelphia University, 3 October.

National Council for Family Affairs (2008) National Strategy for Senior Citizens. Available at:
http://www.ncfa.org.jo/Default.aspx?tabid=71&language=en-GB. [Accessed 7 January 2011]

Population Reference Bureau (2010) World Population Data Sheet. Washington: PRB.

Shishani K. (2007) Health and future needs for elderly people within the demographic transfer. Development and Population Journal, Special Edition 13, 57-68.

Sullivan M.P., Forrester D. and Al-Makhamreh S. (2010) What makes for effective trans-national social work collaboration? Reflections on an evaluation of a social work training workshop in Jordan. International Social Work, 53(2), 217-232.

United Nations (2009) World Population Ageing. New York: Department of Economic and Social Affairs.
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