EDUCATION IN JORDAN

Importance of integrating
a cultural module in the
community nursing curriculum
Noha Al-Shdayfat, Fadia Hasna, Mohammad Al-Smairan, Gillian Lewando-
Hundt, Tamador Shudayfat
Noha Al-Shdayfat, Assistant Professor, Faculty of Nursing, Al al-Bayt University; Fadia Hasna, Associate Professor, Faculty of
Health Sciences, American University of Madaba, Jordan; Mohammad Al-Smairan, Assistant Professor, Renewable Engineering
Department, Engineering Faculty, Al al-Bayt University; Gillian Lewando-Hundt, Professor of Social Sciences in Health and
Co-Director of the Institute of Health, University of Warwick, Coventry, England; Tamador Shudayfat, Lecturer, Department of
Community Health Nursing, Faculty of Nursing, Al al-Bayt University, Jordan

dr.nuhash@aabu.edu.jo

L ittle is known about the health status, health-seeking

behaviours, and current health service provision in the
northeastern region, or Badia, of Jordan. Badia is an
Arabic word used to describe the arid/semi-arid regions of
the Middle East, where the annual rainfall averages less than
200 mm (Al-Smairan, 2006). In 2006, a European Union
(EU)-funded project—The Bedouin Health Project—assessed
different aspects of Bedouin life in the Badia, with a focus on
health-service seeking and utilisation (Community Research
and Development Information Service (CORDIS), 2011).
This assessment helped policymakers to provide the semi-
nomadic Bedouin community with health and social services
specific to their health needs and that would improve their
quality of life. Moreover, on the basis of the evidence drawn
from the research findings, it provided health and social care
professionals the information necessary to help them improve
their services to this population.
ABSTRACT
Introduction: The Bedouin Health module was one of the proposed
interventions funded by the European Union in 2007–2008, with a focus on
health services and utilisation of these services for the Bedouin people in
the north of Jordan. Aim: This study aimed to evaluate the sustainability
of integrating this module into the community health nursing courses at
Al al-Bayt University, Jordan. Method: Two focus group discussions were
carried out with five faculty members and five students involved in the
implementation of the Bedouin Health module. Leading questions were
prepared for both groups. Results: Four main themes emerged across both
focus groups: self-expression, sustainability, acceptance, and motivation.
Conclusion: The findings of this study identify how crucial it is for nursing
students and faculty members to be culturally competent when practising
One of the most important findings of this research
project was that providers often lacked the necessary cul-
tural competence to care for the Bedouin community
(Hasna et al, 2010). Hence, nursing educators could use
the findings of this project to support the Bedouin Health
module, with the aim of increasing the cultural competence
of nursing care providers and nursing students, particularly
the universities that send their students to the Badia to
train. The intervention was initiated in public universities
in the northeastern Badia of Jordan, where the module
was integrated into the community health nursing courses
taught to the fourth-year nursing students. The Bedouin
Health module units were incorporated into the fourth-
year courses of the bachelor’s degree in nursing programme
at Al al-Bayt University, Mafraq, Jordan.
Background
Culturally sensitive health-care services are essential to pro-
mote the health of people living in remote areas, and the
sustainability of these services is crucial. Examples of cultur-
ally sensitive programmes using varied strategies have been
reported in different parts of the world. In Israel, Bedouin
girls who attained high school education were trained to be
liaison workers between maternal/child health service staff
and the Bedouin community in the Negev desert (Belmaker
et al, 2006). Similarly, in Italy, selected personnel from the
Gypsy/Roma/Traveller community were trained to be
liaison workers between their community members and
the health providers (Van Cleemput et al, 2010). A project
in Canada (Thompson Rivers University, 2010) aimed to
recruit and retain Aboriginal and non-Aboriginal nursing
© 2016 MA Healthcare Ltd

students and train them to deliver a culturally competent

community health care in the Bedouin community.
health service to the Aboriginal community.
The Bedouin people primarily reside in Arab countries,
KEY WORDS
and studies about this population group are limited. The
w Bedouin w community health nursing w Jordan w nursing students
Bedouin Health module project was the first of its kind
w focus groups
in Jordan.

44 British Journal of Community Nursing January 2016 Vol 21, No 1

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Setting
Jordan is a small country in the Middle East. It has a popula-
tion of about 6.3 million (Department of Statistics [Jordan]
and ICF International, 2013) and almost 80% of the country
is a desert, or Badia (Al-Tabini and Hawmdeh, 2004). Jordan
is geographically divided into 12 governorates grouped into
three main regions: North, Central, and South. Most of the
Bedouin people live in the Badia in the southern and eastern
parts of the country (El-Shati, 2001).
This study was carried out among the Bedouin in the
northern Badia of Jordan. Desertification is a common fear
threatening the region, causing degradation of resources and
demographic displacement. The Badia has an arid climate,
harsh weather conditions, and scarce natural vegetation, which
have limited the population to only about 5% of the country’s
total population.This has consequently limited the availability
of services and utilities, such as electricity and cold water.The
Bedouin people in the northern Badia used to live a nomadic
life; however, today, only 5–10% of the Bedouin population
remains nomadic, travelling the area in their black, goat hair
tents called beit sha’ar or ‘house of hair’.
Although many Bedouins are no longer nomadic and have
settled in rural or urban areas, modernisation has had little
effect on the Bedouin cultural identity (El-Azhary Sonbol,
2003); the conservative nature of their culture continues to
influence and have a large effect on the community’s health
decisions. Despite government efforts to provide the Badia
with basic services, the quantity and quality of these serv-
ices are considered inadequate. The level of education in the
northern Badia was slightly below both the national and rural
population averages. This is probably because the work avail-
able in the Badia does not require the kind of skills obtained
in schools (Abu-Jaber and Gharaibeh, 1981; Chatty and
Colchester, 2002; Nimri, 2008). Some of the lifestyle habits
specific to the Bedouin people that increase the incidence of
communicable health diseases in the northern Badia are: rais-
ing livestock, consuming unpasteurised milk and milk prod-
ucts, drinking the rainwater collected in ponds, and some-
times drinking/eating from the same cup/dish (Abu-Jaber and
Gharaibeh, 1981; Chatty and Colchester, 2002; Nimri, 2008).
The number of people in this region with disabilities (learn-
ing, mental, hearing, or physical) is slightly higher than the
country’s national average. This is probably because of mar-
riages between close relatives. Most of these disabilities are
seen in males; females may hide their disability, fearing that the
stigma will affect their chances of marriage as well as that of
their other female relatives with no disability but living within
the same family (Al-Smairan and Hasna, 2008).
Health service provision
Health services in Jordan are delivered through the public
and private sectors. The Ministry of Health is the main pro-
© 2016 MA Healthcare Ltd
vider of public health services, delivering health care at three
levels: village centres, primary health centres, and comprehen-
sive health centres (CHCs) (Hasna et al, 2010). Although the
health-care system in Jordan appears to function well overall,
it faces many problems and serious challenges. For example,
some subpopulations lack access to health care and/or cannot
British Journal of Community Nursing January 2016 Vol 21, No 1
EDUCATION IN JORDAN
afford health services. Bedouins who inhabit the Jordanian
desert and remote areas constitute one of the primary chal-
lenges for the health-care system in Jordan.
Hasna et al (2010) evaluated the quality of primary health
care provided in the rural northeastern Badia, using the
Maximizing Access to the Quality (MAQ) checklist combined
with ethnographic observation.The authors found that nurses
were key providers of health services, but their education was
inadequate for the Badia context. Indeed, most of the health
providers working in northern Badia are not from the Badia
(Lewando Hundt et al, 2012). These findings suggest a need
for well-trained nurses who understand the culture and can
provide culturally sensitive and nonjudgmental health services
to the Bedouin in this region. In the long run, a culturally
competent health-care workforce may reduce disparities in
access to care among the Bedouin population.
Although the health-care needs of Jordanian Bedouins are
looked after by the Ministry of Health and Royal Health
Services, some of the challenges faced are completely different
from those in other parts of Jordan. The study area is com-
posed of a large region with few people, most of whom travel
seasonally with their animals; non-Bedouin health profession-
als working in the Badia might not be familiar with the health
issues that affect this subpopulation. However, even though the
Bedouin culture in Jordan is similar to that of other countries
in the Mediterranean region, the health systems are not.This is
evident in the case of the Bedouins in Lebanon, where neither
nationality nor health insurance is offered by the Lebanese
Government to Bedouins.
Bedouin Health module
In 2010, it was planned to incorporate a Bedouin Health mod-
ule into the syllabus of the community health nursing course
for fourth-year nursing students at Al al-Bayt University. The
module comprises 6 classroom-based theory sessions followed
by twice-weekly clinical training sessions in the Badia for a
period of 7 weeks.
Two courses were revised to include the module. One
was the community health nursing theory course: a three-
credit course given to fourth-year nursing students and
incorporating six theory, classroom-based sessions in which
all nursing students (150 in total) attended six sessions (one
unit discussed each time). The second course—the practical
component of the module—was integrated into the clinical
community health nursing course: a three-credit course in
which the students visited the Badia. For 7 weeks (2 days per
week), the students carried out field-based practice in north-
ern Badia clinics, communities, schools, and households.The
nursing students were divided into five groups. Each group
was accompanied by one nursing faculty member. In the
end, focus group discussions were carried out to explore the
students’ and faculty members’ attitudes toward the sustain-
ability and clarity of the module.
The staff of Al al-Bayt University carried out the imple-
mentation of the module, and have shared training materi-
als with another two government-funded universities: the
Hashemite University and Jordan University of Science
and Technology.
45
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EDUCATION IN JORDAN
Table 1. Questions presented to study participants
Questions to faculty members
Were the project objectives clear to you?
Was the organisation of the training programme suitable?
What did you think about the students’ reaction to and feelings regarding
learning about Bedouin health?
What are the strengths of this project?
What are the weaknesses of this project?
In your opinion, do you think this module needs to be sustained, and how?
Any other comments?
Questions to students
Was the objective of the module clear to you?
What are the strengths of this project?
What are the weaknesses of this project?
Do you think this module needs to be sustained, and how?
What did you learn from this experience?
Has your attitude toward the Bedouin community and health changed?
What were your main concerns during the training?
What else could be done to ensure sustainability of the module?
Do you think it is a good idea to continue to offer the programme?
After this experience, would you work in the Badia if you were offered a job?
What effect has participating in this project had on you?
What changes would you like to see in the future?
Any other recommendations to ensure sustainability of the module?
Rationale: sustainability of interventions
for cultural competency
Cultural competency is crucial to provide quality care
and overcome the disparities in health care. This study was
designed to explore nursing students’ and faculty members’
attitudes regarding reform of the community health nursing
courses to make them more culturally competent, especially
because the Bedouins are the main target population for the
clinical training courses at Al al-Bayt University.
Method
A qualitative approach was adopted in the current study. Two
focus group discussions were carried out, with a group of
five faculty members involved in the implementation of the
Bedouin Health module. In addition, a group of five, fourth-
year nursing students, who had participated in the revised com-
munity health courses after integration of the Bedouin Health
module, were invited for a meeting at Al al-Bayt University
to discuss the module. Leading questions based on the group-
discussion themes were prepared for both groups (Table 1).
46
The study protocol was approved by the Institute Review
Board of Al al-Bayt University. All the faculty members who
accompanied the students during their practical training in the
field were invited to participate in the focus group discussion.
Five students (who were well informed and committed dur-
ing the course) were nominated by the faculty members to
participate in the group discussion.
The participants voluntarily participated and were informed
that they could withdraw from the study at any time.They also
signed a consent form indicating their willingness to participate
in the study; the participants’ consent included agreeing to
taping of the group discussions. Data collection and analysis
were carried out by the team leader and research assistant of
the Bedouin Health Project in Jordan. The names of the par-
ticipants were kept confidential.
All the focus group discussions were audio-taped. Notes
and comments were documented by the principal investiga-
tor. Each focus group discussion took approximately 1 hour.
The participants did not receive any payment for their par-
ticipation. The audio-taped data was transcribed manually.
The data was examined, categorised, and tabulated, and then
analysed using a thematic analysis approach.
Results
Four key themes were derived from the content analy-
sis: self-expression, safeguarding sustainability, acceptance,
and motivation.
Self-expression
There was a consensus among the faculty members that the
objectives of the Bedouin Health module were clear. One
faculty member found the contents of the Bedouin Health
module very informative and specific to Bedouin culture:
‘The content of the module is taking into consid-
eration the Bedouins’ nature.’ [Faculty member,
32 years old, female]
However, another faculty member felt that the mod-
ule emphasis was on health problems that were also shared
by the rural Jordanian population and were not specific to
Bedouin health:
‘The Bedouin Health module addressed the rural
health problems and not Bedouin health problems.’
[Faculty member, 27 years old, female]
All students indicated that the objectives of the module were
clear to them. One student stated that:
‘Students who did not have any idea learnt
about Badia.’ [Nursing student, 20 years old, male]
A nursing student from the Badia region said:
‘Although I am a resident of Badia and I am
© 2016 MA Healthcare Ltd
Bedouin, I learnt more about it through the mod-
ule.’ [Nursing student, 21 years old, female]
The students stated that they also learnt most about the
Badia through the projects they worked on, which made them
aware of Badia issues, such as, environmental problems (sulphur
British Journal of Community Nursing January 2016 Vol 21, No 1
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dumping in Jaber village in Badia) and community assessment
in Badia. One faculty member stated:
‘Module was descriptive, we initiate some interac-
tive practical project[s], such as Sulfur dust pollu-
tion in Jaber village.’ [Faculty member, 25 years
old, male]
However, the faculty members reported facing some
obstacles during clinical practice sessions in the Badia.
Owing to the nursing curriculum’s focus on curative care
and the de-emphasis on community health nursing, it was
difficult for them to convince the nursing faculty admin-
istration about the importance of practising in the Badia.
In addition, the faculty members cited a lack of context-
specific community health nursing textbooks (most of the
reference materials used come from the USA or UK, and
do not incorporate the local context). Hence, the group
discussion’s faculty participants recommended creating com-
munity health nursing textbooks that highlighted the health
needs of the Bedouins and other Jordanian subpopulations.
One of the faculty members stated:
‘I would rather if we [have] the Bedouin Module
contents within a community nursing textbook.’
[Faculty member, 35 years old, female]
The faculty members also highlighted logistical issues such
as transportation between the university and villages and
between the health centre and patients’ houses. For some fac-
ulty members, experiencing difficulties with public transport
helped them to understand some of the struggles the Bedouins
face everyday:
‘I experienced myself the difficulty of moving
from one place to another in Badia because of the
[scarcity] of the transportation.’ [Faculty member,
32 years old, male].
Sustainability
In response to a question about the module’s sustainabil-
ity, the faculty members revealed how they perceived the
module as being ‘descriptive’ and accordingly, had adapted
it to incorporate interactive practical projects. Project topics
included environmental health threats in the Badia and a
community needs assessment.
The students recommended that project materials be kept
in local health centres, mosques, and municipal libraries, as
resources for the public to use and to be disseminated to dif-
ferent communities in the Badia, ensuring knowledge transfer.
They also suggested that the Bedouin Health module be made
mandatory for nursing students at universities where students
conduct clinical rotations in the Badia.
The students suggested that, in the future, all health and
© 2016 MA Healthcare Ltd
social providers in Badia should be Bedouins, in order to
guarantee the sustainability of the module and reduce turno-
ver. One nursing student commented:
‘I would rather if the health providers be Bedouins,
especially if the services are meant to be for women,
British Journal of Community Nursing January 2016 Vol 21, No 1
EDUCATION IN JORDAN
a qualified Bedouin nurse would be the best person
to do this because she understands their culture’
[Nursing student, 21 years old, female]
However, this will not be an easy change to implement,
given that it is a social stigma to be a nurse in Bedouin society,
particularly for Bedouin females.
Motivation
The faculty members described their students as active rather
than passive recipients of the training, which was made pos-
sible by the interactive project component in the module. One
faculty member stated:
‘Our students become more positive and motivated
to implement the module once they [are] involved
in practical projects.’ [Faculty member, 29 years
old, male]
The students discussed facing rejection from the commu-
nity at the beginning of their community health practice. For
example, in Jaber village in the Badia, the school principal said
to the students:
‘What will you [be able to] offer ... us from your
closed doors (meaning ivory towers)?’ [Nursing stu-
dent, 20 years old, female]
However, within 3 weeks, the Jaber community had accept-
ed them.The school principal even apologised and told the Al
al-Bayt university team: ‘you broke [down] closed doors and
reached the local community’.
The students noticed a lack of health awareness among the
local community as well as a shortage of outreach activities
organised by the health centres. To remedy this, the students
sought to raise the awareness of the local community about
public health problems and available health and social services.
As one student said:
‘We have enhanced the Bedouins’ knowledge about
different health problems through health education
sessions, we improved their knowledge about chronic
diseases, family planning, breast feeding, breast self-
examination, environmental problems such as air
pollution and other problems. We also told them
about the locations and types of social and health
services provided by certain public and private agen-
cies to the Bedouins.’ [Nursing student, 21 years
old, female]
Acceptance
The students in one village described how they had inte-
grated into the village community with the support of a
major stakeholder. These students approached the village
imam (religious leader) and convinced him to talk about the
module and encourage cooperation with the students during
Friday prayers.
‘We met the imam of the village masjid (mosque)
and we could convince him to talk about the
47
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EDUCATION IN JORDAN
Bedouin module after Friday Khutba (sermon).’
[Nursing student, 20 years old, female]
The students said that the course had enriched their practice
and life experiences (e.g. leadership skills, knowledge about
Bedouin tradition and culture, and understanding of the nurs-
ing profession).
‘I learnt from the Bedouins the importance of fam-
ily life and intimacy.’[Nursing student, 21 years
old, female]
‘I learnt how to reach [out to] people meaning
breaking the fear from the ghost of the Badia for
people not from the Badia.’ [Nursing student,
22 years old, male]
Discussion and implications
for clinical practice
The Bedouin Health Project has had a meaningful effect on
the health services offered to the Bedouin community. Some
of the implications would be to put all the key players on board
to work together on key issues of transportation and access,
as well as cultural sensitivity and communication skills of the
providers when they are placed in the Badia region. Thus,
an evaluation of its opportunities to be sustainable through
an intervention approach becomes crucial.The project’s team
developed the Bedouin Health module on the basis of the
findings of the Bedouin Health Project
The findings of this study showed that it is crucial for nursing
students and faculty members to be culturally competent when
practising community health care in the Bedouin community.
This can be achieved by developing a theoretical understand-
ing of the Badia culture and context before sending students
for training. Faculty members and students demonstrated
motivation and self-reliance in terms of applying the module,
probably because practising community health nursing in the
Badia is a new experience for them. The students and faculty
members learnt about the Badia in the theoretical lectures prior
to the training. Consequently, they might become committed
and motivated to provide health care for other members of the
community in the Badia.
KEY POINTS
It is crucial for nursing students and faculty members to be culturally
ww
competent when working with the Bedouin community
Both the students and faculty members involved were clear about the
ww
module’s objectives and described their experience with the module as
largely positive
In spite of the limitations and obstacles reported by the participants in the
ww
focus group discussions, they supported the implementation of the module
More research is necessary to evaluate future health-care providers’
ww
(i.e. nursing students) attitudes toward integrating a culturally sensitive
module into their curriculum
48
The results of the focus group discussions showed that
both faculty members and students realised the importance
of this intervention and supported permanently reforming
the nursing curriculum to integrate the module and ensur-
ing sustainability of the programme. Some of the focus group
participants also suggested further research about Bedouin
health, culture, and traditions, as well as the ethics of home
visits for this population. Faculty members highlighted the lack
of resources about the Bedouin community and recommended
that culturally sensitive community health nursing textbooks
be published to teach nursing students about providing health
care to Bedouin patients.
Both students and faculty members described their expe-
rience with the module as largely positive. We hope that,
in the future, they might consider working as health-care
providers in the Northern Badia or other remote areas.
Furthermore, most of the health-care providers in north
Badia are not from the Badia, and might not be familiar with
the Bedouin culture. They should be provided with thor-
ough training on culturally sensitive practice, with a special
focus on communication skills.
Though many studies highlighted the importance of pro-
viding a culturally sensitive health services for disadvantaged
communities living in remote areas (i.e. Bedouins in the
Mediterranean region, indigenous or Aborigines in Australia
and Canada, and Gypsies/Roma/Traveller in the EU), to the
best of our knowledge, none of the studies aimed to evaluate
the future health-care providers’ attitudes toward integrating a
culturally sensitive module into their curriculum.This experi-
ence was unique as, currently, none of the universities adjacent
to the Badia in the Mediterranean region have similar culturally
sensitive programmes to qualify nursing students to be effective
prospective health care workers in the Badia.
The findings of this study are beneficial to decision makers
in the academic sector in Jordan, Mediterranean countries,
and other parts of the world (where Bedouins, indigenous
and Aboriginal communities live). It is essential for prospec-
tive health-care providers for disadvantaged communities
(medical, nursing, and allied health sciences students) to be
equipped with the knowledge and skills required for cultur-
ally competent practice. Qualitative research is needed to
determine the attitude of Bedouin community members
toward the effectiveness of the nursing students’ cultural
competent practice. BJCN
Accepted for publication: 10 December 2015
Declaration of interest: The authors acknowledge the funding and
support of the European Commission for this study through INCO
DEV Framework 6 STREP 015362.
© 2016 MA Healthcare Ltd
Acknowledgments: The authors are grateful to the Bedouin Health
Project administrators for their support. We also thank the faculty
members and nursing students, who participated in our focus groups,
for their cooperation.
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 EDUCATION IN JORDAN

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Research Skills for Nurses and Midwives

This book aims to provide nurses and midwives with a sound
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