June 14, 2024

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Executive summary

Mental health is becoming a priority for most health care systems around the world and was particularly accelerated during the unprecedented COVID-19 pandemic. Recently, mental disorders have been found to affect about 1 in 7 children and adolescents worldwide, with 50 per cent of disorders arising before the age of 14 years.

In Jordan and in many other countries, efforts to manage mental health conditions are reactive rather than proactive, focusing mainly on treatment rather than prevention and promotion.
Globally, children, adolescents, and pregnant and new mothers are at higher risk and more vulnerable to psychological distress that may not meet diagnostic criteria for mental disorders but that may affect their health and well-being. For children and adolescents, psychological distress may result in poor mental health, causing further problems in their biopsychosocial health and learning that might not be addressed.
The poor mental health of pregnant women and new mothers contributes to complications that may impact their infants and increase the risk of further problems and disorders.

Worldwide mental health research conducted in educational settings involving school-aged children and adolescents focuses mainly on early and late adolescence. Despite the significant need of support for these age groups, the dearth of knowledge, proposed interventions and research are observed in humanitarian settings. In Jordan, mental health for children and adolescents, and maternal health services are not prioritized. Mental health services in Jordan are not well defined or understood in primary mental health care. Children, adolescents, and women during pregnancy and the postpartum period are receiving the attention of health care professionals and policymakers; however, such attention is emphasizing a biological-oriented care model to meet physical needs rather than the bio-psycho-social care model to meet the mental health and psychosocial support (MHPSS) needs.

Integrating children, adolescent and maternal mental health care requires strengthening care delivery systems and system changes to facilitate such integration. This involves bringing mental health services close to people who need it and enhancing the capacity of primary health care professionals in mental health. Providing mental health services in primary health care settings integrates both delivery systems and referral of people with mental health needs to more specialized services. Delivery systems include prevention, promotion, identification, diagnosis and treatment. This integration utilizes a holistic MHPSS approach to emphasize the promotion of well-being, prevention of mental health problems, and ensures quality and accessible primary mental health care for those with mental health conditions, along with referrals for conditions that cannot be addressed at the primary health care level.

To support the need to strengthen MHPSS services for children, adolescents, and pregnant and new mothers in Jordan, UNICEF MENARO, in collaboration with WHO EMRO, initiated a regional implementation research effort to explore how MHPSS can be most effectively implemented in primary care settings.
The regional research effort, which included a secondary literature review, in-depth analysis and critical stakeholder consultations, contributed to a deeper understanding of MHPSS needs, the available services, and critical gaps across the promotion, prevention, care and treatment within primary health care, as well as emphasizing MHPSS linkages to the social welfare, child protection and education sectors. The information gathered through this effort provided specific recommendations to establish the foundation and support the integration and delivery of MHPSS for children, adolescents, and pregnant women and new mothers at the primary health care level.

In general, the literature review showed that the mental health of children and adolescents has attracted the attention of researchers in the past few decades.
Several studies attempted to address mental health problems that are serious and affect children’s and adolescents’ well-being. In Jordan, mental disorders are estimated to be the leading cause of poor health among children and adolescents aged 10–19 years, accounting for almost a quarter of this age group’s total disease burden, measured in (DALYs). Nearly 1 in 6 (16.3 per cent) of adolescents were estimated to be living with a mental disorder in 2019, with depression and anxiety being the leading causes. Studies showed that 11–17 per cent of school-attending adolescents and adolescents in juvenile correction agencies are affected by suicidality related to depression.
Unfortunately, we lack information on the prevalence of suicidality among children and adolescents in Jordan. Stigma and fear of being labelled as mentally ill contributed to poor engagement in, adherence to, and use of mental health services among adolescents in Jordan.

Severe mental health disorders are often not detected among children and adolescents, as well as other underdiagnosed and underreported less severe conditions that contribute to poor mental health of children and adolescents. Fibromyalgia, alexithymia, social anxiety, ineffective coping, risk behaviours and bullying were associated with mental health problems among children and adolescents. Among women, postpartum depression (PPD) is one of the most common mood-related disorders associated with childbearing and disproportionately affects women in lower-middle-income countries. In Jordan, PPD affects approximately 22 per cent of women.
A recent study reported 50 per cent of 1,107 women screened experienced postpartum depression, which was among the highest when compared to studies in other countries in the region. In another previous study, 25 per cent of screened postpartum women (total of 315) suffered from moderate to severe depression, and 50 per cent of the sample had mild depression.

The Jordanian efforts to improve and promote mental health have focused mainly on adults and improving services coverage in the country. Although efforts have resulted in improving mental health services through increasing points of service for mental health, there are still gaps that need to be filled, such as lack of validated screening tools for mental health for children and adolescents at schools and primary care centres; lack of management protocols for children, adolescents and pregnant/new mothers; limited attention to prevention and promotion; and a focus on specialized services rather than integration through primary health care (PHC). Furthermore, Jordan lacks legislation and policies that specifically support mental health care for children, adolescents and pregnant women/new mothers. Mental health is addressed in the three main health policies for the country: the Ministry of Health National Strategic Health Plan (2018–2022), the Health Sector Reform (2018–2022), and the National Strategy for Health Sector in Jordan (2016–2020). Additionally, Jordan has an endorsed a National Mental Health and Substance Use Action Plan (2022–2026). The country is currently operating under the 2011 National Mental Health Policy. This policy was reviewed in 2016 and is considered relevant and reflective of Jordan’s current context and mental health priorities. The policy informed the development of the National Mental Health and Substance Use Action Plan (2018-2021).

Stakeholders identified several obstacles and gaps related to integrating the mental health of children,
adolescents, pregnant women and new mothers into primary care services.

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