From burekas to whole-wheat bread
The annual Health Ministry conference on public health heard ways of preventing illness by sharing roles with the public.
PROF LINDA NEUHAUSER Photo: Judy Siegel-Itzkovich
Health promotion and disease prevention have always been a stepchild of the
health system, even though heading off sickness and encouraging well-being are
very cost effective. In the US, 99 percent of health resources are spent on
treating those who already sick, according to Prof. Linda Neuhauser of the
University of California at Berkeley’s School of Public Health at a Health
Ministry conference on promotion and prevention in the Jerusalem International
Convention Center earlier this month.
In Israel, the Health Ministry has
always been led by directors-general who come from senior hospital positions,
thus their natural orientation is more toward treatment than health promotion.
But regarding budgets for public health, Israel looks a bit better than the US,
as 2% of all national health expenditures here go to that cause – but if it were
20%, the population would surely be a lot healthier in the long
Unusually for Health Ministry events, the refreshments did not
include any transfatladen cakes, cookies, burekas and soft drinks; instead
Weinstein insisted on healthy salads, whole-wheat, vegetable-filled sandwiches
and tea for the 600 participants.
Neuhauser – who as an expert in public
health and epidemiology well knows the difference between cake and sandwiches –
was making her first visit to Israel to attend the conference, which was
organized by Ruth Weinstein, the ministry’s head of health promotion in the
public health division headed by Prof. Itamar Grotto.
specializes in health literacy and the participatory design of health
communication to change behavior for the better.
Just writing booklets
and telling people how to be healthier is not the answer.
ago, we launched in California a $20 million program to encourage the population
to eat vegetables and fruits. We know how much obesity and diabetes are causing
harm to America.”
But after 10 years, she and her team found that while
well-educated people ate more fresh produce, there was no overall change as a
result of this government investment.
The poor ate even less than
Thus, Neuhauser said, she is especially interested in “leveraging
participatory approaches to improve the relevance of communication to meet the
literacy, linguistic, cultural and access needs of diverse audiences.”
co-principal investigator of the UC Berkeley Health Research for Action Center –
which works with residents to co-design and evaluate multi-media health
communication resources – she has reached over 30 million households in the US
and overseas. She and her group also work with heath insurance plans and other
public and private organizations on strategic planning, training and
communication resources to improve health literacy and clear
She began her career “as a nutritionist and gave good
scientific advice to my clients about diets. But I soon realized that they
weren’t taking my advice. Most people didn’t implement it in their lives, and I
found my colleagues had the same experience. I was very discouraged, and after a
year of this, I gave up my profession.”
Idealist and energetic, Neuhauser
went to western and central Africa to work as a health officer and adviser for
the World Health Organization.
In Mauritania, her job was to develop with
that country’s health ministry a national vaccination program.
years, experts had gone there and launched science-based programs to benefit the
people. But they didn’t work. It was disastrous.
A fifth of all the
babies there died because they weren’t being vaccinated against diseases. It was
heartbreaking and very discouraging. Again, I thought I had to leave my
But instead of a final decision to resign, she decided to
throw out her plans and spent six months traveling through the African country
and talking to people.
“They didn’t trust vaccines, and even if they took
their children to get the shots, there were problems, because, for example, the
nurses didn’t know how to keep the vaccines cold. But I found that the camel
traders had the best ideas. They figured out how to take care of the vaccine
before use and how to get mothers in with their children for shots. The camel
drivers solved all my problems in six months!” In her two decades of health
promotion work, Neuhauser said, “I’ve learned one thing: if you use
participatory methods with your programs, you’ll be much more
In 20 years, nobody had asked the people out in the field for
After we began to ask people’s advice, within two years
we were very successful. An amazingly high 85% of the children had been
vaccinated. So I decided that for the rest of my career, I would do
participatory design. I went to Berkeley and was one of the founders of the
Health Research for Action Center.”
Only half of American adults take
their medications as prescribed, said Neuhauser, “so it’s hard to manage
hypertension, diabetes and other problems properly. There are growing heath
inequalities. One of the problems is the way we do our work. Traditionally, we
have sent messages to people about observing healthier behaviors. But people
have lives to live, and they don’t bridge between what they’re used to and what
they should do, so we were not successful enough.
“If we focus on telling
people how to live, we will fail because they are influenced by their family,
community, culture and organizations they’re connected to. We used to focus
mostly on risk factors for disease and less on empowerment and hope.”
by the time somebody is obese or has o t h e r ingrained unhealthy behavior, the
process has been going on for a long t i m e .
N e u h a u s e r realized
she had to do more to promote health at very early age.
Berkeley team created a kit based on the ideas of those who would use it.
California has a very heterogenous population, with 600,000 annual births and
many immigrants and migrants from Mexico.
A large number can’t read or
Neuhauser decided to prepare a cardboard- box kit for all
new parents, because “the best investment for health promotion is at the
youngest ages,” she stressed.
Before producing the kit, the Berkeley team
carried out a serious survey of California parents.
“We found a very low
average level of health knowledge. Seventy-seven percent of them conceded that
they didn’t have the information for giving their children the best start in
life. We set ambitious goals, to give information to at least 500,000 parents
with low cultural and literacy levels who know how to read like children in the
sixth or seventh grade.”
Health educators had been used to a topdown
approach, writing booklets and distributing them. But as in Mauritania, many
young Californians didn’t understand them.
“We worked to identify all the
stakeholders and users, parents and health- and social-service providers who had
to implement programs. Then there were the media, politicians and others. We
pulled them all together in a series of groups. We performed research with
users, focus groups, interviews and community meetings. I always kept the
African camel drivers in the back of my mind,” related Neuhauser.
team found that parents didn’t now how to check whether the slats on the baby
cribs they had were at the proper distance and height so babies wouldn’t get
strangled or fall out.
“They came up with ways to explain things using
practical advice in culturally appropriate language. We then performed usability
testing. We went through five prototypes of the kit before approving the final
The team distributed the kits – which included not only
understandable booklets and books to read to babies but also multimedia material
– in preschools, childcare institutions, healthcare clinics and
“We spoke a lot to fathers, because they generally felt left
out when it came to baby care. We also spoke to prisoners and people in the
military. We carried out a three-year longitudinal study for evaluation of the
kit and found that heath and service providers thought it wouldn’t work. We were
told that parents don’t like to read. But,” said the Berkeley expert, after
giving them out to parents, “we found that 87% of them had used the kits within
weeks of receipt.
Among Spanish speakers, the rate was an incredibly high
95%. Within six weeks, the Spanish speakers had raised their knowledge about
parenting to the level of English speakers. We were also very pleased to note
significant improvements in parents’ knowledge and practice.”
they give a kit – which now costs $14 to produce – to every new mother before
she left the obstetrics department with her baby. But the messages on better
health are relevant to adults as well. The kit has been produced in five
languages, including Spanish, which had been tested on a Latin family to ensure
it was suitable, along with Korean, Chinese and Eastern languages.
the past decade, they have continually revised it after assessing what worked
and what didn’t.
“The late Steve Jobs of Apple was the genius of design
science. He tried every product out on potential audiences,” she
“The whole family is involved in it,” concluded Neuhauser. By now,
the kit has reached over five million young parents, not only in California but
in the state of Victoria in Australia – which includes the disadvantaged
aborigine population – and in several US states including Colorado.
Israelis she spoke to during her visit were very interested in participatory
Although literacy is much higher here, there are new immigrants
and migrants with serious health problems that could benefit from an Israeli
kit. Because of the health system and the smallness of the country, she said,
there is “every hope that you will be very successful.”
DESPITE much praise for Israel’s health system and increasing awareness of the
need for health promotion, Dr.
Yossi Harel-Fisch – who has been keeping
his finger on the pulse of the country’s youth for two decades – had a sorry
tale to tell the conference participants.
Rates of anger, risky behavior,
recreational drinking of alcohol, physical inactivity, long hours of computer
use and negative feeling about their schools remain high among Israeli youth,
said Harel-Fisch, head of the national research program for the health of youth
at Bar-Ilan University’s School of Education.
As the head of BIU’s
International Research Program on Adolescent Well-Being & Health, he is the
person who conducts surveys here to provide comparative data for the World
Health Organization’s Health Behavior among School-Age Children (HBSC)
The BUI researcher said that from his first survey to today,
Israeli youth live in a completely different world. From then, there were
massive waves of immigrants from the former Soviet Union and Ethiopia, a
different culture, two terror-filled intifadas, the murder of a prime minister,
one disengagement, two wars and a surge of migrants.
Today, the Internet
and smartphones, he said, have turned the world upside down.
words today that never existed then. And today, at least Health Ministry senior
officials don’t smoke at their meetings...
and the Education Ministry has
recognized the importance of health. We learned how to make coalitions of
partners and set up evidence-based policy and programs.”
He agreed with
Neuhauser that participatory health promotion is the way to go. As evidence, he
cited an Internet campaign to fight the huge increase in binge drinking among
teenagers that has even killed some.
At age 11, the rate of Israelis who
have had five alcoholic drinks at once went in two years from 6% to
“Now we have reduced the higher figure by half. We must have been
doing something right about content,” Harel-Fisch said.
example from computer terminology, I saw that we have the hardware right, but we
had to find the right software.”