From burekas to whole-wheat bread

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 term.

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.

Neuhauser 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.

“Some years 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 before.

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.”

As 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 communication.

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.

“For 20 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 profession.”

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 successful.

In 20 years, nobody had asked the people out in the field for their opinions.

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.”

But 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.

Therefore, the 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 speak English.

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.

The 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 one.”

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 hospitals.

“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.”

Finally, 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.

Over 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 noted.

“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.

The Israelis she spoke to during her visit were very interested in participatory design.

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.”

MEANWHILE, 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) survey.

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.

“There are 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 27%.

“Now we have reduced the higher figure by half. We must have been doing something right about content,” Harel-Fisch said.

“Taking an example from computer terminology, I saw that we have the hardware right, but we had to find the right software.”