(photo credit: Ariel Jerozolimski [file])
The old public health strategy for getting people to change their behavior was to cast bread upon the waters in mass education campaigns and hope that some would bite. Today, with limited funds and too little proof that this "broad-casting" approach bore fruit, health promotion experts are for "tailoring" - customizing educational messages and interventions to high-risk groups.
Promoting health in a multicultural society was the topic of the 12th Annual Conference on Health Education and Promotion, organized two weeks ago by the Health Ministry's Public Health Services and its health education and promotion department. Hundreds of people (mostly women) from the ministry, health funds, municipalities, non-governmental organizations and other groups attended the day-long conference, listening to lectures and viewing posters that explained research studies carried out in the community.
THE GROWING (yet still inadequate) emphasis being put on preventing disease rather than just treating it was reflected in the appearance of Health Minister Ya'acov Ben-Yizri and associate director-general Dr. Boaz Lev. Ben-Yizri said the conference was a change of pace for him after spending much time since taking office going on hospital tours and meeting patient groups. Health education in Israel, with its heterogenous population, is complicated, he said, "but we have nothing to be ashamed of. We don't always succeed in our struggle with the Treasury for funding, but we must believe in what we're doing."
Lev, whose office supervises the ministry's "Israel 2020" program on setting national targets for health promotion, said he had just returned from a World Health Organization-Europe conference in Istanbul on obesity and how to prevent it. "There is great political importance to these issues, as we have to bring awareness of the need for disease prevention to the political level - the government and the Knesset. We must continue to offer curative medicine as we do today, but need to give a big boost to prevention and health promotion."
A ministry Web site on these issues will soon be established, said Ruthie Weinstein, head of the ministry's department of health promotion, so that innovators can explain their techniques, with a databank so successful ideas can be adapted elsewhere. A first-ever Hebrew journal on disease prevention and health promotion will be produced three or four times a year by Weinstein's department and edited by the University of Haifa's Dr. Orna Baron-Epel.
PROF. KAREN GLANZ - an expert in behavioral science, health education and epidemiology at Emory University in Atlanta, Georgia and head of its disease prevention research center - was the main guest speaker. She focused on "tailoring" health promotion to specific groups. Glanz reported on a skin cancer prevention study she conducted among relatively poor Asian groups in Hawaii and in wealthy Caucasians on New York's Long Island. "We thought people might be motivated to make changes in their behavior by knowing they were at high risk for melanoma, the potentially fatal skin cancer," she said. "In this project, we were trying to see if tailored mailed intervention would be more relevant than mass-distributed information because it was suited to individuals aged 20 to 60. Some 600 stuck to the program the whole summer. With surveys, we identified people with high risk factors. Those selected received materials in packets, with a personal skin cancer prevention profile that compared their own risk with the average, and sun exposure charts to fill in. They were advised to wear hats, stay out of the sun, use sunscreen, speak to their doctor. A control group received standard informational materials but no active or personalized intervention."
Glanz reported the results: those who received personalized materials exposed themselves to the sun less during peak hours, performed self-exams of their skin, and were more likely to use sunscreen. The tailored approach was inexpensive, reached high-risk populations and definitely changed attitudes and behaviors.
Glanz, who has Israeli relatives, noted that Israel's multicultural society is particularly suited to tailored health promotion, with Jews, Arabs, immigrants, haredim, religious and secular, and groups within the groups.
"I learned, for example, that Jews have higher cancer rates than Arabs in general, but that lung cancer rates among Arab males are the highest of all. Do you reach them by the mass media or via 'small media' organizations, religious leaders, cultural or ethnic portrayals and in various languages? I learned it is not culturally acceptable for women in Arab villages to walk about. But to get them to exercise, they can walk in groups outside their villages."
Dr. Ronny Shtarkshall, a sex education expert at the Hebrew University-Hadassah Braun School of Public Health and Community Medicine, noted that even subgroups are not homogeneous.
"A student of ours studied various hassidic groups and found them very different from each other in smoking behavior. It can range from 15% of youth to 40%... Every influence on health behavior is dependent on culture, and without this context, we can't change behavior."
He recalled that a few years ago, he worked among South African blacks in KwaZulu, where the HIV carrier rate is very high. "We asked tribal elders, who have authority in the tribes, to help youths to help avoid HIV," Shtarkshall said. "The shield and lance are highly recognized tribal symbols. The elders said fighters aim not just at killing, but to protect women and children, so they advised using a shield with a condom on lance. I would never have thought of doing this, but the elders had the ability and understanding, and the youths were on the edge of tears. This symbol defined anew the role of fighters - against AIDS."
A SUCCESSFUL Israeli Defense Forces program to discourage smoking among paratroops on a base in the Negev was presented by Hagai Levine, an officer in charge of the project who said it had become a model for smoking cessation in the whole IDF. Military doctors who live and work on the base are the key, said Levine.
"Tobacco companies in the past made cynical use of the image of combat soldiers, giving the impression that those who smoke are macho. We presented new enlistees with a different image - non-smoking sportsmen who set an example to others. There was enforcement as well, and smoking was not allowed in public areas but only in restricted outdoor locations."
The base clinic initiated sessions between recruits and doctors. "We taught how to avoid getting hooked on smoking, just as we teach about avoiding stress fractures in the feet. A survey showed that most of our officers are non-smokers, that non-smoking and having a higher rank go together, so those who aspired to be officers understood that they should not smoke," Levine said. As more IDF soldiers smoke when they complete their service than when they begin, the pilot program was found to be a key to smoking cessation efforts. "We showed we can change norms, and basic training is a great opportunity, maybe the last, to change habits," Levine concluded.
The Health Ministry's Levinsky Street clinic for preventing the spread of sexually transmitted disorders among foreign workers in Tel Aviv offers disease prevention courses. The clinic's Zahala Yitzhaki described how Filipina women, who arrived with a low self-image and are dependent only on themselves, can be empowered by health education.
"They come in their 20s and stay for the seven years they are allowed to work here. They usually do not have regular sexual partners or long relationships, and some are sexually abused by relatives of the elderly people to whom they are caregivers or even by the elder himself." Coming on Sunday, their day off, they learned in 17 meetings about personal initiative, health promotion, human rights and sexually transmitted diseases. "Many had no familiarity with their own anatomy," Yitzhaki said. "They learned self defense, and some asked about diseases their bosses had, such as Alzheimer's and Parkinson's"
Anat Amit Aharon of the Tel Aviv Municipality's social services division worked with children of foreign workers. She vividly recalled one private kindergarten that served as the home-away-from-home for 30 children in a tiny apartment run by a woman from Ghana. "It was crowded, with naked walls and electric wires exposed. The two rooms were wall-to-wall playpens; the babies were almost never taken out and were even fed inside them. Parents brought food in plastic containers that were not refrigerated. Older siblings arrived after school, the floor was dirty and the noise unabated.
Many of the parents, she said, are illegals without a permanent address and afraid of being deported; some are even unemployed and the victims of violence. "We went to leaders of the foreign worker community and to kindergarten teachers to hand out material. We gave a baby-massage course, taught parents first aid and offered dental health education. We handed out invitations to children to come to family health clinics, and they came. The program, which attracted 500 participants in the past six years, was very successful."
Other lectures and poster sessions described health education among specific groups such as Arab women, Ethiopian Jewish immigrants, Beduin, haredim and the mentally ill. All reported success in changing behaviors - losing weight, cutting accidents, taking folic acid to minimize congenital defects in babies, and using medications correctly. It is clear that the tailoring of health promotion interventions to specific groups will increasingly become the strategy of public health professionals.