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An Ecological Approach
to Regional Public Health
May Farah discovers how the Faculty of Health
Sciences is taking on the region’s public health concerns,
such as tobacco control, urban health, and childbirth.
With its 50th anniversary just around the corner, the Faculty of
Health Sciences (FHS) is seizing the occasion of the momentous milestone
to reflect on its achievements during the past five decades and
to consider where to go from here.
“We decided this was a good opportunity to reflect on where
we have been, where we’re going, and how we’ll be reconnecting
with the region,” says Dr. Iman Nuwayhid, the faculty’s
assistant dean and the person charged with heading up the celebratory
events. Dean Huda Zurayk couldn’t agree more. “FHS and
its faculty are undergoing a process of change. Everybody is contributing
to a review of the curriculum, projects, and research,” she
says, “so this is an exciting time for us. We are motivated
by the contribution and impact we want to make as a faculty, internationally,
regionally, and nationally.”
The Faculty of Health Sciences was established at the American University
of Beirut in 1954 under the name of the School of Public Health.
It was the first—and ultimately vastly successful—effort
in the region to establish a public health program outside a medical
school. In 1978, the name of the school was changed to the Faculty
of Health Sciences to accommodate the addition of related health
programs. Today, the faculty hosts four academic departments: Environmental
Health, Epidemiology and Population Health, Health Behavior and
Education, and Health Management and Policy, as well as a Medical
Laboratory Technology
program in collaboration with the Faculty of Medicine.It is one
of the few schools of public health outside of the United States
to be accepted as an applicant for accreditation by the US Council
on Education for Public Health.
Through its different degree programs—Bachelor of Science
in Health Sciences, a Master of Public Health, and three master
of science programs (in epidemiology, in population health, and
a major in environmental health as part of the Interfaculty MS in
Environmental Sciences)—the faculty aims to prepare health
professionals who can address the most pressing public health concerns
in Lebanon and the region. “Through our teaching, research,
and service to the community, we strive to make a contribution on
many levels,” says Zurayk. “Our best contribution is
to attract students from Lebanon and the region to our degree and
training programs.” Graduate student enrollment grew by 75
percent with the introduction of revised and new graduate programs
in the 2002-03 academic year. In the current academic year, graduate
enrollment has reached 126 students, which is approximately one
third of the total FHS student body. There are now 11 regional graduate
students, with seven of them on scholarships from the Ford Foundation,
the Wellcome Trust, and the Arab Fund.
The faculty remains dedicated to keeping abreast of pivotal issues
affecting public health. One such major change, and a direction
the faculty has been taking for the last several years, is a new
approach in the field of community health. “Health must now
be seen in terms of the larger picture; we must consider its determinants,
whether they are biological, social, cultural, or associated with
any other factor,” explains Zurayk. “We need to view
these aspects in an interlinked fashion and understand them when
we are considering how to improve and promote health services.”
Adopting an Ecological Approach to Public Health
This shift to a more holistic view represents an ecological model
or approach to the study and practice of public health care. “The
objective is to arrive at a real understanding of the determinants
of health at a fundamental level,” says Assistant Professor
Rima Afifi-Soweid, acting chair of the Department of Health Behavior
and Education. “With the ecological model, we go beyond thinking
simply of the self to also consider what influences the self on
various levels, from friends, family, and physicians to broader
influences—like organizations, the mass media, and cultural
norms—and beyond that to the policies of the country.”
The ecological model requires the examination of all levels of influence.
It’s a way of taking the blame away from the self and considering
all mitigating circumstances. As an example, Afifi-Soweid uses the
issue of breast-feeding. What influences a woman’s decision
to breast-feed, she points out, is not just personal attitudes and
beliefs, but goes beyond to consider the opinions of her doctor,
parents, family, and friends. Then there are the broader influencing
factors, such as the hospital and the woman’s place of work;
and then the even broader considerations, including the community
and the policies of the country.
“So we’re thinking of health in a multidimensional way,
because if we don’t change the environment around an individual,
then we may not be able to change the individual,” she explains,
noting that this approach has been coming in public health for some
time. The participation of people is important in this process,
Afifi-Soweid stresses. It is not enough for health officials to
understand, but we have to engage the public, so that we all become
facilitators. And we’re teaching this to our students.”
With the ecological model in mind, the graduate program in public
health underwent a transformation recently to accommodate such new
directions. “We hadn’t looked at the program as a whole
for a while, and then about three years ago we began to do so,”
says Dr. Nuwayhid, who conducted a study of FHS alumni and their
employers in 1999. “We
considered our own students and what core competencies we wanted
them to acquire.”
The faculty also studied similar programs around the world, assessed
their own objectives, and then redesigned the program. “We
wanted a program with a regional focus. By blending the major disciplines
of public health into the curriculum in an integrated way, we can
develop our students’ capacity to examine critical public
health issues from a variety of perspectives,” explains Nuwayhid.
This approach is also found in the faculty’s ongoing research—such
as its studies on tobacco control, childbirth patterns, urban health,
and water quality, among others.
Studies on Regional Tobacco Control
“Teaching and research are interdisciplinary,” says
Zurayk. “We do our work together, which is a strength of the
faculty, and we bring together other faculties as well.” The
study on tobacco control, funded by the International Development
Research Centre’s Research for International Tobacco Control
(IDRC/RITC), says Afifi-Soweid, was undertaken with an ecological
approach in mind and comprised two parts. The first focused on the
level of policy analysis and involved meetings with the various
ministries concerned, such as health, education, and economy (because
tobacco is a source of revenue for the country), as well as with
the media.
“We were looking at it broadly and asking specific questions,”
explains Associate Professor Kassem Kassak, chair of the Department
of Health Management and Policy and a member of the study team.
“We wanted to learn what the influences of tobacco-related
policy were, as well as to understand the political, social, and
economic relationships in Lebanon that contribute to sustaining
one of the world’s highest rates of tobacco use.”
The second part looked at a phenomenon traditionally particular
to the Arab region that is growing in popularity: nargileh smoking.
“There is not enough said about it and there is not enough
known,” explains Dr. Samer Jabbour, assistant professor in
epidemiology on joint appointment with the Faculty of Medicine.
“We are asking about the level of knowledge, attitudes, and
behavior, especially among the youth and pregnant women, to determine
what they know.” He acknowledges that they are beginning to
see an emerging pattern among the young: that they are taking up
smoking the nargileh much more than cigarettes.
Assessing Regional Changes in Childbirth
Another study using the ecological model approach concerns the issue
of changing patterns of childbirth in the region. The faculty had
been researching births in Lebanon, when the study eventually grew
into a regional project. “Our colleagues in Egypt were also
interested in doing this,” says Tamar Kabakian, assistant
professor in health behavior and education and coordinator of the
regional initiative. “When we succeeded in getting a Wellcome
Trust grant to carry out a three-year regional study, we were able
to put together research teams in Egypt, Palestine, Syria, and Lebanon.”
Now in its third year, the project has been looking at all aspects
of the childbirth process, including women’s needs and perceptions
of care, what’s happening in hospitals, what consumers think
of the services, and other issues that are only being addressed
in a few of the countries, such as c-section births, prenatal health,
and postpartum care. “We are trying to get at some of the
forces behind why women choose certain services,” says Kabakian.
“Every team looks at its own country’s context. The
general framework is the same, but the specific research questions
may differ.” This year, the teams began working on intervention
and how to intercede to make maternity care safer and more oriented
to what women want and need. Kabakian added that FHS is in the process
of applying for a second cycle grant from the Wellcome Trust to
continue the work and involve more investigators.
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Population Health and the Urban Health Study in Beirut
The Urban Health Study is a research initiative that deals with
the social context of health. Focussing on poor communities situated
on the outskirts of Beirut, the study was undertaken under the auspices
of the Center for Research on Population and Health (CRPH), based
at FHS. Marwan Khawaja, associate professor in the Department of
Population Health and director of CRPH, led a multidisciplinary
team of researchers whose objective was to prepare a policy-relevant
analysis on the health consequences of economic impoverishment,
lack of social support, and population change, particularly displacement.
The study was conducted in two phases. The first phase undertook
a comprehensive survey of households in those communities, and the
second phase examined the factors that impact the health of various
subsets of the population, including adolescents, even married women
in their reproductive years, and the elderly.
In May 2003, as part of an innovative approach involving partnership
with the community, the results of the Urban Health Study were communicated
directly to the representatives of the three communities studied,
as well as to representatives of relevant non-governmental organizations
and to the Ministry of Social Affairs, which sponsored the study.
“The sharing of the findings is part of the center’s
objective to not simply conduct a study and leave the community,”
says Khawaja, “but to share the findings, intervene, and allow
the concerned community to be involved in prioritizing interventions.”
This is in keeping with the mission of CRPH: to strengthen and enrich
population and health research through collaboration among researchers
and professionals in Lebanon, as well as in the region and internationally,
and then to disseminate these findings to experts, policymakers,
and to the public.
Water Quality Control and Promoting
Healthy Cities and Villages
in Lebanon
When it comes to the issue of water and environmental health research,
the faculty’s ecological model is being applied to a number
of projects currently under way. For example, Professor May Jurdi,
chairperson of the Department of Environmental Health, is heading
a study dealing with the development of water quality control for
Lebanon’s Ministry of Water and Energy Resources.
“This is an assessment of water sources used for drinking,”
says Jurdi. “The Lebanese Water Authority supplies water to
households and we are assessing the water source system and distribution
network.” To that end, Jurdi and her team have devised a quality-measuring
tool, developed monitoring controls, and trained the required manpower.
“To ensure that the water pumped through the network is safe
for drinking, we set up a monitoring program and trained 59 technicians
on the job over a six-month period,” she added.
Although that part of the project has been completed, efforts have
now shifted to an integrated water resource management project,
in conjunction with the Economic and Social Commission for Western
Asia (ESCWA) and other UN agencies. “We are trying to assess
the safety of complimentary water sources in households—municipal,
bottled, and from wells,” she explains. “Little is known
about these sources and what economic or cultural variables affect
their utilization. We want to determine how good each alternative
is and gauge what the public level of awareness is regarding the
safety of these water sources.”
Another important FHS concern is promoting the concept of Healthy
Cities and Villages, which was launched by the World Health Organization
(WHO) to ensure that cities and villages develop in a sustainable
way. “This involves not just looking at the environment, but
at the physical, social, psychological, and health factors a well,”
says Jurdi, again illustrating the ecological approach in practice.
Support for the Public Health Community
The list of FHS initiatives doesn’t stop there. A number of
other studies deserve recognition, such as the one focusing on the
societal burden of disease. For this WHO-funded global effort, Lebanon
was one of the 15 to 20 developing countries selected to conduct
the study, which was aimed at assessing the burden of disease in
different countries. Because priorities have always been based on
mortality, the research question was: what causes death and what
are the diseases that kill? “But what about diseases that
don’t kill but disable and then put a burden on society, socially
and financially?” asks Associate Professor Abla Sibai, chair
of
the Department of Epidemiology and Population Health, who headed
the faculty’s engagement in the project with Dr. Nuwayhid.
FHS also hosts numerous workshops emphasizing training and capacity-building
in the region. A recent workshop effort, organized by its Health
Education Resource Unit and funded by the United Nations Population
Fund (UNFPA), dealt with “Incorporating Reproductive and Sexual
Health and HIV/AIDS Prevention into Youth Programs in the Arab Region.”
The aim of this project is to build on previous initiatives in order
to enhance the capacity of existing community-based organizations
involved in reproductive health education and promoting the awareness
and prevention of HIV/AIDS among Arab youth.There is also the Flagship
Program of FHS, which provides intensive training on options for
health sector reform and for which financing for participants from
the region is provided by the World Bank Institute and the Ford
Foundation. The program, which began conducting its series of workshops
in 1999, has so far trained a total of 331 people, of which 178
participants were from Lebanon and 153 from other countries in the
region. The Flagship Program recently has been asked by the Ministry
of Health and Medical Education in Iran to conduct a series of workshops
there for its health sector officials.
Suffice to say that on the eve of its 50th anniversary, the Faculty
of Health Sciences has much to celebrate. And it is looking ahead
to fifty more years of addressing health issues of concern, nationally,
regionally, and internationally.
“The faculty is committed and enthusiastic,” says Dean
Zurayk. “Our efforts are being recognized and have attracted
research and scholarship funds from major organizations like the
Ford Foundation, the Mellon Foundation, the Wellcome Trust, the
Arab Fund, IDRC, and UNFPA, among others.” That funding money
has increased significantly over the past decade (from $530,000
in 1995–2000 to over $2.2 million for 2000–05) reflects
the growing interest and need for the studies and projects in the
area of health that the faculty has been committed to accomplishing.
“Despite being a small faculty, our contribution to and collaboration
with the region is important,” says Zurayk. “We have
raised funds to bring regional students who otherwise couldn’t
afford to study in our faculty and we are collaborating with many
organizations in Lebanon and in the region, including the Institute
for Community and Public Health at Birzeit University in Palestine,
the Social Research Center at the American University in Cairo,
Damascus University, the University of Jordan, and others. We work
together on research projects and exchange faculty and expertise,”
she explains.
“We are part of a community and a region and consider them
when we are teaching and researching issues of health,” Zurayk
adds. “The studies we carry out are in the context of identifying
the factors that influence community health. What we learn from
them will ultimately influence public health policy.” |
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