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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.

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.”