Shaping Health: Conducting A Community Health Needs Assessment in Israel's Northern Periphery

Introduction: The impact of social determinants on health status and outcomes has been widely established. However, it is recognized that health systems' ability to address community health needs may be limited. To better understand the interrelation between social determinants of health and health outcomes, health systems need to understand the health concerns and needs of populations. The aim of this study was to map the perceived health needs of residents in the Galilee region, Israel's northern periphery through a community health needs assessment (CHNA). Methods: The study employed a mixed-methods approach. We conducted a CHNA in the Galilee between November 2019 to January 2020 (n=750). Additionally, we conducted focus groups using design thinking methodology to better understand the underlying causes of existing gaps between community and healthcare representatives (n=47). Quantitative data was analyzed using multiple logistic regressions and qualitative data was analyzed using a content and thematic analysis. Results: Galilee residents perceived sense of community (78%) as the major strength while cancer (53%) was perceived as the major health problem followed by heart disease and stroke (28.4%). The adjusted odds ratios for the association of each predictor with each perceived social and structural determinants of health among respondents indicated that Arab respondents were more likely to report race/ethnicity discrimination, domestic violence, lack of parks and recreation, neighborhood violence, limited places to exercise, school dropout and limited access to healthy food, as determinants affecting health than Jews. Conversely, Jews were more likely than Arabs to report access to mental health services, access to transportation, lack of job opportunities and access to a doctor's oce as determinants affecting their health. Qualitative analysis revealed residents felt a 'lack of health security' as a result of problematic access to specialty and mental health services, especially for elderly populations. Conclusions: CHNA can inform the design of tailored interventions that will improve health for Galilee residents addressing their socioeconomic-cultural-geographical characteristics. The study's ndings raise the need to create such tailored approaches to address the lack of health security felt by residents and improve not only health services provision but the social determinants affecting their health.


Introduction
Health and health care inequities are the result of a myriad of social, cultural, and economic factors that for the most part fall outside the traditional expertise of the health sector [1]. The impact of social determinants on health status and outcomes has been widely established [2]. However, it is also recognized that health systems' ability and capacity to address these concerns may be limited, highlighting the need for novel partnerships between hospitals and the community [3][4][5].
To better understand the interrelation between social determinants of health and health outcomes, health systems need to understand populations' health concerns and needs. Both objective and perceived measures are essential in assessing communities' health needs. Perceived needs re ect how residents perceive their surrounding environment and living conditions. Objective health needs are the existing access and provision of health care services and the prevalence of disease in a given community [6]. A common way for assessing perceived health needs is by conducting Community Health Needs Assessment (CHNA, a data-driven approach to determine health needs in the service area of a health system) [7]. With limited resources, communities residing in social peripheries and underserved areas are often underrepresented, and their needs are unheard. The CHNA ndings can serve as a valuable tool to mitigate the diverse communities' perceptions and knowledge with professional and political decisionmakers, locally and nationally [8].
The Azrieli Faculty of Medicine, Bar-Ilan University was set up in the Galilee region, Israel's northern periphery, home to 1.6 million residents of which, 53% are Arabs citizens. Although the Israeli periphery does not meet the de nition of rural or frontier, as even the most remote villages are about an hour's distance from an urban center; the Israel Central Bureau of Statistics (ICBS) de nes the northern and southern areas of the country as peripheral [9].
Galilee residents have higher mortality and morbidity rates than residents living in the city of Tel Aviv or the center of Israel (the standardized to age death ratio in the Northern district is 5.3 per 1,000, whereas in Tel Aviv district, it is 4.9 per 1,000) [10,11]. The differences between the center and the periphery are also re ected in relatively low accessibility to medical services, lower number of hospital beds and fewer specialized departments, and the longest waiting times per capita. Additional and signi cant gaps are apparent in medical staff distribution (1000 per person). Recent data (years 2015-2017) demonstrates that although some progress was made, the gap between the Northern district and Tel Aviv remains both in doctors (2.1 in the north and 5.3 in Tel Aviv); nurses (4.5 in the north 6.2 in Tel Aviv); as well as allied health professions (3.5 in the north, 6.8 in Tel Aviv) [12].
The current study aimed to map the perceived health needs of residents of the Galilee communities by administrating the rst ever CHNA. Using the CHNA as a platform, enables to not only understand residents' differential points of view but also expose their awareness to the different health and social issues in their region and communities. Given the persisting health disparities observed, and the lack of consistent policies to reduce observed gaps in care in Israel's north periphery [12], the use of upstream mechanisms can draw out not only the current challenges and needs perceived, but serve as the basis for developing interventions to mitigate and reduce health inequities [13].

Study setting and data collection
We conducted the CHNA from November 2019 to January 2020 in the Galilee, Israel's northern periphery. The Galilee region spans 4,473 square km, is comprised of 61 municipalities and 15 regional councils, 17 cities, that are divided into ve municipal clusters: Eastern Galilee, which includes the Golan Heights; Western Galilee which includes the major coastal cities of Acre and Nahariya; Beit HaKerem which

Analysis:
Descriptive statistics of respondent characteristics were calculated for the entire sample as well as according to ethnicity. In addition, we conducted a sub-group analysis to assess whether perceptions differ according to the municipal cluster of residence. Associations between the independent and control variables (respondent characteristics), and dependent variables (community strength, health needs, health problems and social determinants) for both ethnicity and municipal clusters were assessed using chi-square tests. Multiple logistic regressions were used to measure the association between each dependent variable and the independent and control variables. Categorical variables were recorded as dummy variables before being included in the multiple logistic regressions. In addition, the municipal clusters variable was recoded due to low response rate in two clusters. Clusters were merged together according to geographic adjacency. Western Galilee was merged with Beit-HaKerem , and the Galil Amakim with Kineret Amakim. Findings reported for the univariate analyses include any variable found to have a p value <0.05, however, a Bonferroni correction for multiple testing removes statistical signi cance, except where p < 0.0012. Analyses were performed using IBM SPSS Statistical package V.27.0.
Ethics approval for the study was obtained from the Azrieli Faculty's ethical review board.

CHNA Survey
A total of 750 respondents completed the survey, 645 of those were in Hebrew and 105 responses to the survey in Arabic. Our survey included 424 (56.5%) respondents from the Eastern Galilee, 165 (22%) respondents from the Western Galilee-Beit Hakerem, 161 (21.5%) respondents from Galil and Kineret Amakim cluster.
In both the Hebrew and Arabic language surveys, respondents perceived themselves to be in 'good' or 'very good' health (43.6% and 47.9%, accordingly). Overall, we found signi cant differences in the characteristics of Jewish in comparison to Arab respondents (Table 1). When we compared groups characteristics according to their residence in municipal clusters, minimal differences were found, alluding to a regional socio-demographic similarity between the clusters (data not shown).

Community strengths
Thematic analysis of open-ended responses on community strengths was conducted. Coding revealed that for both Jews and Arabs, community support, solidarity, caring for one another, and the knowledge that someone will help in a time of need was deemed the main strength of the Galilee communities (78.1%). Interestingly, quality of life (30.3%) and community services (22.9%) were not perceived as a major strength. When comparing Arab and Jewish respondents on perceived community strengths, we found signi cant differences ( Table 2). Jewish respondents rated a sense of community highly (81.7%), as opposed to Arab respondents (55.2%); Quality of life was rated by almost a third of the Jewish respondent as a strength, whereas only 14.3% of Arab respondents identi ed it as such. The adjusted odds ratios for the association of the independent variables with each perceived community strength measure (controlling for the community characteristics-control variables) are shown in table 1s (supplementary les). Non-religious respondents, compared to religious respondents, were more likely to report community services as a strength. Jewish respondents were more likely than Arabs to report quality of life and sense of community as strengths. Sense of community was also more likely to be reported by respondents who live in a village and have an academic degree as opposed to those residing in the city and/or non-academic (p<0.0012).
Qualitative ndings were supported by our quantitative survey data. Many respondents expressed the uniqueness of Galilee communities: "living in a community as we once knew, without high-rises, everything is close, and everyone knows everyone." Many participants also mentioned as a strength the caring and support of their community: "There is a good connection between residents, almost everyone participates in each other's joyous events as well as those in times of sorrow, like death, the whole village participates. We divide who will make food for the family in grief, we will support families who have undergone tragic events like res, helping with xing the homes". Respondents also felt that living in the Galilee was a strength as it was an area where "good neighbors, both Jews and Arabs, live in a place of multiculturalism, simplicity and humility." Health needs assessment of the community A recurring theme across all domains was what respondents deemed as the "lack of health security in the region." This stemmed not only from poor access to services but also the low quality of care provided.
When we asked respondents to openly reply and answer what they think are the major health needs of their community, we found two main domains: Health services in the community (47.60%) and access to specialists (33.1%). In addition, emergency services, and age-based services -elderly and childcare were also found to be a major need (17.8%, 16.90%, 15.70%, accordingly).
Health Promotion and preventive medicine were deemed by 14.5 % of respondents as an important need. We found a signi cant difference between Arab and Jewish respondents, with about a fth (21%) of Arabs respondent as opposed to only 13.5% Jews mentioning the lack of health promotion infrastructure such as outdoor sport equipment, walking/running/cycling trails, public parks, and the existence of environmental hazards such as polluting factories in their community (Table 2). Additionally, many Arab respondents mentioned the lack of nancial support for health promoting activities such as afterschool activities/sport activities. Qualitative data also revealed a major obstacle to healthy lifestyle, with many respondents mentioning the problematic access to fruits, vegetables and healthy foods due to higher prices in local supermarkets. Interestingly, health promotion and preventive medicine was the only need that was signi cantly different according to municipal cluster of residence, with respondents in the Western Galilee -Beit HaKerem (21%) stating it as a major issue as opposed to those residing in the Eastern Galilee (11.4%).
Despite the wide geographic spread of primary care clinics, the qualitative analysis indicated the lack of basic health services in the community as a concern of all survey participants. Participants highlighted limited clinics' operating hours and availability of services such as blood tests, nurses and doctors. Many respondents also mentioned the problematic access to specialists, including long waiting times or the need to travel great distances to receive care, especially for specialties areas such as rehabilitation and dermatology. An additional barrier to care mentioned was the lack of professional services for the elderly in the region, including availability of gerontologists or family practitioners specializing in gerontology.
Community mental health services were also viewed as problematic, with the HMOs not providing services adequately in the region, long wait times, and lack of support for disadvantaged populations.

Identi ed Health Problems
When assessing needs according to respondents' ethnicity, we found signi cant differences in the awareness and perceptions of health problems. Univariate analysis showed that both Jews and Arabs perceived cancer (53%) as the major health problem followed by heart disease and stroke (28.4%).
Health problems were found to be signi cantly different according to the clusters of residence, with agerelated illness identi ed by 47.9% of the 'Western Galilee -Beit HaKerem" as a major issue; Eastern Galilee respondents identi ed heart disease and stroke (31.3%) and mother and infant health (36.2%) as their major health problems; Obesity was identi ed as a health problem by "Galil Amakim-Kineret respondents" (29.2%); Smoking was identi ed by 17.4% of "Galil Amakim-Kineret Amakim" respondents. Finally, violence was identi ed as a health problem by 16.8% of "Galil Amakim-Kineret Amakim" respondents (Table 3).
Table 3s (supplementary les) presents adjusted odds ratios for the association of the independent variables with each perceived community health problem. After controlling for respondents' characteristics, ethnic differences remained signi cant, with Jewish respondents more likely to report age-related illness and mother and Infant health than Arab respondents. Arabs were more likely than Jewish to report diabetes, obesity, and violence as health problems.

Social and Structural Determinants of Health
Identi cation of structural social determinants and their effect on community health differed signi cantly between Arabs and Jews in all aspects ( and to a lesser extent parks and recreation (14.4%) ( Table 3).
Tables 4s and 4.1s (supplementary les) present adjusted odds ratios for the association of the independent variables with each perceived Social and structural determinant of the health of the communities controlling for the respondents' characteristics. Arab respondents were more likely to report race/ethnicity discrimination, domestic violence, child abuse/neglect, affordable childcare, lack of parks and recreation, neighborhood violence, limited places to exercise, school dropout/poor schools, and limited access to healthy food, as determinants affecting health than Jews. Conversely, Jews were more likely than Arabs to report access to mental health services, access to transportation, lack of job opportunities and access to a doctor's o ce as determinants affecting their health.
Respondents from Western Galilee -Beit HaKerem clusters were more likely to report residence near a polluting factory; respondents from Galil Amakim -Kineret Amakim were more likely to report neighborhood violence than Eastern Galilee. In addition, respondents who live in a village were more likely to report access to transportation and access to a doctor's o ce as determinants affecting health than respondents who live in a city. In comparison, respondents who live in the city were more likely to report a lack of parks and recreation and neighborhood violence as social determinants of health.
The Community-Health Services Interface -Identifying key issues and possible solutions from the Focus Groups: In accordance with the rural health needs assessment model [15] and following the CHNA analysis, we conducted focus groups to better understand Galilee communities' pains and gains. Focus groups participants, both community and health services representatives, raised three main 'pains' in current health care provision: Low awareness of the population to the importance of prevention and lack of supporting policies to do so; quality of care provided; lack of infrastructure.
1. Prevention -Low awareness and lack of supporting policies: Participants in all focus groups stressed the low awareness of the Galilee population to the importance of maintaining a healthy lifestyle and preventing chronic disease. This was often paired with the lack of policies and infrastructure to create a support system to promote such activities including: Lack of public spaces for exercise; Low access to healthy foods due to high cost and low availability; Lack of nutritional services that are culturally t and affordable.
2. Quality of Care -Barriers to quality care were mentioned both from the provider and patient perspectives. Barriers in access to professional training and low awareness of clinicians to new clinical recommendations, technologies, and drugs. Lack in provision of tailored services to t the community served, such as the lack of appropriately tailored dietary counseling to Arab as well as ultraorthodox populations. Lack of awareness to the effects of socio-economic determinants in treatment plans, such as prescribing medications and treatments that the patients cannot afford Lack of integration among care providers, a case manager of sorts, to help mitigate the sense of 'being lost' those patients and their families feel while trying to navigate the system.
3. Lack of infrastructure -both patients and providers talked of the effect the problematic Galilee infrastructure and lack of budget have on access to and quality of care. Not enough specialists in the periphery; Lack of specialist clinics, such as foot clinics and distance and problematic public transportation make access incredibly di cult.
It is important to note that the community representatives differed in their 'pain perspectives'. While municipal representatives knew the overall macro burdens regarding access to care, they lacked a deeper understanding of the barriers affecting patients that NGOs representatives expressed. Interestingly, we did not nd a difference, but rather a consensus in the 'pains' perceived by community and health care representatives across the ve municipal Galilee clusters.
The discussion on gains was dominated by the health system representatives, who shared the many activities, interventions and services provided to improve care. These included patient education activities, community volunteering to improve prevention awareness, technological innovations such as development of new apps or remote care infrastructure.

Potential solutions and collaborations
Both system and community representatives worked together to ascertain possible solutions and collaborations to improve care in the region. We identi ed in the ve municipal clusters three common over-arching areas for intervention and improvement: Improvement of care provision, community-based partnerships to improvement prevention awareness, and institutional integrated care model to provide quality care.
1. Improving the quality of care -interventions included: Creating an infrastructure for patient-familyprovider partnership to improve care; Professional training not only on clinical but cultural and community focused practices; Provision of remote accessible services such as 24/7 pharmaceutical service; Addressing the psychological and not only the clinical aspects of chronic disease as part of treatment; Creating system support for assisting disadvantaged patients in acquiring medications, healthy foods, and exercise.
2. Community-based prevention partnerships -the community representatives mentioned that often, they are interested in setting-up such partnerships, but do not always have the skills or tools to do so.

Solutions suggested included: A 'Health Promotion and Prevention
Van' that would travel between different communities with relevant educational materials; Creating a community wellness infrastructure for at risk patients such as subsidized memberships to the gym; Creating community-health systemeducation system partnerships to address prevention from an early age and creating strong voluntary health promotion counselors made up of retired health professionals that reside in the region.
3. Creating a regional integrated care model -bringing together third and private sectors, municipalities, and the healthcare system to create an integrated care model to address the care pathway from prevention to care. This includes building a complex multi-faceted model in which all partners work together and invest resources. While there were small nuances in the model suggested, such as the place of religious leaders within the care-provision model, all groups believed that creating a holistic care model is essential for the region.

Discussion
We conducted the rst-ever community health needs assessment (CHNA) in the Galilee region. Our main goals were to identify the needs, problems, and strengths as the diverse Galilee communities perceived them. As Marmot stated, empowering individuals and communities is key to reducing health inequities and promoting populations' health [20][21][22]. The ndings of this CHNA can serve as a basis for designing and implementing interventions to improve not only the living conditions but reduce health inequities for Galilee residents so that they may live ourishing lives regardless of their place of residence, gender, ethnicity, and socio-economic status.
Our multivariate analysis ndings show that municipal clusters were not signi cantly different in their health needs and perceptions of social determinants. As such, the Galilee region can be perceived as a fairly homogenous geographical area. Common health needs included health promotion and preventive medicine, access to community health services and specialists, and chronic diseases (cancer, diabetes, and obesity). These ndings were also supported by focus groups participants that highlighted the low awareness and lack of supporting policies for health prevention. They also stated that the main barriers to attaining quality health care such include access to technology and professional training as well as the lack of providers' awareness to tailoring services that address the diverse communities' characteristics and needs alongside the lack of infrastructure and access to community health services and specialists.
Interestingly, ethnicity was the major driver for differing perceptions of health problems. While common issues of health promotion and preventive medicine were shared by both Arab and Jewish respondents, Arabs signi cantly perceived diabetes, obesity, and violence as the most pressing health problems. Both Jewish and Arab respondents identi ed social and structural problems such as residence near a polluting factory, poverty, and the need for affordable housing as concerns. However, Arabs reported more social problems than Jews, such as ethnic discrimination, domestic violence, child abuse, affordable childcare, lack of parks and recreation, neighborhood violence, a place to exercise, school dropout, and limited access to healthy food.
The differences observed in our survey between Arab and Jewish communities, albeit similarities attributed to residing in the same regional unit, demonstrate the "double periphery" phenomenon [23]. The Arab population residing in the north of the country suffers not only from residing in the geographic periphery but also from peripheral social status due to their ethnicity. The double periphery analytical and theoretical framework views peripherality as the politicization of remoteness, distinctiveness, and dependence, combined with the peripherality of minorities [24,25]. A recent report published by the Taub Center, comparing between the Arab and Jewish communities in Israel, found that Arabs are less likely to use health services and primarily specialists [26]. In addition, Arabs are more likely to use health services when their health becomes severe, a pattern of behavior that characterizes lower-income communities and can be in uenced by social and cultural characteristics [27]. These ndings coincide with the annual inequality reports published by the Israeli Ministry of Health in which an ongoing gap between Israel's peripheries and center districts regarding health services use and access, both in the community and hospitals setting as well as shortage of professional medical staff persist [28,29]. When tailoring solutions, one should address the Northern region's geographical similarities, but bear in mind the ethnicity-based differences that require equitable resource allocation for the Arab society as well as culturally competent social and health services.
Despite an array of perceived health needs and challenges, sense of community was perceived as a strength by all clusters, regardless of ethnicity, and was seen as an added value for living in the Galilee. It has been recognized that poor health found in deprived communities is a result not only of low socioeconomic status but also low sense of community [30,31]. Improving the sense of community through social activities, integration and communication can offset an individual and community's wellbeing and reducing the harmful health effects of social isolation [32][33][34]. Consequently, a recent study demonstrated that strengthening disadvantaged communities by empowering their sense of place and community as well as creating partnerships between community groups, services providers, health commissioners, and academia may assist in addressing societal and structural health inequities [35].
CHNA surveys may be a useful tool for promoting sense of community and addressing structural inequities by bringing to light needs of the periphery alongside downstream policies. Civil society organizations and academia have long examined the state of health in the peripheries and offered alternative solutions to current health system models [12]. One such example is the work done by Northern Ontario School of Medicine (NOSM). NOSM, located in the underserviced rural communities of northern Ontario, engaged these communities and identi ed their need to develop a health workforce that is sustainable and responsive to community needs [36,37]. Similarly, the Azrieli Faculty of Medicine, Bar-Ilan University operates out of and within the northern periphery of Israel. As such, it views itself as a partner in developing upstream processes, by mapping and identifying needs as well as developing and implementing interventions. We believe that enabling communities to become active players in shaping their lives and responding to their perceived needs will strengthen their trust in local institutions.

Limitations
There are a number of limitations to the snowball methodology we adopted. Our sample is lacking in representation of different Galilee communities, mainly Arab speaking and Jewish Ultraorthodox communities. As this survey was disseminated electronically, it was di cult to reach ultraorthodox residents who do not use electronic interface or social media [39]. Additionally, as can be seen, we encountered low response rates among the Arab sector. We consulted local experts from the Galilee Society Research Institute, which conducts the largest Arab household survey in the country, to better understand this phenomenon [40] Interviews we conducted with the director and head of research of the Galilee Society highlighted that low response rate to surveys conducted in Arabic is not uncommon in Israel. Lack of trust and political climate were described as major barriers in conducting surveys in the Arab population [41]. To overcome this and encourage response and trust, we asked for assistance in dissemination through key stakeholders in the Arab Galilee ecosystem, such as the Galilee Society Research Institute, Faculty members, and leading municipal leaders. Additionally, we strategically sought out the participation of representatives from the Arab and Jewish ultraorthodox communities in the focus groups conducted. The analysis did not reveal signi cant different perceptions than those found in the CHNA survey.

Conclusions
Our study ndings highlight Galilee residents, perceived major health problems and needs, and a lack of health security. Particularly, the Arab community perceived more structural and social inequities than the Jewish residents. The study's ndings raise the need to create diverse responses both in terms of health services and social determinants. To address the concerns and needs of the Galilee population a possible suggested solution is to use existing community resources and increase accessibility and quality of care through integration of services of the different health and community services providers. Implementing such interventions require tailoring to the Galilee residents, socioeconomic-cultural-geographical characteristics, providing ultimately not only health security to all residents, but reducing the persisting health inequities.

Declarations
Ethical Approval and Consent to participate Ethics approval for the study was obtained from the Azrieli Faculty's ethical review board #10-2019.

Consent for publication
Not applicable.
Availability of data and materials Not applicable.
Competing interests SS serves as an associate editor on the editorial board of the IJEqH.

Funding
This study was supported by a planning grant received from The Russell Berrie Foundation.
Authors' contributions NRG and MGO completed all analyses and prepared an initial draft of the manuscript. SS supported planning of the methods, data collection and approach and contributed and reviewed the initial draft. All authors contributed to conceptualizing the project, to interpretation of ndings, and provided critical revisions to the manuscript. All authors reviewed the manuscript.