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.
Respondents were predominantly female (77.3%), Jewish (86%), secular (66.8%) with academic diplomas (73.9%), and middle class according to their reported monthly household income (13,000-17,000 NIS (22.3%), 17,001 – 24,000 NIS (20.8%)). About 53% of respondents' age ranged from 40-64, and on average, they had three kids. 78.3% of the respondents lived in a village (Table 1).
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 significant 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).
Table 1
Sample characteristics for the entire sample and by Ethnicity
|
|
Total
N (%)
|
Jewish N=645
|
Arab
N=105
|
P.value
|
Sex (%female)
|
580 (77.3)
|
514 (79.7)
|
66 (62.9)
|
P<0.001
|
Age
|
|
|
|
|
18-29
|
57 (7.6)
|
37 (5.7)
|
20 (19)
|
P<0.001
|
30-39
|
180 (24)
|
149 (23.1)
|
31 (29.5)
|
40-49
|
200 (26.7)
|
166 (25.7)
|
34 (32.4)
|
50-64
|
196 (26.1)
|
179 (27.8)
|
17 (16.2)
|
65-74
|
99 (13.2)
|
96 (14.9)
|
3 (2.9)
|
+75
|
18 (2.4)
|
18 (2.4)
|
0
|
Religion
|
|
|
|
|
Jewish
|
645 (86)
|
645 (100)
|
0
|
P<0.001
|
Christian
|
47 (6.3)
|
0
|
47 (44.8)
|
Muslim
|
42 (5.6)
|
0
|
42 (40)
|
Druze
|
16 (2.1)
|
0
|
16 (15.2)
|
Religiosity
|
|
|
|
|
Not religious
|
501 (66.8)
|
458 (71)
|
43 (41)
|
P<0.001
|
Not so religious
|
100 (13.3)
|
62 (9.6)
|
38 (36.2)
|
Religious
|
98 (13.1)
|
85 (13.2)
|
13 (12.4)
|
Very Religious
|
28 (3.7)
|
26 (4)
|
2 (1.9)
|
Don't know
|
23 (3.1)
|
14 (2.2)
|
9 (8.6)
|
Education
|
|
|
|
|
High School diploma
|
100 (13.3)
|
91 (14.1)
|
9 (8.6)
|
P=0.021
|
Professional school
|
96 (12.8)
|
90 (14)
|
6 (5.7)
|
BA
|
302 (40.3)
|
250 (38.8)
|
52 (49.5)
|
MA and above
|
252 (33.6)
|
214 (33.2)
|
38 (36.2)
|
Household Monthly Income
|
|
|
|
|
Less than 2500 NIS
|
13 (1.8)
|
11 (1.8)
|
2 (2)
|
P=0.353
|
2,501-4,000 NIS
|
17 (2.4)
|
12 (2)
|
5 (4.9)
|
4,001-5,000 NIS
|
20 (2.8)
|
16 (2.6)
|
4 (3.9)
|
5,001-6,500 NIS
|
27 (3.8)
|
21 (3.5)
|
6 (5.9)
|
6,501 – 8,000 NIS
|
58 (8.2)
|
49 (8.1)
|
9 (8.8)
|
8,001 - 10,000 NIS
|
80 (11.3)
|
71 (11.7)
|
9 (8.8)
|
10,001 – 13,000 NIS
|
87 (12.3)
|
79 (13)
|
8 (7.8)
|
13,001 – 17,000 NIS
|
158 (22.3)
|
140 (23)
|
18 (17.6)
|
17,001 – 24,000 NIS
|
148 (20.8)
|
122 (20.1)
|
26 (25.5)
|
Over 24,001 NIS
|
102 (14.4)
|
87 (14.3)
|
15 (14.7)
|
Municipal clusters
|
|
|
|
Eastern Galilee
|
424 (56.5)
|
410 (63.6)
|
14 (13.3)
|
P<0.001
|
Western Galilee – Beit
HaKerem
|
165 (22)
|
153 (23.7)
|
12 (11.4)
|
Galil Amakim - Kineret Amakim
|
161 (21.5)
|
82 (12.7)
|
79 (75.2)
|
Locality
|
|
|
|
|
City
|
163 (21.7)
|
138 (21.4)
|
25 (23.8)
|
P=0.578
|
Village
|
587 (78.3)
|
507 (78.6)
|
80 (76.2)
|
Perceived health status
|
|
|
|
|
Not good
|
63 (8.5)
|
59 (9.2)
|
4 (3.8)
|
P=0.001
|
Good
|
325 (43.6)
|
291 (45.5)
|
34 (32.4)
|
Very good
|
357 (47.9)
|
290 (45.3)
|
67 (63.8)
|
Children number (Mean±SD)
|
2.64 (1.48)
|
2.77 (1.47)
|
2.0 (1.41)
|
P<0.001
|
Table 2
Community Health Needs Assessment survey by Ethnicity
|
|
Total
N=750
|
Jewish N=645
(86%)
|
Arab N=105
(14%)
|
P. value
|
Community strengths (%yes)
|
|
|
|
|
Quality of life
|
230 (30.3)
|
211 (32.7)
|
15 (14.3)
|
P<0.001
|
Sense of community
|
593 (78.1)
|
527 (81.7)
|
58 (55.2)
|
P<0.001
|
Community services
|
174 (22.9)
|
156 (24.2)
|
18 (17.1)
|
P=0.11
|
Health needs of the community (%yes)
|
|
|
|
|
Health promotion and preventive medicine
|
110 (14.5)
|
87 (13.5)
|
22 (21)
|
P=0.04
|
Hospitals
|
89 (11.70)
|
75 (11.6)
|
14 (13.3)
|
P= 0.62
|
Community mental health services
|
19 (2.50)
|
18 (2.8)
|
1 (1)
|
P= 0.27
|
Emergency services
|
135 (17.8)
|
122 (18.9)
|
10 (9.5)
|
P=0.02
|
Childcare
|
119 (15.70)
|
98 (15.2)
|
20 (19)
|
P= 0.32
|
Elderly services
|
128 (16.90)
|
107 (16.6)
|
18 (17.1)
|
P=0.88
|
Community health services
|
361 (47.60)
|
306 (47.4)
|
53 (50.5)
|
P= 0.56
|
Access to specialists
|
251 (33.1)
|
209 (32.4)
|
39 (37.1)
|
P= 0.34
|
Health problems (%yes)
|
|
|
|
|
Age-related illness
|
322 (42.9)
|
305 (47.3)
|
17 (16.2)
|
P<0.001
|
Cancer
|
400 (53.3)
|
339 (52.6)
|
61 (58.1)
|
P= 0.29
|
Dental problems
|
130 (17.3)
|
119 (18.4)
|
11 (10.5)
|
P=0.045
|
Diabetes
|
207 (27.6)
|
154 (23.9)
|
53 (50.5)
|
P<0.001
|
Heart disease and stroke
|
213 (28.4)
|
176 (27.3)
|
37 (35.2)
|
P=0.094
|
Infectious diseases
|
63 (8.4)
|
62 (9.6)
|
1 (1)
|
P= 0.003
|
Lung disease (COPD)
|
36 (4.8)
|
33 (5.1)
|
3 (2.9)
|
P=0.32
|
Mental Health
|
138 (18.4)
|
126 (19.5)
|
12 (11.4)
|
P=0.047
|
Mother and Infant Health
|
227 (30.3)
|
221 (34.3)
|
6 (5.7)
|
P<0.001
|
Motor and Vehicle Crash
|
68 (9.1)
|
47 (7.3)
|
21 (20)
|
P<0.001
|
Obesity
|
145 (19.3)
|
110 (17.1)
|
35 (33.3)
|
P<0.001
|
Smoking
|
72 (9.6)
|
51 (7.9)
|
21 (20)
|
P<0.001
|
Sexual Transmitted Infections
|
2 (0.3)
|
2 (0.3)
|
0
|
P=0.568
|
Substance Abuse
|
37 (4.9)
|
28 (4.3)
|
9 (8.6)
|
P=0.06
|
Violence
|
30 (4.0)
|
4 (0.6)
|
26 (24.8)
|
P<0.001
|
Other
|
6 (0.9)
|
6 (0.9)
|
0
|
P=0.321
|
Don't know
|
19 (2.6)
|
19 (2.9)
|
0
|
P=0.216
|
Social and structural determinants of health (%yes)
|
|
|
|
|
Residence near a polluting factory
|
45 (6.0)
|
34 (5.3)
|
11 (10.5)
|
P=0.037
|
Race/ethnicity discrimination
|
18 (2.4)
|
6 (0.9)
|
12 (11.4)
|
P<0.001
|
Pollution
|
50 (6.6)
|
37 (5.7)
|
13 (12.4)
|
P=0.011
|
Access to mental health services
|
185 (24.6)
|
178 (27.6)
|
7 (6.7)
|
P<0.001
|
Domestic violence
|
14 (1.8)
|
4 (0.6)
|
10 (9.5)
|
P<0.001
|
Access to transportation
|
274 (36.5)
|
268 (41.6)
|
6 (5.7)
|
P<0.001
|
Poverty
|
40 (5.3)
|
31 (4.8)
|
9 (8.6)
|
P=0.111
|
Affordable housing
|
43 (5.8)
|
30 (4.7)
|
13 (12.4)
|
P=0.002
|
Child abuse/neglect
|
16 (2.1)
|
6 (0.9)
|
10 (9.5)
|
P<0.001
|
Affordable childcare
|
103 (13.7)
|
79 (12.2)
|
24 (22.9)
|
P=0.003
|
Parks and recreation
|
160 (21.3)
|
97 (15)
|
63 (60)
|
P<0.001
|
Neighborhood safety/violence
|
49 (6.5)
|
16 (2.5)
|
33 (31.4)
|
P<0.001
|
Limited places to exercise
|
173 (22.9)
|
136 (21.1)
|
37 (35.2)
|
P=0.001
|
Lack of job opportunities
|
246 (32.8)
|
237 (36.7)
|
9 (8.6)
|
P<0.001
|
School dropout/poor schools
|
40 (5.3)
|
23 (3.6)
|
17 (16.2)
|
P<0.001
|
Limited access to healthy food
|
92 (12.3)
|
71 (11)
|
21 (20)
|
P=0.009
|
Access to a doctor's office
|
445 (59.3)
|
436 (67.4)
|
9 (8.6)
|
P<0.001
|
Other
|
54 (7.2)
|
52 (9.9)
|
2 (1.9)
|
P=0.024
|
Don't know
|
7 (0.9)
|
7 (1.1)
|
0
|
P=0.283
|
Table 3
Community Health Needs Assessment survey by Municipal Clusters
|
|
Western Galilee - Beit HaKerem N=167 (22%)
|
Eastern Galilee
N=431
(56.8%)
|
Galil Amakim- Kineret Amakim
N=161
(21.2%)
|
P. value
|
Community strengths (%yes)
|
|
|
|
|
Quality of life
|
61 (36.5)
|
132 (30.6)
|
37 (23)
|
P=0.028
|
Sense of community
|
141 (84.4)
|
350 (81.2)
|
102 (63.4)
|
P<0.001
|
Social services
|
42 (25.1)
|
97 (22.5)
|
35 (21.7)
|
P=0.729
|
Health needs of the community (%yes)
|
|
|
|
|
Health promotion and preventive medicine
|
36 (21.6)
|
49 (11.4)
|
25 (15.5)
|
P=0.006
|
Hospitals
|
22 (13.2)
|
55 (12.8)
|
12 (7.5)
|
P=0.163
|
Community mental health services
|
5 (3)
|
10 (2.3)
|
4 (2.5)
|
P=0.894
|
Emergency services
|
32 (19.2)
|
80 (18.6)
|
23 (14.3)
|
P=0.418
|
Childcare
|
21 (12.6)
|
64 (14.8)
|
34 (21.1)
|
P=0.08
|
Elderly services
|
20 (12)
|
79 (18.3)
|
29 (18)
|
P=0.161
|
Community health services
|
71 (42.5)
|
208 (48.3)
|
82 (50.9)
|
P=0.283
|
Access to specialists
|
53 (31.7)
|
136 (31.6)
|
62 (38.5)
|
P=0.225
|
Health problems (%yes)
|
|
|
|
|
Age-related illness
|
80 (47.9)
|
192 (44.5)
|
56 (34.8)
|
P=0.041
|
Cancer
|
89 (53.3)
|
231 (53.6)
|
83 (51.6)
|
P=0.905
|
Dental problems
|
21 (12.6)
|
88 (20.4)
|
23 (14.3)
|
P=0.038
|
Diabetes
|
53 (31.7)
|
106 (24.6)
|
49 (30.4)
|
P=0.133
|
Heart disease and stroke
|
32 (19.2)
|
135 (31.3)
|
48 (29.8)
|
P=0.011
|
Infectious diseases
|
8 (4.8)
|
48 (11.1)
|
8 (5)
|
P= 0.009
|
Lung disease (COPD)
|
11 (6.6)
|
23 (5.3)
|
3 (1.9)
|
P=0.111
|
Mental Health
|
35 (21)
|
76 (17.6)
|
29 (18)
|
P=0.634
|
Mother and Infant Health
|
43 (25.7)
|
156 (36.2)
|
31 (19.3)
|
P<0.001
|
Motor and Vehicle Crash
|
19 (11.4)
|
26 (6)
|
23 (14.3)
|
P=0.003
|
Obesity
|
33 (19.8)
|
65 (15.1)
|
47 (29.2)
|
P=0.001
|
Smoking
|
11 (6.6)
|
34 (7.9)
|
28 (17.4)
|
P=0.001
|
Sexual Transmitted Infections
|
0
|
1 (0.2)
|
1 (0.6)
|
P=0.538
|
Substance Abuse
|
15 (9)
|
10 (2.3)
|
12 (7.5)
|
P=0.001
|
Violence
|
0
|
3 (0.7)
|
27 (16.8)
|
P<0.001
|
Other
|
1 (0.6)
|
6 (1.4)
|
0 (2.5)
|
P=0.225
|
Don't know
|
8 (4.8)
|
9 (2.1)
|
3 (1.9)
|
P=0.142
|
Social and structural determinants of health (%yes)
|
|
|
|
|
Residence near a polluting factory
|
24 (14.4)
|
9 (2.1)
|
13 (8.1)
|
P<0.001
|
Race/ethnicity discrimination
|
0
|
8 (1.9)
|
10 (6.2)
|
P=0.001
|
Pollution
|
17 (10.2)
|
14 (3.2)
|
19 (11.8)
|
P<0.001
|
Access to mental health services
|
35 (21)
|
126 (29.2)
|
26 (16.1)
|
P=0.002
|
Domestic violence
|
1 (0.6)
|
4 (0.9)
|
9 (5.6)
|
P<0.001
|
Access to transportation
|
76 (45.5)
|
165 (38.3)
|
36 (22.4)
|
P<0.001
|
Poverty
|
5 (3)
|
25 (5.8)
|
10 (6.2)
|
P=0.323
|
Affordable housing
|
14 (8.4)
|
17 (3.9)
|
13 (8.1)
|
P=0.043
|
Child abuse/neglect
|
2 (1.2)
|
8 (1.9)
|
7 (4.3)
|
P=0.112
|
Affordable childcare
|
27 (16.2)
|
50 (11.6)
|
28 (17.4)
|
P=0.118
|
Parks and recreation
|
24 (14.4)
|
74 (17.2)
|
64 (39.8)
|
P<0.001
|
Neighborhood safety/violence
|
5 (3)
|
4 (0.9)
|
40 (24.8)
|
P<0.001
|
Limited places to exercise
|
30 (18)
|
103 (23.9)
|
41 (25.5)
|
P=0.208
|
Lack of job opportunities
|
45 (26.9)
|
174 (40.4)
|
30 (18.6)
|
P<0.001
|
School dropout/poor schools
|
12 (7.2)
|
12 (2.8)
|
16 (9.9)
|
P=0.001
|
Limited access to healthy food
|
24 (14.4)
|
50 (11.6)
|
20 (12.4)
|
P=0.653
|
Access to a doctor's office
|
95 (56.9)
|
303 (70.3)
|
54 (33.5)
|
P<0.001
|
Other
|
14 (8.4)
|
36 (8.4)
|
5 (3.1)
|
P=0.074
|
Don't know
|
1 (0.6)
|
4 (0.9)
|
2 (1.2)
|
P=0.830
|
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 significant 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 identified it as such.
Table 3 demonstrates the similarities and differences according to the residence in municipal clusters. Respondents residing in the Western Galilee - Beit HaKerem found the quality of life as a community strength (36.5%), whereas only 23% of respondents from Galil-Kineret Amakim identified it as a strength. Sense of community was identified by most Western and Eastern Galilee residence as a community strength (84.4% and 81.2% accordingly), and by about two third of Galil Amakim residence (63.4%).
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 files). 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 findings 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 fires, helping with fixing 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 significant difference between Arab and Jewish respondents, with about a fifth (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 financial 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 significantly 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.
Table 2s (supplementary files) presents adjusted odds ratios for the association of the independent variables with each community health need. After adjusting for all respondents' characteristics, all the outcomes of the perceived community health needs were not found to be significant (p>0.0012).
Identified Health Problems
When assessing needs according to respondents' ethnicity, we found significant 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%). Besides cancer and cardiovascular disease, Jews identified additional major health problems to be age-related Illnesses such as arthritis, vision/hearing loss, dementia (47.3%), and mother and Infant health (34.3%). In comparison, Arab respondents identified additional major health problems to be: diabetes (50.5%), obesity (33.3%) and violence (24.8%) (Table 2).
Health problems were found to be significantly different according to the clusters of residence, with age-related illness identified by 47.9% of the 'Western Galilee - Beit HaKerem" as a major issue; Eastern Galilee respondents identified heart disease and stroke (31.3%) and mother and infant health (36.2%) as their major health problems; Obesity was identified as a health problem by "Galil Amakim- Kineret respondents" (29.2%); Smoking was identified by 17.4% of "Galil Amakim- Kineret Amakim" respondents. Finally, violence was identified as a health problem by 16.8% of "Galil Amakim- Kineret Amakim" respondents (Table 3).
Table 3s (supplementary files) 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 significant, 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
Identification of structural social determinants and their effect on community health differed significantly between Arabs and Jews in all aspects (Table 2), apart from poverty, which was shared by both communities. Access to a doctor's office (67.4%), access to transportation (41.6%), and lack of job opportunities (36.7%) were the three most important barriers perceived by Jews. Access to mental health services was also found as an essential barrier (27.6%). Survey findings in Arabic reflect a different picture in which parks and limited places to exercise (60%, 35.2% accordingly), neighborhood safety (31.4%), and affordable childcare (22.9%) were perceived as the structural social determinants impeding communities' health (Table 2).
Respondents from "Galil Amakim- Kineret Amakim" significantly identified Parks and recreation (39.8%), access to a doctor's office (33.5%), neighborhood safety/violence (24.8%), access to transportation (22.4%), and access to mental health services (16.1%) as the most important social and structural determinants of health. Interestingly, respondents from the Eastern Galilee cluster identified access to a doctor's office (70.3%), lack of job opportunities (40.4%), and access to mental health services (29.2%) as the main social and structural determinants of health. Similar to the eastern Galilee cluster, residents in the Western Galilee - Beit HaKerem clusters identified access to a doctor's office (56.9%) as an important social structural determinant, but in addition stated that access to transportation as important (45.5%), and to a lesser extent parks and recreation (14.4%) (Table 3).
Tables 4s and 4.1s (supplementary files) 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 office 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 office 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 fit 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 fit 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 difficult.
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 find a difference, but rather a consensus in the 'pains' perceived by community and health care representatives across the five 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 identified in the five 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-family-provider 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 system-education 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.