What can we learn from the Jerusalem Community–Academic Partnership case study in an ultra-orthodox neighborhood?

Abstract

Community–academic partnerships can be useful models for sustainable interventions. The Jerusalem Community–Academic Partnership (J-CAP) was established to address local health needs identified by a population survey. It engaged stakeholders and public health students as part of their training. We describe the establishment and processes of this partnership over a 3-year period.

Part 1 of the program entailed mapping and undertaking a quality assessment of health promotion (HP) programs in Jerusalem. Part 2 (Years 2 and 3), described herein, entailed a participatory process wherein a particular neighborhood, with a predominantly Ultra-Orthodox population, was chosen for intervention. A local steering committee was set up, and students assessed assets and needs by direct observation, in-depth interviews, and focus groups, followed by the development of intervention programs using a participatory process. Neighborhood assets and needs identified in the first year served as a basis for the participatory process of developing intervention programs. Assets identified included the local community center and swimming pool. Barriers to a healthy lifestyle included a lack of health literacy, time constraints, socioeconomic factors, and local lifestyle and environmental characteristics. Students focused on public spaces, preschool children, and young women and mothers when designing, together with local leaders, intervention programs related to healthy nutrition and physical activity. The participatory process contributed to strengthening partnerships among several services and agencies investing in the health of Jerusalem residents. The students’ critical service-learning contributed to their understanding of HP in the real world and the local community. The students’ reports, which were submitted to the community center management, could serve to inform future interventions.

Introduction

Participatory processes among professionals and stakeholders can contribute to the quality and sustainability of health promotion (HP) interventions (1–3). Case studies have been published in recent years describing the added value of these processes to academia, service providers, and the community. However, very few reports describe these processes systematically and in detail to enable evaluation of their effectiveness (4).

The initiators of the Jerusalem Community–Academic Partnership are members of a School of Public Health with a long-standing tradition of multi-disciplinary teamwork involving the community. The School’s founders developed the community-oriented primary care (COPC) (5) model in the 1940s in South Africa (6,7), bringing it to Jerusalem in 1959 (8). They pioneered the concept of combining the social determinants of health with a ‘community diagnosis,’ which assesses the health needs of a defined population, as well as involving the community in that process. This concept was incorporated into training for students.

Several terms are used to describe community-partnered research, like CBPR (community-based participatory research) or action research. The most recent one is community–academic partnership (CAP) (4). Drahota et al. (1) suggest using the term CAP to describe initiatives characterized by equitable control by the relevant community and academic researchers, and shared goals that are relevant to that specific community. However, in their systematic review, most of the CAP case studies did not report partner characteristics (1).

Pellecchia et al. (4) suggested several implementation strategies that are relevant for CAP, including: ‘(a) building a coalition, (b) conducting local consensus discussions, (c) identifying barriers and facilitators to implementation, (d) facilitating interactive problem-solving, (e) using an advisory board or workgroup, (f) tailoring strategies, (g) promoting adaptability, and (h) auditing and providing feedback.’ All of these strategies are specifying the ‘group dynamic/equitable partnership’ dimension of the CBPR model, described by Wallerstein et al. (9).

The Jerusalem CAP (J-CAP) for promoting healthy nutrition and physical activity was established in 2017. It followed a needs assessment of Jerusalem residents, which indicated that only 12% performed the recommended amounts of physical activity, and only 17.6% consumed five fruits and vegetables daily (10). J-CAP established a coalition of stakeholders and incorporated the training of students pursuing master’s degrees in public health (MPH) over three academic years. The first J-CAP project was a systematic mapping and quality assessment of health-promoting programs addressing healthy nutrition and physical activity operating in Jerusalem (11,12). A subsequent project, described herein, focused on an Ultra-Orthodox neighborhood in West Jerusalem, where MPH students and the community center were engaged as partners. A conservative, strict religious observance, modest dress, large family sizes, and the separation of men and women during prayer and in many social activities characterize the Ultra-Orthodox lifestyle (13).

We aim to describe the process of the J-CAP project following the eight implementation strategies suggested by Pellecchia et al. (4), analyze the implementation within this Ultra-Orthodox neighborhood according to the CBPR dimensions/domains and constructs, and present what we have learned from this specific process and outcome.

Methods

As previously mentioned, the J-CAP project included two parts, the first was more general and focused on the entire Jerusalem municipality, and the second was specific to the Ultra-Orthodox neighborhood chosen for the project’s implementation. The two parts used the eight strategies advocated by Pellecchia et al. (4) to guide the description of the partnership processes.

Part 1. J-CAP initiation

Building a coalition and conducting consensus discussions

At the J-CAP coalition’s first steering committee meeting, a consensus discussion took place. The coalition included representatives of the Jerusalem municipality, the district health office, health maintenance organizations (HMOs), non-governmental organizations (NGOs), and academia. All coalition members were involved in HP in Jerusalem.

At the meeting, the framework of the proposed collaboration was presented and discussed. This included mapping and evaluating HP programs in Jerusalem and focusing on one neighborhood. Participants shared their experience implementing programs and activities, and the matching of expectations was conducted.

Identifying barriers and facilitators to implementation, and facilitating interactive problem-solving

The main barrier identified at the first meeting was that evaluating the quality of the programs was perceived as judgmental and posed a potential threat for some J-CAP partners. A consensus was reached that mapping and evaluating the HP programs would serve the purpose of improving existing activities on a citywide basis, without singling out individual programs for criticism. Two facilitators to implementation were identified: 1. a research grant that enabled the appointment of a project coordinator; and 2. the opportunity to involve MPH students as part of their public health training via participation in a workshop during their final semester, providing a summative experience to integrate the knowledge and skills acquired during their 2-year degree program. The project coordinator, who worked jointly with all partners, enabled interactive problem-solving.

Identification and evaluation of HP programs in Jerusalem and providing feedback and additional training

The first stage of identifying and evaluating the various existing HP programs in Jerusalem using the European Quality Instrument for Health Promotion tool has been previously described (11). The results of this effort were presented to the steering committee. The evaluation revealed a need for capacity building of HP workers in the municipality sector. A training course was offered to coordinators at the neighborhood level, providing them with the basic knowledge and skills for preparing and implementing HP programs. As a result of the initial findings, we decided to focus on one neighborhood for a more extensive participatory intervention.

Part 2. A case study for a participatory intervention

The chosen neighborhood is very densely populated with 21,000 inhabitants, primarily Ultra-Orthodox, of whom 33% are aged 0–12 years. The neighborhood was chosen for intervention based on the following criteria: a. the Ultra-Orthodox population in Jerusalem had meager participation rates in physical activity and low rates of consumption of the recommended quantity of fruits and vegetables per day (10); b. the neighborhood had a low density of HP programs (12); and c. the neighborhood health coordinator (E.G.) who was nominated by the community center had participated in the training course mentioned above and was recommended by the training provider as being highly dedicated to HP. This neighborhood was chosen despite the known barriers to collaborative projects in an Ultra-Orthodox community (14).

Using an advisory board or workgroup

The participatory process, spread over two academic years, started by engaging the director of the neighborhood community center (A.G.) as a member of the J-CAP coalition. After that, a working group was assembled that included the community center director and her team, the health coordinator of the Jerusalem municipality, the health promotor of the regional office for health, a health promoter of the largest HMO in the neighborhood, and academic faculty members.

Tailoring strategies and promoting adaptability

• 1) Step 1. During the 2018 academic year, MPH students performed a local needs assessment and asset mapping. The assessment included interviews of seven key informants, three focus groups (young mothers, young women, and a group of older adults, who were invited by the director of the community center), and observations of the built environment and food stores using PhotoVoice (documentation by photos to reflect reality). Students observed main roads as well as small alleys. They recorded and transcribed the interviews and focus group discussions and then divided them into themes, categories, and subcategories (15). A group of four students analyzed the data manually and revealed connections between the categories. The results were presented (see below) to the J-CAP steering committee and discussed. A decision was made to establish a local (neighborhood) steering committee for developing subsequent intervention programs.

• 2) Step 2. The second step, involving students during the 2019 academic year, was the development of appropriate HP programs. Students took part in the first meeting of the local steering committee, which included the community center director and team members, the J-CAP working group, and women (mostly Ultra-Orthodox) volunteers from the community. During the first meeting, the needs assessment results and recommendations were presented and discussed. There was agreement by all participants on the HP programs’ primary goals: 1. increasing consumption of fruits, vegetables, and tap water; 2. decreasing sugar consumption; and 3. increasing awareness of the importance of healthy nutrition and physical activity. Three working groups were established, composed of students and members of the steering committee, each group guided by an academic teacher. The groups focused on 1. public spaces, 2. preschool children, and 3. young women and mothers. ¹ Each group utilized different and various tools to collect the additional data needed for the development of the intervention program:

  • 1. The public spaces group collected data by PhotoVoice and interviewed key informants.

  • 2. The preschool children’s group focused on mapping the existing programs and activities in the community by interviewing the health coordinator. Information on children’s health behaviors could not be collected as the directors of the nursery schools and kindergarten refused to cooperate with the J-CAP project, even though the initial contact and request for collaboration was made by a female student, who herself belonged to the Ultra-Orthodox community.

  • 3. The young women and mothers’ group collected data on healthy eating and physical activity, as well as on obstacles and facilitating factors, using a self-administered questionnaire comprising 20 questions that were mostly open-ended, and filled in electronically or by hand. Volunteers from the community took part in these data collection efforts. The students presented the information collected to the local steering committee, where the local partners added new information. The discussion prompted ideas regarding potential interventions.

Auditing and providing feedback

Based on the data collected and discussions in the local steering group, students jointly prepared detailed programs (goals, objectives, activities, evaluation) with members of their working groups. The local steering committee members adopted the programs at their last meeting. As the community leaders had control over the decision-making process, they were able to implement several of the proposed programs in the community center, supported by the research grant.

Program steps, findings and outputs

Step 1

The assets and needs assessed in 2018, which provided the context domain of the CBPR in the neighborhood, were divided into two main categories: personal and environmental factors, which were further subdivided (Table 1). Two main assets were identified: a high level of awareness of a healthy lifestyle, and the community center’s existing activities, some in cooperation with the main HMO serving the neighborhood. Despite this awareness, lifestyle practices prevalent in this Ultra-Orthodox community presented obstacles to practicing healthy behaviors. The community is of a relatively low socioeconomic status. Men mainly devote their lives to learning the Torah (Jewish studies), whereas women must financially support the family while taking care of their children (a mean of 6.6 per family) (16,17) and housekeeping. For men, time spent on physical activity is perceived as a waste of precious hours that should be dedicated to Torah studies. For women, there is not enough free time. Another obstacle is the lack of appropriate spaces for physical activity performance, as culturally, these need to be gender segregated.

Table 1.

Description of assets, needs, and deficiencies determined in the assessment of the intervention neighborhood—categories and quotations.

	Category	Subcategory	Quotations
Assets	Personal factors	Knowledge and awareness	‘Healthy lifestyle is everything: physical activity, healthy nutrition, mental health.’‘Women develop an awareness of health, and they bring it home.’
	Environmental factors	The community center	‘The community center is centrally located and provides a variety of activities.’‘There are gym classes also for adults.’
		A swimming pool	‘There is a swimming pool in the neighborhood, and many children participate in swimming classes, supported by an HMO.’
		Facilitating action by the community center and HMO	‘The community center is very attentive to the residents. They distribute questionnaires to learn about their needs and aspirations and plan their activities accordingly.’‘Baby-land program (a result of a needs assessment) contributes to women’s mental and physical health.’‘Collaboration between the community center and the HMO initiated a weight-reduction group.’
Needs anddeficiencies (obstacles)	Personal factors	Socioeconomic status (SES)	‘Most of the neighborhood residents are of low SES.’‘The pool is costly.’‘Healthy products are too expensive.’
		Lack of time	‘In multi-child families, mothers can hardly find time for themselves.’‘Time is a critical factor. Physical activity should be accessible, not only the matter of cost but also physically accessible. If it wastes time in getting there, they will not do it.’
		Health literacy	‘There are insured people who don’t know that their HMO provides group workshops on health topics.’‘There is no one to consult with on health issues.’
		Men’s Ultra-Orthodox lifestyle	‘Men are the weak point. They are less aware of health. They don’t have time for physical activity, which is not a normative behavior.’‘They invest more in learning Torah otherwise, it is wasting time.’
		Wishes to remain a separate community	‘We have a problem with mixed groups of Orthodox and Ultra-Orthodox.’‘We can participate in activity only if it is restricted to Yeshiva students.’
	Environmental factors		‘There are not enough parks, they are not clean enough, and there is not enough shade.’‘There is no sports field suited for football or basketball.’‘There is no bicycle lane which is comfortable to ride on.’‘There are not enough playgrounds for children . . ., given their numbers in the community.’

Observations throughout the neighborhood revealed a crowded locality with few well-equipped playgrounds. Food stores and supermarkets had vast displays of junk food and sweets. The prices of fruits and vegetables were disproportionally high, while sweets were very cheap and handy.

Step 2

Each of the three working groups of the 2019 workshop presented the data collected and proposed interventions.

• a) The ‘public spaces’ group. This group described a non-supportive built environment, which included a lack of walking paths and sports facilities, unaesthetic streets, and neglected residential yards. The preferred walking path mentioned by key informants was the forest, located very close to the neighborhood. However, the lack of lighting there prevented use late in the evening when the women have the free time to walk. The JNF (Jewish National Fund) representative, approached by J-CAP representatives, rejected a proposal to light the walking path in the evening, due to possible light pollution and interference with wildlife.

• b) The preschool children’s group. Due to a lack of cooperation with the education system, the J-CAP team decided to reach young children by designing an intervention for young mothers visiting playgrounds with their children.

• c) The young women and mothers’ group. A total of 53 young women responded to the questionnaire. Most (76%) preferred drinking sweet beverages over water, and 52% consumed 0–2 portions of fruits and vegetables per day. The majority mentioned that the main obstacle to consuming more fruits and vegetables is the time and effort needed in preparation (rinsing, cutting). Some mentioned cost as an obstacle. When asked which snacks they usually bring for their children to the playground, 40% brought fruits, and the others sweets or salty snacks. Most reported that convenience is the main reason for choosing the type of snack. As for physical activity, 30% reported doing some physical activity 3–6 times a week, mainly walking. The main obstacle was a lack of spare time, but they expressed that having partners or a group for physical activity might facilitate their participation.

Following the students’ presentations, the local steering committee discussed several intervention programs to achieve the predetermined aims. Specific objectives and measures were defined to achieve these goals, and specific activities (environmental changes, advertising, and activities) were proposed, as well as ways for evaluating them. The local steering committee approved the programs.

Implementation

Prior to the interruptions caused by the COVID-19 pandemic, several activities were implemented by the community center including,

• a) ‘Baby-land’ program for mothers after birth, which promoted physical activity, a typical breakfast, and lectures on health issues;

• b) A program aimed at increasing children’s consumption of fruits and vegetables, comprising advertising the added value of eating fruits and vegetables and a competition in which each child participating in the program received a special card to record daily whether they ate fruits or vegetables. After 2 weeks of monitoring, children participated in a lottery, and three of them won a prize;

• c) At a summer day camp, after the first COVID-19 wave, instructors focused on healthy nutrition and physical activity as well as on healthy creativity; and

• d) The community center team received pedometers, and a healthy breakfast with a vegetable salad and wholewheat bread at every team meeting.

Discussion of the findings and lessons learned

The J-CAP for promoting healthy nutrition and physical activity in Jerusalem combined academic knowledge with an opportunity for practical experience for the students in partnership with service providers and the community. It aimed to develop HP activities for the community and by the community, in this case an Ultra-Orthodox neighborhood with specific needs and challenges. The neighborhood was chosen despite the known potential challenges in obtaining full cooperation, especially from the men. Several studies involving this type of community in Israel describe these challenges and suggest solutions, such as engaging a mediator from the relevant target group (14). The first national health survey of Ultra-Orthodox women was assisted by an Ultra-Orthodox NGO, which had the reputation of being dedicated to HP among this population (18). We believed that establishing contact with the education system via a student from an Ultra-Orthodox background, partnering with the local community center’s leaders and using them as mediators might facilitate the interaction, but the results were mixed.

Many CAP initiatives in academic institutions in Israel have been initiated in the last decade with the stated goal of social change in different communities together with a change in the students’ attitudes and perceptions. All used the term ‘CAP’ to emphasize reciprocity between academia and the community (19), while they varied in terms of the issues addressed and the ways in which students were involved. Golan and colleagues suggested four principles for evaluating the students’ involvement in the community: commitment, continuity, capabilities, and context (19). Although we did not ask students directly, we assume that the students involved in all 3 years of the J-CAP experience were committed to the participatory process and its potential outcomes. In their evaluations of the work-shop experience, students noted that they felt part of a ‘significant’ activity that answered a real need and harnessed the commitment of all partners. One of the student groups commented that ‘the process of becoming acquainted with the neighborhood needs, lifestyle and norms of its residents, was an interesting learning experience and [we] wish it will benefit the community.’

The criterion of continuity seems to be one of the weaknesses of our process. Every year new students were involved in the project for only one semester. However, even though three different groups of students took part in the process, there was some continuity. Having a committed coordinating team in uninterrupted contact with the community center over a 2-year period, enabled that continuity. The Vermont Community–Academic Partnership (20), which teaches public health to medical students through action, solved this issue by focusing on short-term projects involving them in community agencies’ work. Our program involved a structured long-term process that required investment of time and effort.

As students commented, the one-semester course format was too short to complete their complex mission. They had to contribute, voluntarily, several additional hours a week to accomplish their task, investing beyond what is expected in a two-credit course. One lesson learned for future initiatives is that academic partners should adjust the students’ requirements to the time frame allotted in the curriculum or adjust the time frame to the scope of their mission.

As for capabilities developed by practical learning, since Paulo Freire developed his ‘critical pedagogy’ philosophical views of learning (21), it is acknowledged that learning involving practice and a democratic teacher–student relationship is a more significant experience. Adopting this way of learning also increases the interaction between participants and the real world (22). The ‘real world’ to which our students were exposed was a new context for most of them. The interaction with an Ultra-Orthodox community with their unique lifestyle (16,17) presented challenges. One of their characteristics is their desire to remain a separate community, which can create communication barriers. Another characteristic is their distrust of national/secular authorities, including the University. A recent example of that is their reported defiance of the Ministry of Health regulations during the second wave of the COVID-19 outbreak (23). One group of students could not accomplish their task as they had to deal with too many obstacles, and a fruitful collaboration could not be established, despite our efforts. A possible consideration for the future is to involve representatives of the community’s education system and religious leaders in the local steering committee to gain their commitment to the process. Similarly, including a JNF representative in the steering committee might have resulted in a favorable compromise regarding lighting the only available walking path for women.

The students’ role in preparing a needs assessment, analyzing the data, and planning interventions with the community was similar to other CAPs involving schools of public health (2,3,24–26). Mackenzie et al. (3) describe a very similar list of activities, which they termed ‘critical service-learning.’ Their reflections on the experience, similar to ours, included an enhancement of students’ cultural humility as well as developing a ‘triad relationship between student, faculty and community agency.’

Many publications describe the efficiency of including students as service providers while they are being supervised and gaining practical and academic experience. For example, trained medical students monitored outpatients during the COVID-19 out-break and detected problems requiring further treatment (27). By that they contributed both to patient health and reduced the burden on the professional teams, while learning. The Johns Hopkins Bloomberg School of Public Health used the argument of having the free service of students to engage community-based organizations to partner with their students (26). However, as Mackenzie noted ‘Service-learning should be about social change, not just filling a gap in services’ (3).

Another advantage of involving students is that they tend to be less authoritative and patronizing than seasoned professionals. This characteristic might contribute to improved trust in the health and social systems. For example, in Australia, a nursing-student-led clinic (28) focusing on improving health literacy and access to health services in a disadvantaged community succeeded in improving people’s health and saved expenses, along with the ‘removal of medical dominance.’ In Oregon, medical students in their pre-clinical training are engaged in a primary care program focusing on navigating the health system (29). Patients, reflecting on their relationship with the students, reported having ‘a sense of comfort,’ and that they felt that the student was ‘on their side.’ In all those examples, there was a mutual gain for the target community and the students who were exposed to the real life of different populations.

The whole participatory process of the J-CAP, both in general and specifically for the program in the chosen neighborhood, followed the eight strategies suggested by Pellecchia et al. (4). These provided us with guidelines for describing the process. The first five strategies ((a) building a coalition, (b) conducting local consensus discussions, (c) identifying barriers and facilitators to implementation, (d) facilitating interactive problem-solving, (e) using an advisory board or workgroup) specify the partnership processes domain of the CBPR model developed by Wallerstein et al. (9). The combination of the contexts and partnership processes in our case (Wallerstein et al. first and second domains (30,31)), indicated that we had a weak entry point to the process. A CBPR partnership should have equal power relations between all actors (30), however, the J-CAP was the partner deciding on the health issues to deal with, according to the research grant’s goals (physical activity and nutrition). Health is a central construct of the contexts’ domain. The other construct that posed a drawback was the Ultra-Orthodox community’s mistrust of the University (as mentioned above). All the other constructs of the contexts’ domain facilitated the process: the capacity and readiness of academia, comprising the research grant, a project manager, and students as part of their training in public health and HP; and the capacity and readiness of the community center in the chosen neighborhood, as they already had a trained health coordinator and several volunteers from the community, and a funded municipal program to address nutrition and physical activity, at that time. The second domain, partnership process, refers to the structural and relational constructs. The partners of the 2019 academic year were described earlier as well as their involvement in decision making about the primary goals of the intervention, based on a previous year’s data collected by students. Through joint working groups of students and community members, as well as frequent working meetings of the project coordinator with the director of the community center, trust was gradually built. Trust was built by co-creation and humility as well as by establishing shared goals (32). This bi-directional communication and co-learning enabled the implementation of the intervention domain: the planning process involved students and local community volunteers in a participatory process that was empowering for both partners and integrated community knowledge. As for the community center with which we made our joint journey, they confirmed that they gained a lot from the partnership with academia. The director of the community center and its staff are now routinely engaged in HP activities and appreciate their importance. Their central role in the partnership made a major contribution to the sustainability of the HP approach. This expresses the achievement of some constructs of the intermediate outcome domain: changes in community center policy and practice, and culturally based and sustainable interventions (31). The students’ reports, which included the needs and assets assessment as well as the planned suggested programs that were submitted to the community center management, could serve to inform future interventions.

The following summarizes what we have learned from the J-CAP case study in an Ultra-Orthodox neighborhood:

Facilitators

• a. The capacity and readiness of both the academic partners and a community center to commit to a long-term structured process.

• b. Community members had decision-making power.

• c. A continuous, bi-directional communication and co-learning between the academic partners and the community center.

Challenges

• a. Different students each year–a challenge to continuity and long-term trust-building with community members.

• b. Time was too short for completing the students’ tasks.

• c. Cultural/religious distrust of authorities like the University–very difficult to overcome–long-term relationship of 3 years was still not enough (this was one of the weak entry points).

• d. Partners in the steering committee did not include all stakeholders responsible for making implementation decisions.

• e. There was inequality between partners (J-CAP decided on the health issue–one of the weak entry points).

Limitations

Unfortunately, COVID-19 curtailed the later J-CAP activities. As the students claimed, the time allotted did not allow for a deeper process and a more representative sample as a data source. We were able to focus on women’s and children’s needs only as we could not obtain the cooperation of men of the community. Another limitation is that we did not have a structured process evaluation that continued after the academic year.

Conclusion

The J-CAP, which involved MPH students over three academic years, was a platform for strengthening partnerships with several services and agencies investing in the health of Jerusalem’s residents. The students’ critical service-learning contributed both to their understanding of HP in the real world and to the community center and the residents of a community with special needs and challenges. In planning CAP experiences, consideration should be given to accessibility for all segments of the target population as well as to prioritizing activities according to the population’s identified needs.

We would like to thank the study participants, the Jerusalem municipality, and Bayit VeGan community center, who agreed to collaborate with us and share information on existing health promotion initiatives. We also acknowledge the important contribution and assistance in data collection by the graduate students of the Braun School of Public Health, The Hebrew University-Hadassah.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Israel Ministry of Science, Technology and Space (grant no. 313633).

Ethical approval

Ethical approval was granted by the Helsinki committee of the Hadassah Medical Center: HMO-16-0331

ORCID iD

Milka Donchin https://orcid.org/0000-0002-3657-1740

1.

Men in the community expressed their unwillingness to be involved.