Ethical Communication Issues in Health Promotion Activities amongst Ultra-Orthodox [Haredi] Jews in Israel
David A. Rier
Chapter to appear in in Rubin, D.L., & Miller, A.N. (Eds.),
Health Communication and Faith-Based Communities.
Notwithstanding the intended benefits, the dissemination of health promotion information, like other health communication practices, raises questions of ethics (McLeroy, Gottlieb, & Burdine, 1987). This chapter describes information dissemination for health promotion activities of three organizations in Israel, whose intended populations are members of Jewish ultra-Orthodox (haredi) communities. Given the distinctive culture of these communities (described below), health-promotion organizations must adapt their approaches—not only to conduct realistic, successful interventions, but also in order to maintain ethical standards.
The first of the three organizations is a women’s information center that mails health information, adapted to their religious beliefs, to haredi women who are without Internet access. We refer to this organization as “The Health Information Center.” The second organization aims to promote the health of ultra-Orthodox Jewish women through a wellness approach; one of its main goals is to empower women regarding their health and to provide them with culturally appropriate medical care. We refer to this organization as “The Wellness Center.” The third is a haredi anti-smoking organization called HAVIV, and in this chapter we focus on its annual anti-smoking campaign for youths carried out on the Purim holiday.
These organizations share a commitment to serve the particular needs and concerns of members of ultra-Orthodox Jewish communities. Their work raises various pragmatic and ethical health communication challenges involving their communities’ religious beliefs and cultural views. The three cases presented in this chapter can also yield insights into health communication approaches for other communities with unique cultural needs (such as, amongst faith-based communities, traditional Muslim and Christian societies).
The description of the cases follows an overview of several ethical issues in communication for health promotion that may be particularly relevant to interventions targeted at members of ultra-Orthodox religious populations. It serves as a background for the discussion of ethical issues associated with the particular cases presented in this chapter. Apart from literature reviews, this chapter is based on interviews with key figures at these organizations and health promotion practitioners. Also, one of us (D.R.) is himself haredi, and has written about conducting women's health research in this community (Rier, Schwartzbaum, & Heller, 2007, 2008).
Ethical Issues in Health Communication for Health Promotion
Various moral and ethical issues are inherent in health promotion communication activities (Faden, 1987). Drawing on a larger framework of ethical issues in health communication (Guttman, 2000), this section presents thirteen ethical issues as they may relate to communication for health promotion in religious populations, by religiously-affiliated organizations. These thirteen issues were found to have particular relevance to the three organizations working with haredi populations described in this chapter. However, we suggest that these and other types of ethical issues may also arise in the activities of other health communication initiatives in faith communities. The thirteen issues are organized according to the following four topics: (1) goals and health topics; (2) strategies and methods; (3) values and norms; and (4) ethical precepts in communication.
Goals and Health Topics
A major concern in health promotion interventions, but one often overlooked, is who has the mandate to try to persuade members of various groups to change their health-related behaviors (Paisley, 1989). In the case of members of religious populations one may ask whether secular government agencies, whose interests may differ from those of the religious community, have this mandate (and, in whose eyes do they have it?). Another issue is, how would individuals from faith communities respond to health information that is not sanctioned by their religious leaders? This raises yet another ethical issue: what obligations do religious leaders bear regarding health promotion for their followers?
Health issues often concern sensitive topics or deeply held beliefs. This is particularly relevant when the intended population is composed of members of deeply religious communities who may regard references to certain health topics as invasive, embarrassing, or against their religious beliefs. In some cases, the actual topic cannot be mentioned directly. Yet indirect references can result in confusion or misunderstandings. In other cases, health communicators may insert health information on sensitive topics about which they believe the members of the faith organizations should learn, into initiatives that the intended population specifically wanted to hear about. For example, researchers report how HIV issues were introduced into multicultural community settings through programs described as “wellness programs” (Pulley, McAlister, Kay, & O’Reilly, 1996).
Strategies and Methods
Communication Strategies and Tactics
Trying to influence people to adopt changes in their current practices or beliefs in order to promote their health can raise concerns associated with the use of persuasive and influence approaches that could infringe on people’s right to autonomy, even when the intention is for (what is perceived as) their own good. As bioethicists note (Beauchamp & Childress, 1994), people’s right to autonomy is a central ethical tenet, and therefore health communicators are obligated to refrain from using manipulative tactics. However, health promotion professionals also have the obligation to help protect people from harm. Thus, they would need to decide what communication methods can be viewed as non-coercive tactics or when, if at all, they can justify using persuasive tactics in order to protect people’s health. In the context of religious communities this dilemma may have an additional dimension, since community members may view religious leaders as having a legitimate authority to endorse tactics that, in other communities, would be viewed as coercive.
Peer Health Communicators
A common health communication strategy is to employ members from within the community to disseminate health information, in particular in communities with unique cultures, and minority and disadvantaged communities (Eng & Smith, 1995; Meister et al., 1992). Although employing peer health communicators helps to address cultural barriers and avoid paternalism, it can also raise ethical concerns if the task of these peer health communicators is to discuss issues considered sensitive and even stigmatizing in the community. The peer health community members may feel their own personal religious beliefs are compromised. In addition, association with the topic might produce a form of secondary stigma jeopardizing their status (and that of their families) in their communities. Finally, in tightly-knit communities, peer communicators might find themselves fielding questions from close friends, neighbors, or even relatives, with potentially awkward consequences.
Another concern involves incentives as a common social marketing strategy in health communication. Incentives (e.g., prizes of commercial products) may promote consumption of commercial goods, which practice may conflict with religious strictures against materialism.
Customizing health information to fit unique cultural beliefs, practices, and needs of populations is considered necessary for disseminating information to members of these groups, and is referred to as “tailoring” on a group level (Campbell & Quintiliani, 2006; Kreps, 1996). Social marketing strategies also emphasize the importance of creating specialized programs for particular populations, referred to as ”segmentation” of the intended audience (Hornik & Ramirez, 2006). From an ethical perspective, tailoring health promotion communication activities for particular groups (e.g., members of a particular religious community) helps fulfill the moral obligation to serve each group (Kreps, 1996). Inequities in communication for health promotion have been associated with the generation, manipulation, and distribution of information among different social groups, with differing levels of social capital. Social and structural factors shape differences in people’s access, attention, retention and capacity to act on relevant information to enhance their health (Viswanath & Emmons, 2006). One-size-fits-all interventions may produce materials or employ channels inaccessible to members of groups in terms of language, metaphors, or practical suggestions. Thus, since members of religious groups may need information that addresses their cultural and religious beliefs and may have more limited access to health information resources, tailored programs may be necessary. However, tailoring programs to members of a given religious community may raise concerns from an equity perspective if members of other religious groups do not receive similar communications.
Another ethical concern related to social marketing involves partnerships with other organizations. Partnerships can play a critical role in outreach activities and in dissemination of health promotion information (Rier & Indyk, 2006a). Some potential partner organizations, however, may be affiliated with commercial products or services that can be detrimental to health directly or indirectly; others may be perceived as hostile to the mores of a particular religious population. Faith-based health-promoting organizations could be reluctant to collaborate with partner organizations (and even with government agencies) which they view as endorsing activities or values that conflict with their own, even if these organizations can contribute to the health and welfare of members of their community. Therefore, faith-based organizations are likely to be limited in the partnerships they can construct.
Values and Norms
The extent to which people should be held responsible and accountable for preserving their own health has become a central issue in discussions on health care (Steinbrook, 2006; Knowles, 1977; Crawford 1979; Petersen & Lupton  2000; Leichter, 2003; Cheek, 2008). Personal responsibility is also a major theme in messages regarding health promotion (Galvin, 2002; Guttman & Ressler, 2001; Kirkwood & Brown, 1995). Personal responsibility can be conceptualized as an obligation to make pro-health choices or to take care of one’s self in order not to burden others. Messages about personal responsibility can empower people and promote their self-efficacy to control their lives and to help promote the welfare of others. However, such campaigns raise ethical concerns regarding appeals that might elicit feelings of inadequacy, shame or guilt among individuals who find that they are not able to adopt the recommended health-promotion practices for varying reasons (Bayer, 1996; Finerman & Bennet, 1995). Therefore, a condition for using personal responsibility as an appeal for health promotion is that members of the intended population will have the capacities and sense of self-efficacy to adopt the recommended practices or customs, and if they do not, the intervention needs to help enhance those capacities.
Social critics and ethicists point out that the notion of responsibility for disease prevention is often framed as if it were primarily under the control of individuals, thus ignoring structural factors such as culture, work, housing conditions or environmental issues that contribute to health-related problems (McLeroy, Gottlieb, & Burdine, 1987; Galvin, 2002). In the case of members of religious communities, those structural factors outside the realm of personal control may include the economically marginalized situation of members of the community, asymmetrical gender roles, or lack of culturally appropriate health care resources.
In order to reach a given community, health promotion personnel might tailor communications to conform to its accepted gender roles (Earp, et al., 1997; Lupton, 1993). Ethical issues emerge when, for example, in certain ethnic communities health promotion messages utilize an appeal to their cultural notions of ”machismo” in order to appeal to their conceptions of women as the family caregivers and men as protectors to encourage them to adopt particular health-related practices (Sabogal, et al., 1996). Similarly, because faith communities may adhere to certain traditional gender role norms, health communication that aims to be culturally appropriate and effective may appeal to these gender norms. However, such tailoring can clash with "out-group" staff’s personal and professional ideologies about cultural stereotypes and gender inequity. This type of contradiction between moral values of particular cultural groups and ethical principles associated with autonomy and equity are debated among ethicists (Macklin, 1999).
Health as an Ultimate Value
Even advocates of health promotion raise the concern that communication about health promotion may turn seeking good health into an ultimate value. They explain that achieving good health has been associated with moral virtue to such an extent that it has become a significant feature in people’s aspirations and personal goals (Becker, 1993). In Judaism guarding one’s health is considered a mitzva (religious obligation), but as critics note, an over-preoccupation with health, or turning it into a goal in itself, may result in blaming those who are not successful in maintaining their health. Those who are not healthy may be made to feel that they have not been morally worthy (Crawford, 1994; Fitzgerald, 1994). Moreover, from the haredi perspective, a society for whom, “Worship at the gym may have become the secular alternative to going to church” (Fitzpatrick, 2008:448) risks placing an almost idolatrous emphasis on the body, at the expense of cultivating more traditional forms of moral virtue and religious growth (see Shmueli & Tamir, p. 706). Although Jews are obligated to “guard” their health according to religious tenets, some haredim are likely to turn first to prayer and repentance, rather than diet and exercise, as means of ensuring health.
Deprivation of a Gratifying Social Practice
Health promotion recommendations often encourage people to abstain from practices that may have given them pleasure or may have an important cultural or emotional significance. These practices may have particular significance to members of disadvantaged populations, and may include the consumption of foods rich with fats and social rituals associated with smoking (MacAskill, Stead, MacKintosh, & Hastings, 2002). Thus, an ethical issue associated with literally “depriving” members of this population of a practice that is meaningful for them, is whether it can be replaced with another practice to fill the void thus created. By implication: what should be the moral obligation—if any—of those who promote refraining from this practice to suggest (and facilitate) alternatives?
Communication Ethical Precepts
Accuracy and Completeness of the Information
Perhaps the most prominent ethical stipulation identified by communication ethics scholars is the obligation to provide all relevant health information, and not to omit information, even if it may elicit questions or doubts. This ethical precept draws on the ethical principle of respect for autonomy, according to which individuals are entitled to make their own decisions concerning their own welfare (Beauchamp & Childress,1994; Johannensen, 1996). Ethical concerns regarding accuracy and completeness of information can be particularly relevant to faith communities, because some information related to the health topic may relate to issues that are considered to be offensive or taboo in these communities. Therefore, information about them may not be disseminated in full, or at all. A related ethical stipulation is to ensure accuracy of the information disseminated. This poses an ethical challenge in health communication in general about topics such as diet or medications because the behavior change recommendations may be tentative, incomplete, or subject to different interpretations, and might involve risks previously unknown. For example, recommendations about the timing and dosages of early versions of anti-retroviral therapy for HIV/AIDS were later revised (Rier & Indyk, 2006b). Similarly, recommendations to women to use hormone replacement drugs were later dramatically altered, as were recommendations regarding several types of diagnostic screenings (e.g., Gray, Patnick, & Blank, 2008; McPherson, 2004; Kolata, 2009). A dilemma arises when—in order to adhere to the requirements of accuracy—health recommendations are presented in a tentative way, or recipients are told that they themselves have to make the decisions about what behavioral change to adopt. Concerns about accuracy in faith communities may involve the extent to which information about health recommendations that may conflict with religious beliefs may be updated.
Another ethical standard in communication is referred to as sincerity, or the extent to which the communicators mean what they say in the communication initiative to promote health. This ethical precept also relates to the ethical principle of respect for autonomy, because lack of sincerity is manipulative and infringes on people’s right to know the truth (Johannensen, 1996). Yet, there are cases in health promotion when considerations to promote the health and welfare of the intended populations may override obligations to be sincere about the actual goals of the health communication initiatives. For example, health communicators may choose initially not to mention the specific topic they would like to address because it is considered highly sensitive to the particular population (e.g., sexually transmitted diseases). In certain situations, health communication interventions may choose to introduce issues considered sensitive only later on in the intervention, even when addressing the sensitive topic is one of its major goals. The justification for this approach is that there is a need to gain trust and overcome resistance to the topic in the intended population, who would not be willing to hear it initially.
The thirteen ethical issues outlined above mainly draw on ethical principles rooted in Western philosophy and on assumptions about the importance of individualism and moral universalism. Critics maintain that these Western assumptions may be too removed from the sociocultural milieu in which moral choices actually take place. These Western ethical principles do not necessarily reflect the diversity in moral reasoning that may characterize members of minority populations, including members of ultra-religious communities (e.g., Cortese, 1990; Makau & Arnett, 1997; O’Brien & Hallstein, 1999). Because faith communities often consist of traditionally-oriented populations, their moral approach to autonomy, responsibility, family obligations, gender roles, and conceptions of the human body may significantly differ from the moral implications of Western ethical principles. Any exploration of ethical issues embedded in health communication for health promotion in ultra-religious populations should consider this difference of moral perspectives (Macklin, 1999). Awareness of this difference leads to the possible dilemma in health promotion communication of how to manage particular cultural values that are cherished by members of the religious group, but which conflict with common values in public health, or even with moral precepts that people outside the religious group consider universal.
The Israeli Haredi Community
The haredi population is distinguished by an intense commitment to strict Orthodox Jewish doctrine and practice. Particularly in Israel, haredi society defines itself partly by its separation from mainstream culture, including secular journalism and literature (Caplan, 2007). The community includes various Hasidic, non-Hasidic (Lithuanian), and Sephardic (originally Spanish, North African and Middle Eastern) streams, and has established many of its own institutions such as gender-segregated schools, periodicals, and political parties (Rier, Schwartzbaum, and Heller, 2008). Attendance at universities is rare. Instead, the community places utmost emphasis on religious study; for males, particularly in the Ashkenazi Lithuanian stream, the ideal is to study indefinitely. Haredi communities tend to be tightly-knit, with very dense social networks. In accordance with the biblical commandment to be fruitful and multiply (Genesis I:22,28), families are typically quite large (Gurovitch & Cohen-Kastro, 2004; Central Bureau of Statistics, 2007).
Overall, the haredi community is socially conservative, and maintains strong codes of modesty in dress and behavior. These codes apply to speech as well, which fact militates against open discussions of sexuality and related issues. In both private and public speech, euphemisms and circumlocutions are often employed for referring to sensitive, private issues. Very few haredim own television sets, and many eschew secular radio. Internet use, while present, is much less common than in wider Israeli society, and haredim and their leaders define it as a threat to the community. Haredi women are especially unlikely to use the Internet (Barzilai-Nahon & Barzilai, 2005). However, haredim do receive health information from various other sources; among these are the haredi press, and the newsletters published by health funds or hospitals (Schwartzbaum, Rier, Heller, & Goldschmidt, 2004).
Amongst haredim, rabbinical leaders wield very significant influence. Sometimes, as during the recent H1N1 flu epidemic, they issue pronouncements on public health prevention issues (Elyashiv, 2009), which their followers accord the force of law. Receiving endorsements [haskamot] for community interventions from the rabbinic leaders, from each of the various streams targeted, is a key step in securing community cooperation.
Saving human life is of paramount concern in Jewish law, and observant Jews are required to keep in good physical and mental health so that they can perform their religious obligations. Therefore, medicine and medical professionals are highly regarding by haredi Jews (Mittman, Bowie & Maman, 2006). Yet haredi populations have been found less likely to engage in health prevention practices. Researchers who compared the health of ultra-Orthodox people to secular Israelis found that religious women exercised less than secular women, and both religious men and women are relatively more obese than the secular. They also found that the prevalence of never-smokers is much higher in the religious community than among the secular, because religious women rarely smoke (Shmueli & Tamir, 2007). Ultra-Orthodox men, however, according to survey data, smoke at approximately the same rate as men in the general population (approximately 30%; Rosen, 2009).
Research findings indicate that members of haredi communities, compared to non-haredi individuals, are significantly less knowledgeable about, and less likely to engage in preventive health practices such as early breast cancer screening tests (Shmueli & Tamir, 2007; Strauss, 2007). Explanations provided by researchers for the lower uptake of mammography and breast cancer treatment among Israeli ultra-religious women are their heavy household responsibilities, the fear that in their tightly-knit social milieu public knowledge of this sort of illness would damage marriage prospects for their daughters due to fears of hereditary risk, and perhaps a tendency to believe that prayer more effectively cures yet-undiagnosed as opposed to diagnosed disease (Shmueli & Tamir, 2007). Researchers also suggest that ultra-religious women might face some health risks due to multiple births that may lead to their being overweight (Shmueli & Tamir, 2007), and research findings indicate they tend to oppose health care interventions that they believe conflict with their religious beliefs (Remennick, 2006).
Health Promotion by Three Haredi Organizations
Each of the three organizations described in this chapter originated from within, and aims to disseminate health information to, the haredi community. We provide a brief description of each, followed by a discussion of relevant ethical issues, using the framework presented in the previous sections. Information about the organizations was obtained through interviews (a total of ten) with staff members as well as healthcare professionals and municipal workers who had collaborated with them, through information obtained from the organization’s publications and reports from its official website, and via a site visit. For each organization, at least three individuals were interviewed including at least one senior staff member. The research on these organizations was conducted between October 2009 and January 2010. This chapter's description of the organizations and their activities is intended only to provide a background for highlighting several ethical issues with communication initiatives for the haredi population. This chapter does not attempt to provide a comprehensive view of these organizations’ goals and their broader range of activities and accomplishments.
The Health Information Center for Haredi Women
The Health Information Center for women was opened in mid-2000 by a haredi woman who serves as municipal comptroller and advisor to the Mayor on the status of women in the city of B’nai Brak. B'nai Brak is mainly haredi, and the center received the support of the municipality and the city’s religious leaders, eventually moving to a large space in a municipal community clinic. A group of volunteers was trained at no cost by medical professionals from local medical centers. The rationale for a specialized information center is the assumption that haredi women's lack of Internet and secular mass media access disadvantages them in the contemporary medical care system, combined with the awareness that standard health promotion materials might prove offensive or inappropriate for haredi women. The literature of the Health Information Center describes their approach as working “within strict rabbinic mandates", and the organization and its activities have been endorsed by religious leaders from several haredi communities. The center has a website, but it is used only for information about the center itself, and does not contain health information.
The Information Dissemination Approach
The Health Information Center runs a call center, at which women can leave their phone number and questions, anonymously if they wish. Women who call in typically request information on particular health issues, and the center responds by sending them information packets that have been approved by religious authorities. The center is operated by volunteers from the haredi community who have varied backgrounds including hospital administration, biology and education. One volunteer is an information specialist in an academic medical library. The volunteers have received special approval from rabbis to use the Internet for obtaining health information, and are all mature, trusted women, considered to be leaders in the haredi community. Training of volunteers included topics about medicine and the haredi population. The volunteers collect, classify, and reformat women's health information, using print and electronic sources, and adapt it to the intended audience’s religious background.
The call center receives requests for information on topics ranging from the care of minor injuries such as cuts and scrapes, to more critical medical care issues such as chemotherapy and cardiac arrest. Broad topic areas include heart health, fertility, maternity, infants and children, mental health, nutrition, and old age. Although volunteers in the call center do not provide information on topics such as pregnancy termination, the materials they send out do include sensitive topics such as breast and cervical cancer, menopause, and fertility. However, they do this by “translating them into haredi language.” For example, materials exclude graphic images or references to issues that are not considered appropriate to haredi culture. Information packets are mailed discreetly, in an envelope that does not disclose the source. While much of the information is obtained from the Internet, this fact is not mentioned to the women, because of restrictions on its use in haredi communities.
Volunteers also ask their clients if they have a rabbi with whom they can consult, and which community they are from. If necessary, volunteers can refer clients to religious leaders who are associated with the organization and are considered experts on a given health topic. Especially sensitive questions are handled by a volunteer with a degree in counseling, to help ensure callers get appropriate help and referrals.
The Health Information Center also conducts outreach activities such as mounting a series of lectures by health professionals aimed at influential women and opinion leaders in the haredi community, including rabbi’s wives, school principals, heads of organizations and community centers. It has also collaborated with several religious women’s organizations and with the municipalities of towns with large ultra-Orthodox populations. Finally, the center engages in advocacy. For example, the center’s staff heard from their clientele that they could not afford the fees for clinics providing prenatal and early childhood care. Center staff raised this issue with decision makers; eventually, the fee was eliminated.
The Wellness Center for Haredi Women
“B'shvilaych - The Women to Women Well-Health Center” is located in Jerusalem, which has a large haredi population. Established through private funds, the organization’s goals are to promote haredi women’s health by providing them with subsidized medical care in a woman-to-woman environment, to inform them of how to maintain healthy lifestyles, and to create awareness and motivation for early detection and disease prevention. Wellness Center documents characterize haredi women as “always the caretakers of others.” That is, many women prioritize the health of other people as more important than their own, and therefore neglect their own well-being. The Wellness Center therefore tries to convince women that they should engage in health promotion activities, and to legitimize the need for women to take care of themselves not only for their own sake, but for the sake of their families and others who depend on them.
According to the Wellness Center’s staff, although some haredi women are aware that there are actions they can take to promote their health, they may nonetheless believe that when things happen to one’s health it is “all from heaven,” and fail to engage in prevention or screening activities. The Wellness Center’s own data, for instance, indicate that a large percentage of the women who reach them have not received regular clinical breast examinations. In order to help motivate these women to action, staff members make it a point to demonstrate to women the importance of check-ups from both a religious and medical perspective.
In addition to providing the opportunity for clients to get routine well-woman care with female physicians, the Wellness Center conducts workshops and lectures. Specific topics for lectures are often derived from questions raised by women who have visited the center, but the unifying theme is that taking care of health is a Jewish value and fulfills Jewish law. Women therefore are obligated to take an active role and “guard your health very much.”
According to personal interviews with center staff, the women appreciate the way that their needs are understood at the Wellness Center within a religious framework. They are able to talk freely with staff about sensitive topics, and yet do so in a way that enables them to preserve their sense of modesty. This is because center personnel are careful to present information in culturally appropriate ways. For example, if a young woman has questions about sexuality, female physicians working in the Wellness Center will discuss them with her, but they do not attempt to replace traditional haredi “bridal instructors,” religious women teachers who prepare engaged women for married life, including sexuality. The issue of breast cancer will serve as an illustration of how the Wellness Center seeks out appropriate ways to communicate about sensitive topics. According to center personnel, haredi women would not come to a lecture on breast health. Aware that this is a topic on which women are likely to have limited information, Wellness Center staff carefully insert the issue of breast cancer into other discussions. Even then, modesty issues among clients make it impossible for the center’s staff to write the word “breast” in their promotional and educational literature. By writing “a doctor specializing in surgery that is special for women” when they refer to early detection of breast cancer, however, they are able to communicate the topic indirectly.
The Wellness Center has developed various collaborations and has outreach partners in local councils and haredi organizations, including an organization of attendants at the mikve (a ritual bathouse women use for monthly immersion, as mandated by Jewish law prior to resumption of marital relations). The organization also engages in advocacy activities to encourage public healthcare organizations to establish similar health care centers in other locations, centers that are culturally sensitive and can meet the needs of ultra-orthodox women.
Holiday Anti-Smoking Campaign for Youth
The smoking rates of haredi men in Israel are relatively high, especially in comparison to the near absence of smoking among haredi women, and are estimated to be about the same rate as in the general population. Haredi men typically initiate smoking during their advanced education. There are several voluntary organizations with the ongoing aim of encouraging haredi men to quit smoking, and numerous short-term information dissemination initiatives have enlisted the support of religious leaders for smoking prevention among Haredi men. Our focus here is on one small haredi anti-smoking organization composed of just a few voluntary staff members, HAVIV. HAVIV staff members we interviewed echoed the position of the Wellness Center in making a direct link between the religious injunction against harming oneself and their own health promotion activities. They explained that “just as a person is not allowed to cut their hand, they are not allowed to smoke.”
The Purim Campaign
Although the activities of HAVIV focus mainly on smoking cessation workshops and seminars, the organization also conducts an annual anti-smoking campaign for children and youth just before the Purim holiday. Purim is a festive occasion with a carnival-like atmosphere, including dressing up in costumes and celebrations with food and drink. One of the traditions in haredi communities, dating back to previous generations, is to allow smoking during the Purim holiday, even among children. The aim of the campaign is to prevent male youths from smoking during the festivities.
The campaign has been conducted in collaboration with one national health organization (Maccabi Health Services) in addition to local municipalities in haredi townships and communities. Local religious leaders have also been recruited to support the aims of the campaign. Unlike the other two organizations described above, HAVIV has not emphasized religious motivations in the campaign. Based on their experience that religious prohibitions against smoking were not effective, the organization adopted a social marketing approach for the Purim campaign by providing substantial prizes as an incentive if the children promise not to smoke on Purim and the rest of the year. Information about past campaigns was circulated thorough ads in haredi newspapers and in community posters, which are a customary way of disseminating information in the haredi community, and by a van provided by Maccabi Healthcare Services that drove in haredi communities and distributed print materials. Maccabi Healthcare Services also helped fund the publicity and prizes. Most prizes were chosen for their health promoting quality, and included bicycles and helmets. Prizes were awarded by lottery, which children participated in by providing a letter, signed by their parents, their rabbi, or two friends, in which they promised that they would not smoke on Purim and during the succeeding year.
The first campaign took place in a single community. It was assessed by its organizers as being very successful because nearly a thousand letters were received from the vicinity of the single township targeted. In the years that followed the campaign spread to other towns around the country, with similar success. Organizers describe the Purim anti-smoking campaign as an effective, low-cost effort with substantial support from the community. They report getting dozens of letters from youth who stated that a given campaign year was the first time they did not smoke on the holiday.
Challenges and Ethical Issues
The framework presented in the first part of this chapter outlined four types of ethical issues and a series of dilemmas in communication for health promotion in religious populations by religiously-affiliated organizations. The approaches and activities of the three organizations described above can help illustrate not only these dilemmas but also ways that organizations have aimed to address some of them.
Mandate, Goals and Health Topics
Mandate and Goals
All three organizations described here emerged from within the haredi community. Their goals are based on the religious beliefs of its members, beliefs that they themselves share. Further, their activities are officially sanctioned by their religious leaders. Therefore, they believe they have a legitimate mandate to promote intervention messages. In addition, these organizations collaborate with public healthcare organizations or local governments whose official mandate is to provide health care. This can be viewed as adding legitimacy to their activities.
In the case of the two organizations that serve women, the topics chosen by the organizations clearly are relevant to the intended population because they are based on questions the women themselves have asked. In the case of the anti-smoking organization, there is indeed concern among religious leaders about smoking initiation among haredi young men. In the case of the Wellness Center, the staff has found ways to embed a topic that women are less likely to want to hear about (breast cancer) within more attractive health topics.
The issue of the endorsement given to the Health Information Center by religious leaders exemplifies a duality in the role of a faith-related health-promotion organization. In order to appeal to the haredi religious community, the organization's health promotion activities are rabbinically endorsed. Securing and maintaining rabbinic approval requires adherence to haredi norms, preventing the organization from providing information about certain topics considered inappropriate to the community. This puts the information center in the position of a community-based “gatekeeper” (Metoyer-Duran 1991) that might be considered to be withholding information, potentially conflicting with their mission to provide haredi women with health information that is otherwise inaccessible. However, the information and wellness centers can also be viewed as “gate-openers,” because they are channels for providing pertinent information to haredi women, which otherwise they would not have availed themselves to. Indeed, the limitations imposed by the rabbinic endorsement are precisely what enable haredi women to use these centers, since they need not fear exposure to information conflicting with their religious beliefs or norms. It might also be argued that this gate-keeping does not necessarily impair autonomy—at least for adults—because the women in their population have essentially chosen to waive their right to “full disclosure” of health information by remaining in a social world which upholds such restrictions. Yet the act of tailoring (e.g., removing particular images or information) public health communication could still present public health personnel with ethical quandaries about compromising their professional responsibility to transmit all health information they consider relevant. It is also worth asking: What should haredi women do if they desire more comprehensive information than what this organization typically provides? Whose obligation is it to provide them with this type of information, in a manner that is culturally sensitive?
Strategies and Methods
Each of the organizations uses communication approaches adapted to the haredi community and information channels that are accessible and discreet. For example, the Health Information Center generally receives requests via phone and responds to them by post, since their clientele either cannot or do not wish to access the Internet for this purpose. Both organizations providing health information to haredi women aim to do so in a “modest way” that would not offend the women they aim to reach.
Using Peers from the Community
One of the organizations, the Health Information Center, employs volunteers from the community as information providers. The volunteers assemble relevant information and create the packets for the women requesting the information. One potential ethical concern with this practice is that it exposes these women to knowledge and information that has not been made available to other women in their community, and which is considered inappropriate for haredi women. This issue is addressed by the organization by only employing what the head of the center described as mature women, who are also leaders in the community.
Ethical issues associated with material incentives emerged in the anti-smoking Purim campaign for haredi boys. One criticism of using prizes in health promotion activities is that it reinforced materialism. Awareness of this concern guided the selection of the prizes for the campaign, and therefore health-promoting prizes such as bicycles and helmets were chosen. Nevertheless, several of the prizes were popular compact disks and similar prizes, in order to attract the intended audience. As mentioned above, the organizers explained their use of material incentives as a response to their prior experience that rabbinic prohibitions against smoking were ineffective. It can be asked whether they could have tried to connect the anti-smoking message to other values, such as consideration for others.
Customizing and Tailoring
Clearly the three organizations strive to customize the health promotion information and messages to the haredi community. Indeed, this is why they were established. They also are concerned with providing the kind of environment or use of channels that can encourage their intended population to communicate with them. Thus, the Health Information Center enables women to call the center and to receive the information discreetly. The Wellness Center provides a culturally appropriate environment in which women can feel free to talk about health issues in a private, one-to-one setting, and they can also receive on-site physical examinations which they might have been hesitant to get elsewhere.
However, even within the haredi community additional “customizing” may be necessary. Among haredi populations there are diverse groups with differing beliefs, customs, and religious leadership. Meeting these diverse needs within the haredi population can pose challenges. Consider the bicycle offered as grand prize by the anti-smoking campaign. In one particular haredi community, riding a bicycle was considered to be inappropriate because it takes boys away from religious studies. In this case, the child who won the prize was told he could get a different type of prize. Another ethical concern with “targeting” is associated with this campaign. The campaign addresses only boys, and not girls, because girls are not considered to be at risk of smoking in the haredi community. Thus, on one hand, the approach of targeting boys is appropriate. Yet excluding girls from being eligible to win prizes raises issues of fairness. Perhaps the overall goal of haredi health efforts should be to offer a balance of communication interventions aimed at the specific needs of both males and females: breast and cervical cancer prevention/detection for females, prostate cancer prevention/detection and smoking prevention and cessation for males, for example.
The three faith-related organizations maintain contacts and receive support from non-religious public organizations. In the case of the anti-smoking Purim campaign, they received sponsorship in the form of prizes and publicity. The women’s centers receive support from medical centers and their personnel, and from public healthcare provider organizations. Yet, the women's centers were in fact established to be gatekeepers of some of the very information that these secular, public organizations aim to disseminate. This raises dilemmas and challenges among both the haredi and non-haredi organizations, regarding how to address issues when the two disagree. The secular and public organizations may feel they have to compromise certain goals, for example, the way they view gender equity, in order for certain information to reach haredi women. This issue is further discussed in the section on values and norms.
Values and Norms
The theme of personal responsibility emerged in the communication of all three organizations. The anti-smoking campaign focused on the issue of personal responsibility in a positive way by encouraging boys to make a formal and acknowledged commitment not to smoke. This encouragement involved significant others: either the boy’s parents, a rabbi, or friends. This can be seen as a means to help the boys by providing them with a support system to fulfill their promise. Further, the campaign may serve to reinforce social norms that smoking on Purim is not acceptable, which can reinforce the boys’ capacities to resist temptation to smoke on Purim. Yet boys could still face value conflicts and temptation from friends or even family members who wish to uphold the smoking tradition. Both the Women’s Wellness Center and the Health Information Center aim to encourage women to take responsibility for their health and to empower them by giving them health knowledge. In particular, the Wellness Center aims to empower women to care for themselves by giving them religiously appropriate tools. By providing women with information regarding the health of all family members, the Health Information Center implicitly encourages haredi women to be responsible for overall family health as well. Some might question how the goal of empowering women accords with upholding traditional gender roles, This issue is addressed briefly in the next section.
As described in connection with interventions aimed at other populations (e.g., Earp et al., 1997), the communication practices of the two organizations that aim to provide health information to women conform to accepted gender roles in their target communities, among whom women are the caregivers of their families and males issue religious rulings and certify the organization's spiritual reliability. Secular bodies collaborating with these haredi organizations may regard this as conflicting with or compromising their own values related to gender equality. However, as noted above, such accommodations can be justified on practical grounds as necessary for conducting these health communication interventions in this particular community. Particularly since these gender norms are quite firmly entrenched, if not actually intrinsic to being haredi, simple pragmatism suggests a focus strictly on conducting the specific health intervention as effectively as possible. It is also possible to view the haredi organizations, and the populations they serve, as autonomous adults who themselves support traditional gender roles. Indeed, as noted by the head of the Health Information Center, their purpose is not to change gender roles in the haredi community, but to address the present situation and to empower women to take charge of their own health, within their cultural roles.
Moreover, these very gender roles may contribute to an overall protective health effect. Compared with secular Jewish Israeli counterparts, Orthodox Israelis experience less stress and less skin cancer (due to modest dress shielding more skin from the sun). Haredi women rarely smoke (resulting in less lung cancer, presumably), and have a better diet--although Orthodox women do exercise less, are more often overweight, and report less frequent mammograms and clinical breast exams (Shmueli & Tamir, 2007) than the general population. Haredi women also presumably experience fewer sexually-transmitted diseases (STDs) than do their secular counterparts. Finally, the haredi community's traditional reliance on women as responsible for health may confer an advantage on women, over men, due to the former's greater health knowledge and awareness. Are haredi men, for example, as aware of prostate cancer prevention/detection as haredi women are about breast cancer?
Another challenge associated with the issue of gender roles is for the faith-based organizations to determine if and when it would be their obligation to try to influence religious leaders to change restrictions on the presentation and dissemination of health-related information pertinent to the welfare of the community, and for which there is demand. One example was given by a haredi woman who works for the municipality of a town with a haredi population, who convinced the rabbis that women should be told about cervical cancer in the ritual bath houses that are attended by women, although originally this was perceived as improper.
Health as an Ultimate Value
Preoccupation with health as an ultimate value concerns ethicists, social critics, and health promotion researchers (Becker, 1993). Caring for one’s health is part of the obligations of an observant Jew, and therefore ultra-religious people may feel obligated to seek the best health information and healthcare services. Yet, as research findings indicate, recommended health practices such as physical activity have not become the norm in the haredi community, the rate of smoking among men is similar to the rate in the general population, and obesity rates are higher than in the secular population. Thus, the pursuit of health and health as a value in the haredi community may manifest itself in different ways, such as by seeking the best medical doctors or medical treatments.
Deprivation of Social Gratification
The Purim anti-smoking campaign provides an example of how a health promotion activity may deprive the intended population of a gratifying practice. Smoking on Purim may play an important symbolic role for certain youth in the haredi community. In this case it may provide a once-a-year opportunity to relax certain inhibitions, in contrast to the strict demands of haredi daily routines. Fo some the legitimization of smoking cigarettes on Purim represents a short-term "safety-valve" in a society that places constant obligations on its members from childhood. Smoking serves as part of this “freedom” to do something they know is forbidden. Therefore, one challenge is, what can these youths be provided with, or encouraged to do, that can fulfill the role smoking has played in Purim? This raises the challenge of whether the campaign should also offer the intended population an alternative, beyond the incentive of a potential material prize. This concern has been raised in discussions on ethics and health promotion, when members of certain cultural groups enjoy a given practice that can be hazardous to their health, but find it hard to find a substitute for it (MacAskill, Stead, MacKintosh, & Hastings, 2001). Another concern is that possibly the campaign itself, like campaigns against drug use (Guttman, Gesser-Edelsburg, & Israelashvili, 2008), may unintentionally serve as an impetus for certain youth who did not intend to smoke to try smoking on Purim.
Sincerity, Accuracy and Completeness of Health Information
Accuracy of health information intended to influence people’s behavior is a contentious issue, because health recommendations may change with new research findings (McPherson, 2004). The two haredi organizations that disseminate health information aim to ensure the information they provide is accurate by consulting medical authorities (the Health Information Center) and employing medical professionals (the Wellness Center). However, as noted in the section on health topics, according to the mission statements of the information center and the wellness center, they provide only information that is in accordance with rabbinical approval. Thus, the information they provide may not be as ‘complete’ as it could be according to the medical information available about certain topics. Further, on some topics, they may not provide any information. This raises a moral challenge as to whether it is their obligation to inform women there may be additional information they could obtain elsewhere, at the risk of jeopardizing their credibility with the haredi population and its rabbinic leadership. The issue of sincerity emerged regarding the use of the Internet by the Health Information Center for the purpose of obtaining the information they disseminate to the haredi women. As noted above, the center did not disclose to their clients the Internet origin of much of their material. Though the center has received the approval of religious leaders to use Internet for this purpose, it was decided that mentioning its use as a resource might create unease and confusion among the recipients of the information.
Implications: Advocacy Challenges and Dilemmas
Drawing on the ethical issues identified in these three organizations, we have elaborated on the four challenges related to health communication in religious communities that we articulated at the beginning of this chapter. In the process a number of other issues have arisen that can be described as a fifth type of ethical challenge: dilemmas and difficulties related to advocacy. In this section we briefly revisit those issues from this additional perspective.
Issues that Cannot be Discussed
Because certain topics were considered to be sensitive among the organizations we studied, certain information could not be disseminated or certain issues could not be discussed, and could only be implied. We have mentioned that this places these organizations in the position as serving as both gatekeepers of information that they know they cannot disseminate, and gate openers because they are among the few in the community who are aware of that information. This presents a distinct challenge to such organizations: what is their role in terms of advocacy of issues that cannot be discussed within their faith community, but which, the organization thinks, should be? Where do these organizations ‘draw the line’ between their obligation to religious leaders and their obligation to promote health and communicate the necessary information for community members to be able to adopt the recommended practices? One of the haredi women interviewed, who was not a member of these organizations but worked in health promotion in another municipality, said that she saw part of her role as one of influencing religious leaders to allow the discussion of issues that had been considered offensive.
Changing Cultural and Social Factors
Some of the cultural and social factors associated with the faith community may contribute to the etiology of health problems or serve as barriers for health promoting practices. These may be related to gender roles, customs of eating rich, heavy foods at frequent religious and family celebrations, or religious leaders’ devaluation or even disapproval of physical activity because is takes away time from religious studies. This raises challenges for faith-related health organizations regarding their role in changing social and cultural factors that may serve as barriers to health promotion, including religious leaders’ views. One may ask whether the organization should encourage religious leaders to push for a change, and whether it should help find ways to employ substitutes for cultural practices that are meaningful but unhealthy.
Gender Role Issues
A challenge for faith organizations regarding their community's gender roles might be to consider whether certain aspects should be altered, where evidence suggests these pose a barrier to health, or whether these should be taken as a fixed part of the culture of the community which does not need to be (or cannot be) changed.
Adopting the Role of Official Agencies
“Grass roots” faith-based organizations that work in their communities face the challenge of whether they may deflect attention from the obligation of official agencies to develop culturally-appropriate health promotion information dissemination services and channels for this population. The need for the activities of these organizations may indicate that there is a lack of culturally appropriate health care-related resources, which should be provided by the health care provider organization. This leads to an additional challenge: should the organization take up an advocacy role to advance policy changes and to raise health-related issues that are pertinent their community but are not fully addressed by the healthcare system?
These challenges regarding communication and health promotion imply that these organizations may find themselves in a triple role of: a) adapting health information to the mores and sensitivities of their community, thus serving b) a gatekeeper role, and c) practicing advocacy within (toward religious leaders) and outside (towards policy makers) their community. In addition, these organizations need to be attuned to the diversity within their own populations, and develop ways to meet the needs of these diverse groups.
The faith-based organizations described in this chapter clearly serve an important role in the provision of health information to members of the haredi community. These organizations emerged because of deeply felt needs among members of the community, and their approach and activities are tailored to their social and cultural norms and sensitivities, including adherence to the authority of their religious leaders. The goals and activities of each of the organizations involved various ethical concerns, some of which they consciously tried to address, and some of which were taken as a given. Drawing on a larger framework of ethical issues in health communication interventions, the ethical issues we identified in the goals and activities of the three organizations exemplify the types of ethical issues that can be expected in the goals and activities of other faith-based communities, or in communities that have strong cultural traditions. Grappling with these ethical issues is one of the challenges arising from these organizations’ role as health promoters in the community.
We gratefully acknowledge the members of the organizations and healthcare professionals and scholars who provided their time, information and insights. We also thank Naama Appel and Nathan Stolero, whose work on this project included conducting the field work.
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Women’s Wellness Center: http://www.bishvilaych.org/
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