Cases of brucellosis have been reported in various Arab towns in Israel. These are linked to consumption of raw milk, non-pasteurized homemade cheeses or handling infected animals. These dairy products may be consumed privately, given or sold to family, friends and the local community. In this study we assessed, by self reporting, the rates of these behaviors and try to determine if past reported cases of brucellosis in the community is associated with these behaviors.
A large proportion of the respondents reported purchasing and consuming non-regulated dairy products, this may even be under-reported as on the one hand the respondents were aware of the expected behavior and on the other hand may not be aware of where the dairy products comes from. Undesirable behaviors are usually underreported as shown in previous studies [19]. However, we do not know how much of the milk and cheese consumption reported here is from non-pasteurized milk. When pretesting the questionnaire it was clear that people were not sure if the homemade products they consume were made of non-pasteurized milk. But most importantly it is clear that these products could be a source of the disease.
Knowledge is generally regarded as a prerequisite for behavior, the assumption in the past was that if you “know” something is bad for you, you will not consume it [20]. However, knowledge is not enough to drive behavior [21]. In this study, although levels of knowledge were high and even higher in towns that had previous reported cases, there was no association between levels of knowledge and purchase and consumption of non-regulated dairy products after the adjustment for other variables. This implies that just informing the public of the hazards of not pasteurizing the milk is not enough to decrease risk of brucellosis.
Attitudes held by the population towards factors that can enhance transmission of the disease were positively associated with these risk behaviors, also after adjusting for other variables, in multi-variable regression models. Those with more favorable attitudes towards factors that enhance transmission of the disease purchased and consumed more non-regulated dairy products, increasing the risk of contracting the disease. This again is consistent with the literature that suggests that attitudes are correlated with behaviors and many cognitive models are based on this assumption, such as the Health Belief Model [20, 22]. These attitudes included a few concepts. Fatalistic beliefs have been shown to predict risky behaviors among Arabs, such as not using car restraints [23]. According to fatalistic beliefs there is no point in changing behaviors as they do not effect life or health, these are decided by fate or God. Another concept was trust in the source of the homemade dairy products. This trust may be stronger than fear of the disease, maybe due to collectivism. The third concept includes perception of quality of the dairy products, mainly taste and freshness. These qualities seem to be very important and are believed to be much better in homemade products, therefore respondents will accept the risk of the disease and prefer homemade dairy products. This has been reported also in the USA where farm families reported taste and convenience as the main reason for non-pasteurized milk consumption [1, 24]. In Europe, for this reason famous cheeses are made with unpasteurized milk. However, there the farmers comply with the regulations, whereas in Israel this seems to be a problem [6].
All these concepts add up to form strong and deeply engrained attitudes that are based on culture and tradition. There was no difference in attitudes between towns with or without reported cases, suggesting that encountering the disease did not change attitudes. Changing these attitudes may lead to prevention of reported cases, however, they may be difficult to change without a multi-faceted intervention.
The results suggest that in the towns with reported cases, residents consumed more non-regulated cheese, but less non-regulated milk than in towns with no reported cases. This behavior may explain to some extent the reported cases, as in these towns people consumed more cheeses from non-regulated sources, increasing the risk of infection. It seems that encountering cases of brucellosis in the community did not bring about change to traditions of cheese production and consumption. It may be that people found it easier to give up non-pasteurized milk but not the traditional Middle Eastern cheese.
This study suggests an alternative model for the knowledge, attitudes and practices model)KAP (usually referred to as cognitive theories. We suggest that attitudes serve as a value system that provide self-incentives for the continuation of the traditions of dairy consumption, these traditions are risk factors for the outbreaks of brucellosis, and encountering the disease increases knowledge regarding the disease, however does not change behavior. This is in contrast to the more common model where knowledge influences attitudes and attitudes influence behaviors. However, in mass communication research this is often the case and information given to the community via the media, as when an outbreak of the disease occurs, does not necessarily change behavior [25, 26].
It seems that exposure to the disease has not enhanced healthy behaviors as people living in towns with reported cases of the disease consume more cheeses from non-regulated sources. Attitudes towards factors enhancing transmission of brucellosis were associated with consumption of dairy products from non-regulated sources, but knowledge was not. Giving out more information about the disease may not be an effective strategy for controlling the disease.
There may be two options for public health action. The first being the development, implementation and evaluation of a multi-faceted intervention including the community, the media, the healthcare services and local authorities in order to change the norms of consumption of non-pasteurized dairy products. A second option would be to work with the Ministry of Agriculture and the small farmers to secure cattle, goat and sheep free of disease by vaccination and other means, or regulate pasteurization. These public health interventions are only locally and partially performed today, but could be improved and implemented in a wide range of communities and strategies [6, 17, 27].
A major limitation of this study is in the self-reported purchase and consumption of dairy products, however this may be an under-reporting of the behavior as consumption of non-pasteurized dairy products are known to be a source of the disease, or just due to an unawareness that the cheese is not pasteurized. In addition, there may be other differences between the towns that we are not aware of that may confound the results. Another limitation is in the cross sectional methodology that does not permit understanding the directionality of the association or causality, therefore a longitudinal study may help understand the factors affecting the behavior.