Immigrating to a universal health care system: Utilization of hospital services by immigrants in Israel

English-Speaking Immigrants in Israel During the Pandemic: Challenges and Pathways to Resilience

This qualitative study explores the resilience of a community of 108 English-speaking immigrants in Israel facing the stress of the COVID-19 pandemic. It features the social constructivist approach to resilience as a negotiation of adversities using coping strategies understood within the framework of control, coherence, and connectedness. We discuss data in an articulated perspective of themes comprised of language barriers, transnationality, and the us/them divide, which constitute a common thread in the negotiation of resilience. The pathways to resilience, geared to help individuals in the meaning-making process, build distress tolerance, increase social support, embrace a view of a deep human interconnectedness, and take goal-directed value-driven actions, constituting a basis for interventions. Counseling practice should offer English-speaking immigrants to Israel specific resources that encourage acceptance-based coping, culturally relevant practices of mindfulness, as well as tools that promote social interactions and build resilience by cultivating positive emotions and social connection.

The landscape of medical care consumption in Israel: a nationwide population cross-sectional study

Background

The Ecology of medical care was first published in 1961. The graphical square model showed that 75% of the population in the US and England experience a feeling of illness during a given month, 25% seek medical help and only one percent are hospitalized. In 2001, Green and colleagues found the same findings despite the many changes that occurred over the past decades. The frequency of illness, the desire for assistance and the frequency of seeking and getting medical assistance may differ in different populations due to cultural, economic, social, demographic background and local Health policy. This work describes the ecology of medical care consumption in Israel for the first time and examines the socio-demographic effects on consumption.

Methods

This is a Nationwide cross-sectional study. A telephone survey was conducted among a representative sample of the adult population (> 15 years) in Israel. Subjective morbidity rate in the preceding month, the rate of those considering medical assistance and those who got assistance were calculated. Correlation between socio-demographic variables and patterns of morbidity and medical care consumption was examined using a t-test and chi square for continuous quantitative and categorical variables. Logistic regression was used for multivariate analysis.

Results

A total of 1862 people participated; 49.5% reported having symptoms in the previous month, 45% considered seeking medical advice, 35.2% sought out medical assistance and only 1.5% were hospitalized. The vast majority chose to contact their family physician (58%) and the primary care setting provided their needs in 80% of the cases; Subjective morbidity and medical care consumption differed significantly between Israeli Jews and Arabs. Gaps in the availability of medical services were observed as residents of the periphery forewent medical services significantly more than others (OR = 1.42, p = 0.026).

Conclusions

Subjective morbidity is less common in Israel than in other countries, but paradoxically consumption of medical services is higher. An Israeli who feels ill will usually consider receiving assistance and will indeed receive assistance in most cases. However, a greater tendency to forego medical services in the periphery indicates barriers and inequality in the provision of health services. Different cultural perceptions, lack of knowledge and low accessibility to medical services in the periphery probably contribute to the contrast shown between low consumption of medical services and high prevalence of chronic illness in Arab society. The prevailing preference for family medicine and its ability to deal with most requests for assistance suggest that strengthening family medicine in the periphery may reduce those barriers and inequalities.

Socioeconomic disparities in healthcare utilization under universal health coverage: evidence from Dubai household health survey

BACKGROUND

In 2013, Dubai implemented the Insurance System of Advancing Health in Dubai (ISAHD) law which required mandatory health insurance for all residents of Dubai effective in 2016. This study compares the effect of the ISAHD on the utilization and out-of-pocket (OOP) expenditures for low and high socio-economic status sub-groups.

METHODS

The study used the 2014 and 2018 Dubai Household Health Survey (DHHS) a representative survey of Dubai stratified as: 1) Nationals; 2) Non-nationals in households; 3) Non-nationals in collective housing; and 4) Non-nationals in labor camps. The probability that each household would have expenditures was calculated, then multiplied by a weighted estimate of the average total OOP expenditure.

RESULTS

Overall Dubai's health spending rose from 12.8 billion AED (3.4 billion US $) in 2014 to 16.8 billion AED (4.6 billion US $) in 2017. Concurrently, the OOP share in total health spending in Dubai fell from 25% in 2014 to 13% in 2017. From 2014 to 2018, there were increases in the utilization of inpatient, outpatient and discretionary services for all groups except non-nationals living in camps. In 2018, nationals spent a total of 1064.65 AED, non-nationals in households spent 675.01 AED, collective households spent 82.35 AED, and labor camps spent 100.32 AED out-of-pocket per capita for healthcare expenditures. During and after the implementation of ISAHD, there was a substantial growth in the OOP expenditure per capita for nationals and non-nationals in households due to increased utilization. OOP spending did not rise for the lower-income non-National households.

CONCLUSION

Dubai has been successful in reducing the household share of OOP expenditures by shifting the financial burden to government and employers. Emiratis and expatriate households increased their health service utilization after ISAHD but blue-collar workers did not. Remaining non-financial barriers to care for Dubai's blue-collar workers must be identified and addressed.

Unhealthy Immigrants: Sources for Health Gaps Between Immigrants and Natives in Israel

The study focuses on sources for health gaps between Jewish immigrants and native-born Israelis. Unlike traditional immigrant societies where immigration is viewed as economically motivated, immigrants returning to Israel are viewed as the "returning diaspora". Because immigrants in Israel are entitled to the same health benefits and medical services as native-born, we expect Israel to attract unhealthy immigrants in disproportionate numbers. The data for the analysis are obtained from the Israeli National Health Interview Survey (2013-2015). The data set provides detailed information on health status and illness, sociodemographic attributes and origin of immigrants. Three major origin groups of immigrants are distinguished: the former Soviet Union, Western Europeans or the Americans (mostly Ashkenazim), and Asians or North Africans (mostly Sephardim). Our findings lend support to the expectations that the health status of all immigrant groups is poorer than that of native-born Israelis. The nativity-illness gap is most pronounced in the case of male immigrants (from Europe or the Americas or South Africa or Australia) and for female immigrants (from countries in the Middle East or North Africa) and least pronounced in the case of immigrants arriving from the former Soviet Union for both gender groups. Decomposition of the gaps into components reveals that some portion of the illness gap can be attributed to nativity status, but the largest portion of the gap is attributed to demographic characteristics. Neither socioeconomic status nor health-related behavior accounts for a substantial portion of the nativity-illness gap for all subgroups of immigrants.

Traditional health-related practices of Russian-speaking immigrants

The population of foreign-born residents continues to grow in the United States. One of the largest growing groups of immigrants is the population of Russian-speakers moving from the countries of the former Union of Soviet Socialistic Republics (Soviet Union/USSR). Like many other immigrants, Russian speakers present with various health concerns. Empirical literature indicates a gap in research that addresses culturally based beliefs and behaviors related to health in this group of immigrants. A qualitative ethnographic study that addresses the health-related practices of Russian-speaking immigrants was conducted on the East Coast of the United States. Twenty-eight participants, ages 36-86, were interviewed, along with participant observation and analysis of documents. Data analysis revealed three related categories: perception of health, perception of illness, and health-related practices. Perceptions of health were influenced by families and defined roles within the family. Perceptions of illness were outlined by approaches to disease management and remedies to illness. Subsequently, the health-related practices of Russian-speaking immigrants were molded by perceptions of health and illness. Further research is recommended to examine specific health-related practices of Russian-speaking immigrants in the United States and to explore more diverse groups within this aggregate.

Hospitalizations Among Chernobyl-Exposed Immigrants to the Negev of Israel, 1992-2017: A Historical Follow-Up Study

On April 26th, 1986 the nuclear reactor at Chernobyl, Ukraine exploded, causing the worst radiation disaster in history. The aim was to estimate hospitalization rates among exposed civilians who later immigrated to Israel. We conducted a historical follow-up study, among persons exposed to Chernobyl (n = 1128) using linked hospitalization records from Soroka University Medical Center (SUMC), compared with immigrants from other areas of the Former Soviet Union (FSU) (n = 11,574), immigrants not from FSU (n = 11,742) and native-born Israelis (n = 8351), matched on age and gender (N = 32,795). Hospitalizations for specific ICD-10 coded diagnostic groups were analyzed by exposure and comparison groups by gender and age at accident. In addition, the rate of hospitalization, and the duration of hospital days and the number of hospitalizations for these selected diagnostic groups was also calculated. Hospitalizations for specific ICD-10 coded diagnostic groups and for any hospitalization in these diagnostic groups in general were analyzed by exposure and comparison groups and by covariates (gender and age at accident). The rate of any hospitalization for the selected diagnostic groups was elevated in the low exposure Chernobyl group (51.1%), which was significantly higher than the immigrant (41.6%) and the Israel-born comparison group (35.1%) (p < .01) but did not differ from either the high exposure group (46.9%) or the FSU comparison group (46.4%), according to the post-hoc tests. The total number of hospitalizations in the low exposure Chernobyl group (2.35) differed from the immigrant (1.73) and Israel comparison group (1.26) (p < .01) but did not differ from the FSU comparison group (1.73) or the high exposure group (2.10). Low exposure women showed higher rates of circulatory hospitalizations (33.8%) compared to immigrants (22.8%) and Israeli born (16.5%), while high exposure women (27.5%) only differed from Israelis (p < .01). Neither exposure group differed from FSU immigrant women on the rate of circulatory hospitalizations. Post-hoc tests showed that among women in the low exposure group, there was a significant difference in rate of hospitalizations for neoplasms (28.6%) compared to the three comparison groups; FSU (18.6%), immigrants (15.7%) and Israel (13.1) (p < .01). Those among the low exposure group who were over the age of 20 at the time of the accident showed the higher rates of circulatory (51.2%) and neoplasm hospitalizations (33.3%), compared to the other immigrant groups (p < .01). When controlling for both age at accident and gender, hospitalizations for neoplasms were higher among Chernobyl-exposed populations (RR = 1.65, RR = 1.77 for high and low-exposure groups, respectively) compared to other FSU immigrants (RR = 1.31) other immigrants (RR = 1.11) and Israeli born (RR = 1.0) after controlling for gender and age at accident. High RRs attributable to Chernobyl exposure were also found for circulatory diseases compared to other immigrants and Israeli born (RRs = 1.50, 1.47 for high and low exposure compared to 1.11. and 1.0, other immigrants and Israeli born, respectively). Endocrine problems and disorders of the eye also showed elevated RR compared to the immigrant comparison groups. Respiratory and mental disorders did not show any consistent association with Chernobyl exposure. The findings support unique Chernobyl morbidity associations only in some diagnostic groups, particularly for low exposure women. General immigration effects on hospitalizations compared to the Israeli born population were found on all diagnostic groups. There is a need to improve the services and medical follow-up for these Chernobyl exposed groups in specific diagnostic groups.

Using population-level incidence of hepatitis C virus and immigration status for data-driven screening policies: a case study in Israel

BACKGROUND

Most studies estimate hepatitis C virus (HCV) disease prevalence from convenience samples. Consequently, screening policies may not include those at the highest risk for a new diagnosis.

METHODS

Clalit Health Services members aged 25-74 as of 31 December 2009 were included in the study. Rates of testing and new diagnoses of HCV were calculated, and potential risk groups were examined.

RESULTS

Of the 2 029 501 included members, those aged 45-54 and immigrants had lower rates of testing (12.5% and 15.6%, respectively), higher rates of testing positive (0.8% and 1.1%, respectively), as well as the highest rates of testing positive among tested (6.1% and 6.9%, respectively).

DISCUSSION

In this population-level study, groups more likely to test positive for HCV also had lower rates of testing. Policy makers and clinicians worldwide should consider creating screening policies using on population-based data to maximize the ability to detect and treat incident cases.

Patterns of informal family care during acute hospitalization of older adults from different ethno-cultural groups in Israel

Introduction

Informal caregiving during hospitalization of older adults is significantly related to hospital processes and patient outcomes. Studies in home settings demonstrate that ethno-cultural background is related to various aspects of informal caregiving; however, this association in the hospital setting is insufficiently researched.

Objectives

Our study explore potential differences between ethno-cultural groups in the amount and kind of informal support they provide for older adults during hospitalization.

Methods

This research is a secondary data analysis of two cohort studies conducted in Israeli hospitals. Hospitalized older adults are divided into three groups: Israeli-born and veteran immigrant Jews, Arabs, and Jewish immigrants from the Former Soviet Union (FSU). Duration of caregiver visit, presence in hospital during night hours, type of support (using the Informal Caregiving for Hospitalized Older Adults scale) are assessed during hospitalization. Results are controlled by background parameters including functional Modified Barthel Index (MBI) and cognitive Short Portable Mental Status Questionnaire (SPMSQ) status, chronic morbidity (Charlson), and demographic characteristics.

Results

Informal caregivers of “FSU immigrants” stay fewer hours during the day in both cohorts, and provide less supervision of medical care in Study 2, than caregivers in the two other groups. Findings from Study 1 also suggest that informal caregivers of “Arab” older adults are more likely to stay during the night than caregivers in the two other groups.

Conclusions

Ethno-cultural groups differ in their patterns of caregiving of older adults during hospitalization. Health care professionals should be aware of these patterns and the cultural norms that are related to caregiving practices for better cooperation between informal and formal caregivers of older adults.

Second opinion utilization by healthcare insurance type in a mixed private-public healthcare system: a population-based study

OBJECTIVES

To evaluate the utilisation (overall and by specialty) and the characteristics of second-opinion seekers by insurance type (either health fund or supplementary insurance) in a mixed private-public healthcare.

DESIGN

An observational study.

SETTING

Secondary care visits provided by a large public health fund and a large supplementary health insurance in Israel.

PARTICIPANTS

The entire sample included 1 392 907 patients aged 21 years and above who visited at least one specialist over an 18 months period, either in the secondary care or privately via the supplementary insurance.

OUTCOMES MEASURES

An algorithm was developed to identify potential second-opinion instances in the dataset using visits and claims data. Multivariate logistic regression was used to identify characteristics of second-opinion seekers by the type of insurance they used.

RESULTS

143 371 (13%) out of 1 080 892 patients who had supplementary insurance sought a single second opinion, mostly from orthopaedic surgeons. Relatively to patients who sought second opinion via the supplementary insurance, second-opinion seekers via the health fund tended to be females (OR=1.2, 95% CI 1.17 to 1.23), of age 40-59 years (OR=1.36, 95% CI 1.31 to 1.42) and with chronic conditions (OR=1.13, 95% CI 1.08 to 1.18). In contrast, second-opinion seekers via the supplementary insurance tended to be native-born and established immigrants (OR=0.79, 95% CI 0.76 to 0.84), in a high socioeconomic level (OR=0.39, 95% CI 0.37 to 0. 4) and living in central areas (OR=0.88, 95% CI 0.85 to 0.9).

CONCLUSIONS

Certain patient profiles tended to seek second opinions via the supplementary insurance more than others. People from the centre of the country and with a high socioeconomic status tended to do so, as medical specialists tend to reside in central urban areas. Further research is recommended to examine the availability of medical specialists by specialty and residence.

Reasons, perceived outcomes and characteristics of second-opinion seekers: are there differences in private vs. public settings?

Background

In most countries, patients can get a second opinion (SO) through public or private healthcare systems. There is lack of data on SO utilization in private vs. public settings. We aim to evaluate the characteristics of people seeking SOs in private vs. public settings, to evaluate their reasons for seeking a SO from a private physician and to compare the perceived outcomes of SOs given in a private system vs. a public system.

Methods

A cross-sectional national telephone survey, using representative sample of the general Israeli population (n = 848, response rate = 62%). SO utilization was defined as seeking an additional clinical opinion from a specialist within the same specialty, on the same medical concern. We modeled SO utilization in a public system vs. a private system by patient characteristics using a multivariate logistic regression model.

Results

214 of 339 respondents who obtained a SO during the study period, did so in a private practice (63.1%). The main reason for seeking a SO from a private physician rather than a physician in the public system was the assumption that private physicians are more professional (45.7%). However, respondents who obtained a private SO were neither more satisfied from the SO (p = 0.45), nor felt improvement in their perceived clinical outcomes after the SO (p = 0.37). Low self-reported income group, immigrants (immigrated to Israel after 1989) and religious people tended to seek SOs from the public system more than others.

Conclusions

The main reason for seeking a SO from private physicians was the assumption that they are more professional. However, there were no differences in satisfaction from the SO nor perceived clinical improvement. As most of SOs are sought in the private system, patient misconceptions about the private market superiority may lead to ineffective resource usage and increase inequalities in access to SOs. Ways to improve public services should be considered to reduce health inequalities.

A "healthy immigrant effect" or a "sick immigrant effect"? Selection and policies matter

Previous literature on a variety of countries has documented a "healthy immigrant effect" (HIE). Accordingly, immigrants arriving in the host country are, on average, healthier than comparable natives. However, their health status dissipates with additional years in the country. HIE is explained through the positive self-selection of healthy immigrants as well as the positive selection, screening and discrimination applied by host countries. In this article we study the health trajectories of immigrants within the context of selection and migration policies. Using SHARE data we examine the HIE, comparing Israel and 16 European countries that have fundamentally different migration policies. Israel has virtually unrestricted open gates for Jewish people around the world, who in turn have ideological rather than economic considerations to move. European countries have selective policies with regards to the health, education and wealth of migrants, who also self-select themselves. Our results provide evidence that (1) immigrants who move to Israel have compromised health and are significantly less healthy than comparable natives. Their health disadvantage persists for up to 20 years of living in Israel, after which they become similar to natives; (2) immigrants who move to Europe have significantly better health than comparable natives. Their health advantage remains positive for many years. Even though during some time lapses they are not significantly different from natives, their health status never becomes worse than that of natives. Our results are important for migration policy and relevant for domestic health policy.

Association Between Recency of Immigration and Mammography Uptake: Results from a Canadian National Survey

Despite the strong evidence for screening mammography in reducing mortality from breast cancer, uptake is hampered especially in recent immigrant populations. Although mammography screening behaviors of immigrant populations compared to the general population have been widely studied, evidence of the specific characteristics within the immigrant population in a universal healthcare setting, which explain differential uptake is lacking. The current cross sectional study used self-reported data from the 2011-2012 Canadian Community Health Survey to examine the association between recency of immigration and mammography uptake among 1825 immigrant women aged 50-69 years, using multivariable logistic model adjusted for confounders. In the adjusted analysis, non-recent immigrants had a nonsignificantly increased odds of recent mammography uptake, 1.19 (95 % CI 0.41, 3.44) compared to recent immigrants. In the face of evidence depicting differential health care utilization of recent immigrants compared to non-recent ones or the general population, findings from this study highlight further thinking into strategies for improving the health of immigrants.

The Impact of Mental Health Reform on Mental Illness Stigmas in Israel

This study examined public perception of stigmas relating to mental illness six months after a reform, which integrated mental health care into primary care in Israel. The results reveal that the public feels uncomfortable seeking referral to mental health services through the public health system, with Arab Israelis and men expressing lower levels of comfort than did Jewish Israelis. The current reform has not solved the issue of public stigma regarding mental health care. The study suggests that the current reforms must be accompanied over time with appropriate public education regarding mental illness.

Low health literacy and healthcare utilization among immigrants and non-immigrants in Switzerland

OBJECTIVE

This study aimed at investigating the association between functional health literacy and knowledge on when to seek medical help for potentially harmless (overutilization) or serious (underutilization) situations among immigrants and non-immigrants in Switzerland.

METHODS

Data was collected among three immigrant groups and the native population (N=1146) in the German- and Italian-speaking part of Switzerland. Health literacy was assessed with the Short Test of Functional Health Literacy (S-TOFHLA) and three Brief Health Literacy Screeners. Over- and underutilization of healthcare services was assessed with items asking participants about when to seek medical help for minor, respectively major, physical symptoms.

RESULTS

Immigrants were more likely to seek medical help when unwarranted (overutilization). Health literacy, when assessed with the S-TOFHLA, was significantly associated with over- and underutilization. Yet, once controlled for covariates, the association between health literacy and overutilization was negative. Immigration background and micro-cultural differences emerged as important predictors of utilization.

CONCLUSIONS

Results suggest that functional health literacy is directly related to healthcare utilization. The effects might be amplified by (micro-)cultural differences.

PRACTICE IMPLICATIONS

Healthcare providers should be aware of differences in health literacy and utilization patterns among different population groups. Communication between patients and providers should be literacy and culturally sensitive.

The relationship between health services standardized costs and mortality is non-linear: Results from a large HMO population

Older age, male gender, and poor socioeconomic status have been found to predict mortality. Studies have also documented an elevation in health services standardized costs (HSSC) and expenditures in the last years of life. We examined the contribution of HSSC in the last years of life in predicting mortality beyond predictors that have been established in the literature, and whether the impact of HSSC on mortality is linear. Vulnerability, operationalized as being exempt from co-payments due to poverty, being a holocaust survivor, or other reasons, was examined as potentially mediating the relationship between HSSC and mortality. We used longitudinal data obtained from the largest Health Maintenance Organization in Israel. Subjects were insured persons who were over age 65 in 2006 (n=423,140). Predictors included demographics, co-morbidity, and HSSC. All factors significantly predicted time to death. For HSSC, high levels displayed the highest Hazard Ratios (HR), with medium levels having the lowest HRs. The higher mortality rate in the low HSSC group might indicate a risk of underutilizing health services. Vulnerable status remained a predictor of mortality even within a system of universal access to healthcare. There is a need for establishing mechanisms to identify those underutilizing health services. A universal health care system is insufficient for providing equal health care, indicating a need for additional means to increase equality.

Health and health care in Israel: an introduction

Starting well before Independence in 1948, and over the ensuing six decades, Israel has built a robust, relatively efficient public system of health care, resulting in good health statistics throughout the life course. Because of the initiative of people living under the British Mandate for Palestine (1922-48), the development of many of today's health services predated the state's establishment by several decades. An extensive array of high-quality services and technologies is available to all residents, largely free at point of service, via the promulgation of the 1994 National Health Insurance Law. In addition to a strong medical academic culture, well equipped (albeit crowded) hospitals, and a robust primary-care infrastructure, the country has also developed some model national projects such as a programme for community quality indicators, an annual update of the national basket of services, and a strong system of research and education. Challenges include increasing privatisation of what was once largely a public system, and the underfunding in various sectors resulting in, among other challenges, relatively few acute hospital beds. Despite substantial organisational and financial investment, disparities persist based on ethnic origin or religion, other socioeconomic factors, and, regardless of the country's small size, a geographic maldistribution of resources. The Ministry of Health continues to be involved in the ownership and administration of many general hospitals and the direct payment for some health services (eg, geriatric institutional care), activities that distract it from its main task of planning for and supervising the whole health structure. Although the health-care system itself is very well integrated in relation to the country's two main ethnic groups (Israeli Arabs and Israeli Jews), we think that health in its widest sense might help provide a bridge to peace and reconciliation between the country and its neighbours.

Second Medical Opinion: Utilization Rates and Characteristics of Seekers in a General Population

BACKGROUND

Second opinion (SO) is common in medical practice and can reduce unnecessary risks and costs. To date, there is no population-based estimation of how many people seek SOs and what the characteristics of second-opinion seekers are.

OBJECTIVES

To estimate how many people seek SOs, and what the characteristics of second-opinion seekers are.

METHODS

We conducted both a medical records analysis (n=1,392,907) and a cross-sectional national telephone survey with a representative sample of the general Israeli population (n=848, response rate=62%). In the medical records analysis, we linked consultations with specialists at community secondary care and private consultations using claims data. We developed a time-sensitive algorithm that identified potential SO instances. In both methods, we predicted the characteristics of second-opinion seekers using multivariate logistic regressions.

RESULTS

The medical records analysis and the survey findings were highly consistent, and showed that about sixth (14.9% in the medical records vs. 17.2% in the survey) of a general population sought a SO, mostly from orthopedic surgeons. Women, native-born, and established immigrants, people living in central urban areas or close to central urban areas, people with chronic conditions, and those who perceived their health status as not very good, were more likely to seek SOs than others.

CONCLUSIONS

A considerable amount of people sought a SO. Certain patient profiles tended to seek SOs more than others. Such utilization patterns are important to devise policy regarding SOs, due to their implications on expenditure, policy, clinical outcomes, and patient satisfaction.

Evaluating the impact of immigration policies on health status among undocumented immigrants: a systematic review

Over the past two decades, new anti-immigration policies and laws have emerged to address the migration of undocumented immigrants. A systematic review of the literature was conducted to assess and understand how these immigration policies and laws may affect both access to health services and health outcomes among undocumented immigrants. Eight databases were used to conduct this review, which returned 325 papers that were assessed for validity based on specified inclusion criteria. Forty critically appraised articles were selected for analysis; thirty articles related to access to health services, and ten related to health outcomes. The articles showed a direct relationship between anti-immigration policies and their effects on access to health services. In addition, as a result of these policies, undocumented immigrants were impacted by mental health outcomes, including depression, anxiety, and post-traumatic stress disorder. Action items were presented, including the promotion of cultural diversity training and the development of innovative strategies to support safety-net health care facilities serving vulnerable populations.

Differences Between New Immigrants From the Former Soviet Union and Veteran Residents in Knowledge, Perception, and Risk Factors of Stroke

BACKGROUND

Stroke is the fourth most common cause of death in developed countries and a leading cause of acquired disability in adults. Awareness of risk factors and warning signs for stroke has a considerable impact on early arrival at the hospital and early thrombolytic treatment. Delays in seeking medical treatment following the onset of stroke symptoms have been shown to be more common among ethnic minorities.

OBJECTIVE

The aim of the current study was to examine stroke awareness and knowledge among new immigrants from the Former Soviet Union (IFSUs) compared with veteran residents (VRs).

METHODS

The study was conducted by students of the nursing master of arts program. Data were collected during March 2010 and June 2014. Trained registered nurses conducted interviews, using a structured, pretested, open-ended questionnaire. Participants were recruited by a snowball method from among the interviewers' friends and family members, 40 years or older with no history of stroke.

RESULTS

A total of 643 Israelis, 420 VRs (65.3%) and 223 IFSUs (34.7%), were interviewed; 40.7% were men, with a mean age of 52.6 (SD, 9.3) years. Compared with VRs, IFSUs were more likely to report previous myocardial infarction (P = .022), hypertension (P < .001), and diabetes (P = .012). The mean number of stroke warning signs reported by IFSUs was higher than that reported by VRs (P = .031). When asked about risk factors for stroke, IFSUs more often stated hypertension (P = .03), whereas VRs more often reported family history (P = .03). Immigrants from the Former Soviet Union were more aware of strategies for the prevention of stroke than VRs (P = .02). The preferred sources of information about stroke for IFSUs, as distinguished from VRs, were personal doctors (P = .001) and radio programs (P = .03).

CONCLUSIONS

Veteran residents showed lower levels of knowledge about stroke. Educational campaigns aimed at increasing knowledge of stroke among Israel's general population in Israel, as well as culturally targeting specific subgroups, are recommended.

Decision-Making Styles and Levels of Involvement Concerning Breast Reconstructive Surgery: An Israeli Study

PURPOSE/OBJECTIVES

To address decision-making styles among breast cancer survivors considering breast reconstruction.
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DESIGN

A primary analysis of a cross-sectional sample among survivors who chose to have breast reconstruction to examine correlations among patient age, decision-making style, and the level of involvement of decision making.
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SETTING

Hadassah Medical Center in Jerusalem, Israel.
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SAMPLE

70 women who had undergone breast reconstruction surgery in the past five years.
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METHODS

Participants completed decision-making style and demographic questionnaires and an assessment of their level of involvement in the decision-making process. 
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MAIN RESEARCH VARIABLES

Level of involvement in decision making, decision-making model between provider and patient, and decision-making styles were examined.
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FINDINGS

No correlation was found between four main decision-making styles and patient age or the extent of patient decision-making involvement and age. A statistically significant correlation was found between the level of involvement in decision making and the decision-making style of the patient.
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CONCLUSIONS

Nurses should assess patient decision-making styles to ensure maximum patient involvement in the decision-making process based on personal desires regardless of age.
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IMPLICATIONS FOR NURSING

Nurses working in breast cancer care must address the decision-making process of patients diagnosed with breast cancer, including the choice to undergo breast reconstruction after mastectomy. Nurses should understand the complex factors that influence a woman's decision-making style to best help with the decision.

Emergency physician's perception of cultural and linguistic barriers in immigrant care: results of a multiple-choice questionnaire in a large Italian urban emergency department

BACKGROUND

A poor communication with immigrants can lead to inappropriate use of healthcare services, greater risk of misdiagnosis, and lower compliance with treatment. As precise information about communication between emergency physicians (EPs) and immigrants is lacking, we analyzed difficulties in communicating with immigrants in the emergency department (ED) and their possible associations with demographic data, geographical origin and clinical characteristics.

METHODS

In an ED with approximately 85 000 visits per year, a multiple-choice questionnaire was given to the EPs 4 months after discharge of each immigrant in 2011.

RESULTS

Linguistic comprehension was optimal or partial in the majority of patients. Significant barriers were noted in nearly one fourth of patients, for only half of them compatriots who were able to translate. Linguistic barriers were mainly found in older and sicker patients; they were also frequently seen in patients coming from western Africa and southern Europe. Non-linguistic barriers were perceived by EPs in a minority of patients, more frequently in the elderly and frequent attenders. Factors independently associated with a poor final comprehension led to linguistic barriers, non-linguistic obstacles, the absence of intermediaries, and the presence of patient's fear and hostility. The latter probably is a consequence, not the cause, of a poor comprehension.

CONCLUSION

Linguistic and non-linguistic barriers, although quite infrequent, are the main factors that compromise communication with immigrants in the ED, with negative effects especially on elderly and more seriously ill patients as well as on physician satisfaction and appropriateness in using services.

Understanding sickness presenteeism through the experience of immigrant workers in a context of economic crisis

BACKGROUND

Previous economic recessions show that immigrant workers may experience longer periods of unemployment, a situation that may lead employees to presenteeism, the act of working in spite of a health problem. This study explored perceptions about the factors that lead to presenteeism in immigrant workers considering the context of economic crisis.

METHODS

Six focus group discussions were held (February 2012), with men and women from Colombia, Ecuador, and Morocco (n=44) living in Spain and selected by theoretical sample. A qualitative content analysis was performed.

RESULTS

Four categories were identified as factors that influence the occurrence of presenteeism in a context of economic crisis: poor employment conditions, fear of unemployment, employer/employee relationship, and difficulties in finding temporary replacement workers. Furthermore, musculoskeletal, respiratory, and mental problems were related to presenteeism.

CONCLUSIONS

It is important to develop strategies to protect workers from negative working conditions that are associated with deterioration of health.

Reducing health disparities: the social role of medical schools

INTRODUCTION

Medical education based on the principles of social medicine can contribute toward reducing health disparities through the "creation" of doctors who are more involved in community programs.

PURPOSE

This study compared the social medicine orientation of graduates from various medical schools in Israel.

METHODS

The authors conducted an online cross-sectional survey in May 2011 among physicians who are graduates of Israeli medical schools.

RESULTS

The study included 1050 physicians practicing medicine in Israel: 36% who are graduates from the Hebrew University, 26% from Tel Aviv University, 22% from the Technion and 16% from Ben-Gurion University. A greater percentage of physicians who studied either at the Technion or Ben-Gurion are working or have worked in the periphery (∼50% vs. ∼30% at the Hebrew and Tel Aviv Universities). Among Ben-Gurion graduates, 47% are active in social medicine programs vs. 34-38% from other schools. Among physicians active in social medicine programs, 32% of Ben-Gurion alumni estimated that their medical education greatly influenced their social medicine involvement vs. 8-15% from other schools. Hebrew University alumni described their studies as more research-oriented. In contrast, Ben-Gurion graduates described their studies as more social medicine-oriented and they exhibited more positive attitudes about the role of physicians in reducing health disparities.

DISCUSSION

Social medicine-oriented medical education induces a socialization process reinforcing human values regarding doctor-patient relationships and produces positive attitudes among future doctors about social involvement. Findings emphasize the need to develop educational programs with this orientation and to strengthen medical schools in the periphery.