Maternal and child health in Israel: building lives

"Care About us First": Israeli Youths' Perspectives on Child Neglect

Child neglect is considered the most common form of child maltreatment with severe implications for children's development. Nonetheless, there is a dearth of scholarly literature examining child neglect, possibly stemming from a lack of consistent definition. The current qualitative study addresses this gap by aiming to understand the phenomena of child neglect from the direct perspective of youth from the general population, a perspective that has so far barely been considered. Data were collected by 10 focus groups conducted among multicultural youth aged 12 to 15 years in the north of Israel. The qualitative-thematic analysis generated three main themes, each including several subthemes: (a) experience of neglectful behavior (lack of parental care, lack of parental priority, dynamics of blaming the child, rejection, and relinquishment of the child); (b) instrumental characteristics of neglect (lack of material and financial investment in the child, expressions of neglect in providing food and nutrition, poor appearance and hygiene of the child and home); (c) lack of parental involvement (lack of parental guidance, lack of communication and availability, lack of presence in the child's life). The perspectives of the Israeli youth resembled existing conceptualizations of child neglect. The youth also added a new dimension to the conceptualizations in their focus on the emotional context involved in the range of neglectful behaviors they described. This new conceptualization of child neglect is discussed together with some suggestions for how it can inform better professional practice.

Prenatal and postnatal exposure to NO2 and rapid infant weight gain - A population-based cohort study

BACKGROUND

Childhood overweight and obesity is a global public health problem. Rapid infant weight gain is predictive of childhood overweight. Studies found that exposure to ambient air pollution is associated with childhood overweight, and have linked prenatal exposure to air pollution with rapid infant weight gain.

OBJECTIVES

To examine the association between prenatal and postnatal ambient NO2 exposure, a traffic-related marker, with rapid weight gain in infants.

METHODS

We carried out a population-based historical cohort study using data from the Israeli national network of maternal and child health clinics. The study included 474,136 infants born at term with birthweight ≥2500 g in 2011-2019 in central Israel. Weekly averages of NO2 concentration throughout pregnancy (prenatal) and the first 4 weeks of life (postnatal) were assessed using an optimized dispersion model and were linked to geocoded home addresses. We modelled weight gain velocity throughout infancy using the SuperImposition by Translation and Rotation (SITAR) method, a mixed-effects nonlinear model specialized for modelling growth curves, and defined rapid weight gain as the highest velocity tertile. Distributed-lag models were used to assess critical periods of risk and to measure relative risks for rapid weight gain. Adjustments were made for socioeconomic status, population group, subdistrict, month and year of birth, and the alternate exposure period - prenatal or postnatal.

RESULTS

The cumulative adjusted relative risk for rapid weight gain of NO2 exposure was 1.02 (95% confidence intereval [CI] 1.00, 1.04) for exposure throughout pregnancy and 1.02 (95% CI 1.01, 1.04) for exposure during the first four postnatal weeks per NO2 interquartile range increase (7.3 ppb). An examination of weekly associations revealed that the critical period of risk for the prenatal exposure was from mid-pregnancy to birth.

CONCLUSIONS

Prenatal and postnatal exposures to higher concentrations of traffic-related air pollution are each independently associated with rapid infant weight gain, a risk factor for childhood overweight and obesity.

"I'm 'just' a community pediatrician" views and challenges of pediatricians working in the community in Israel

BACKGROUND

There are ongoing changes around the world in the training and practice of pediatricians who work in the community. These changes are driven by the understanding that pediatricians are required to provide not only acute primary care but also to address more comprehensive concerns, particularly the 'new morbidities'. The present study examines the professional identity of Israeli pediatricians in the community in light of these changes, the barriers and challenges to their work and professional adaptations in the field.

METHODS

We used a mixed-methods approach, collecting the perspectives of 137 pediatricians who work in the community through an anonymous online survey, followed by in-depth semi-structured interviews with 11 community pediatricians.

RESULTS

The survey results show that community pediatricians in Israel have limited knowledge on a variety of developmental, behavioral and emotional issues; that they lack working relationships with medical or other professionals; and are rarely engaged with other community services. Three main themes arose from the interviews that support and deepen the survey results: perceptions of the profession (pediatrics in the community vs. community pediatrics), the stature of pediatricians in the community (during residency, the choice to work in the community, their daily work) and barriers and change in community pediatrics (isolation, limited resources and challenges arising from the nature of community work).

CONCLUSIONS

The present study sheds light on the professional identity and the day-to-day challenges and successes of pediatricians working in the community. Continuing medical education, providing a supportive framework and professional community, better resources, more time with patients, and tools and opportunities for professional development would help pediatricians who work in the community to overcome some of these challenges. The research findings reinforce the need for policy change in the field of community pediatrics with a specific community training curriculum, provision of more resources and ongoing support for pediatricians. This requires partnership between the HMOs, the Ministry of Health, the Scientific Council (Israel Medical Association, professional organizations) and NGOs in order to turn individual-level solutions into system-level and policy-changing solutions.

Mothers' Knowledge of Infants' Fever Management: A National Prospective Study

OBJECTIVES

The aim of this study was to describe mothers' knowledge of infant fever management after birth and six months later and its association with sociodemographic characteristics, perceived support, sources of consultation and health education; and to assess determinants of change in mother's knowledge from birth to six months.

METHODS

Mothers (n = 2804) answered a self-reporting questionnaire after giving birth in maternity wards in six hospitals in Israel; six months later follow- up interviews were conducted by telephone.

RESULTS

The mothers' knowledge level of infant fever management was low after birth (mean = 50.5, range 0-100, SD = 16.1), and rose to a moderate level six months later (mean = 65.2, SD = 15.0). Mothers having their first born, with lower household income or education were less knowledgeable about infant fever management after birth. However, these mothers showed the largest improvement after six months. Mothers' perceived support or sources of consultation and health education (partner, family, friends, nurses, and physicians) were not associated with their knowledge at either time. Moreover, mothers stated self-learning from internet and other media as often as receiving health education by health professionals.

CONCLUSIONS FOR PRACTICE

Public health policy for health professionals in hospitals and community clinics is essential to promote clinical interventions promoting mothers' knowledge of infant fever management. Efforts should focus at first time mothers, those with non-academic education, and those with a moderate or low household income. Public health policy enhancing communication with mothers regarding fever management in hospitals and community health settings, as well as accessible means of self-learning is warranted.

A Game-Theory-Based Approach to Promoting Health Policy among Minorities

The importance of designing policy measures that government and other public bodies apply to different populations has been escalating in recent decades. This study seeks the best way to induce conservative minority groups to cooperate with healthcare policy. The case study focuses on the Bedouin population of Israel and its willingness to accept COVID-19 vaccination. The study is based on vaccination data from the Israel Ministry of Health for the country's entire Bedouin population, twenty-four semi-structured in-depth interviews with relevant key stakeholders, and the use of game-theory tools to profile the players, the utility functions, and various equilibrium combinations. By comparing the groups and integrating game-theory tools into the process, we reveal variables that may affect healthcare processes among conservative minority communities. Finally, cross-tabulating the results with the interview findings strengthens the insights and allows a culturally adjusted policy to be adopted. The different starting points of different minority populations have implications for the design of requisite policies in both the short and the long terms. The analysis of the game allowed us to indicate the strategy that policymakers should adopt in consideration of variables that should be taken into account in order to improve cooperation and the ability to apply policy. To increase vaccination rates among conservative minority communities in general and the Bedouin population in particular, trust in the government must be increased in the long term. In the short term, trust in the medical profession must be increased, and also health literacy.

Tale of two countries: attitudes towards older persons in Italy and Israel during the COVID-19 pandemic as seen through the looking-glass of the media

The COVID-19 pandemic has exposed the many challenges and difficulties of healthcare systems caring for older frail people. This public health crisis has indeed jeopardised the concept of the welfare state, in particular the right of older people to uncompromised healthcare. Together with the clinical challenges facing the geriatric patient and the organisational difficulties of the healthcare systems, sociocultural factors may have also played a substantial role in the strategies that countries have applied in coping with the pandemic. In this opinion article, we report attitudes towards the older populations of two countries, Italy and Israel, during the COVID-19 pandemic as viewed through the looking-glass of the media.

Comparison between School-Age Children with and without Obesity in Nutritional and Inflammation Biomarkers

Childhood obesity is a major health problem. We examined differences between children with obesity and normal weight in nutritional and inflammation biomarkers. A cross-sectional study was conducted among healthy children aged 10-12 years from Arab villages in Israel. Parents were interviewed regarding sociodemographic and children's health status. Body weight and height measurements were performed and weight categories were defined using the 2007 WHO growth curves. Blood samples were tested for complete blood count, levels of iron, ferritin, lipids, uric acid, and C-reactive protein (CRP). Overall, 146 children (59.0% males, mean age = 11.3 [SD = 0.5]) were enrolled. In total 43.8%, 14.1% and 42.3% of the participants had normal weight, overweight and obesity, respectively. A multivariable logistic regression model showed that children with overweight and obesity had lower iron, and HDL-C levels than children with normal weight. Levels of CRP, uric acid, LDL-C and lymphocytes were higher among children with overweight and obesity. In conclusion, our findings highlight the worse metabolic and nutritional status in overweight and obese children. Such markers play a role in metabolic syndrome, thus suggesting that metabolic syndrome might start in childhood.

Preventable Cancer in Israel

Background: The cancer burden in Israel is substantial. Recently calculated population attributable fractions (PAFs) for modifiable cancer risk factors in the US and the UK have indicated much room for prevention. Our aim was to estimate PAFs for selected modifiable cancer risk factors in Israel. Methods: Exposure data on selected modifiable risk factors were based on national health surveys conducted in 2013-2015. Data on invasive cancer incidence in 2015 were retrieved from the Israel National Cancer Registry (INCR). Relative risks (RRs) for specific cancer sites were retrieved from the scientific literature. PAFs were calculated for selected modifiable risk factors using an approximate formula. Results: In 2015, 21% of all invasive cancer cases in Israel were attributed to smoking, 9% to excess body weight, and 1.5% to alcohol intake. Moreover, 32% of all invasive cancer cases were attributed to all modifiable risk factors (combined) included in our study. Conclusions: Quantifying the contribution of modifiable risk factors to the incidence of certain cancer types in Israel offers an opportunity for primary prevention and enables informed decision-making with respect to the prioritization of interventions.

Parents' Adherence to Childhood Screening Tests and Referrals: A Retrospective Cohort Study with Randomized Sampling

Routine timely examinations of well-child health are important for achieving children’s good health outcomes. Nevertheless, there is evidence of low compliance with well-child visit recommendations. The aim of the study was to examine potential factors associated with parents’ nonadherence to routine childhood screening tests and their acting on further referrals following unusual findings. A retrospective cohort study was conducted among 14,348 children born in 2016–2017 and registered at mother–child health clinics in a large city in Israel. A sample of 844 children was randomly selected. Screening tests at the age of two months and nine months were examined. A multiple logistic regression examined potential factors associated with nonadherence to screening tests and to further referral for evaluation. Lower adherence to screening tests was found among parents of nine-month-old children, but adherence was higher for nurses’ screening tests than for those of physicians. Children born in a complex delivery process, older mothers with a higher number of children, and Israeli citizens were at risk of not undergoing screening tests. Fewer children in the family and initial physician’s findings were the only explanation for acting to referrals. In order to promote children’s health outcomes and public health, health policymakers should conduct campaigns to convince parents of the importance of screening tests and of adherence to referrals with the aim of ensuring their children’s wellbeing throughout the life cycle.

Burden of treatment, emotion work and parental burnout of mothers to children with or without special needs: A pilot study

The psychological phenomenon of Parental Burnout (PB) results from an imbalance between continuous exposure to chronic parenting stress and available coping resources. The study’s aim was to examine relationships between mothers’ perceived burden of treatment and PB, and their ability to utilize emotion work (EW) as a psychological coping resource. Ninety-eight Israeli mothers (46 had children with special needs with disabilities—W-SND, and 52 had children without special needs—WO-SN) completed questionnaires assessing their perception of burden of treatment, EW and PB. According to the findings, mothers of children W-SND reported significantly higher PB, a higher perceived burden of treatment and deeper EW than mothers of children WO-SN. Additionally, among all the mothers, a positive significant correlation was found between perceived burden of treatment and PB, while among mothers of children W-SND, positive correlations were found between their perceived burden of treatment and deep EW, and between deep EW and PB. These findings suggest that among mothers of children W-SND, PB is related to their perception of the burden of treatment and to performing deep EW. Additional psychological, cultural and environmental factors should be investigated, in order to gain new perspectives regarding PB as a psychological phenomenon that affects parenting and the ability to utilize coping mechanisms for mothers generally and for mothers of children W-SND especially.

Postnatal exposure to ambient temperature and rapid weight gain among infants delivered at term gestations: a population-based cohort study

BACKGROUND

The global prevalence of childhood obesity has risen dramatically recently. Previous studies found an association between rapid infant weight gain and childhood overweight. Evidence suggests that exposure to high ambient air temperatures during prenatal life and during adulthood is associated with birthweight and obesity respectively.

OBJECTIVE

The objective of this study was to examine whether exposure to high ambient temperatures during infancy is associated with rapid infant weight gain in Israel.

METHODS

This is a population-based historical cohort study using data from the Israeli national public network of maternal and child health clinics between 2008 and 2013. We assessed exposure to ambient temperature in the first year of life using a high-resolution hybrid spatio-temporal model and calculated annual mean and minimum temperatures for each infant based on daily mean and minimum temperatures at the community clinic location. We defined rapid infant weight gain as a World Health Organization weight z-score difference >0.67 between birthweight and weight at age one year. We estimated these associations using log-linear and general additive models and adjusted for population group, district, maternal age, parental education, parity, sex, gestational age, birthweight, calendar year and calendar month of birth.

RESULTS

The study population included 217,310 singleton-term infants. Adjusted models demonstrated a positive association between ambient temperature exposure and rapid infant weight gain. Compared to the third quintile of minimum temperature, infants exposed to the first and second quintile had an adjusted relative risk of 0.98 (95% CI 0.96, 1.00) and 0.97 (95% CI 0.95, 0.98), respectively, while those exposed to the fourth and fifth quintiles had an adjusted relative risk of 1.06 (95% CI 1.04, 1.07) and 1.02 (95% CI 1.00, 1.04) respectively. The associations with mean temperature were similar but slightly weaker.

CONCLUSIONS

Exposure to higher ambient temperatures, of emerging importance in the climate change era, is associated with rapid infant weight gain in Israel. Future studies should use additional exposure, covariate, and outcome data to analyse the nature and the source of this association in more detail.

Organizational factors affecting nurses' tendency to report child abuse and neglect

OBJECTIVE

To examine the factors that affect the tendency of nurses working in mother and child health clinics (MCHC) to report child abuse to the authorities.

DESIGN

Cross-sectional survey.

SAMPLE

Three hundred and forty-one female nurses working in MCHC across Israel.

MEASUREMENTS

(1) Social and organizational variables; (2) the tendency to report child abuse and neglect; (3) attitudes toward reporting child abuse and neglect.

RESULTS

On average, the participants perceived that they have good collaboration with other staff members and with welfare services. They showed a favorable attitude toward reporting child abuse, but less than half (44.8%) would report child abuse suspicion to the authorities. None of the organizational variables (MCHC type, collaboration among staff, collaboration with welfare services) were correlated with the tendency to report child abuse and neglect, yet all three variables were significantly correlated with attitudes toward reporting child abuse. Nurses' attitudes toward reporting were mediated by the organizational variables.

CONCLUSIONS

The effect of the organizational factors on the actual tendency to report child abuse is mediated by nurses' attitude toward reporting. Organizational constraints probably encourage MCHC nurses to be cautious before reporting child abuse and neglect to the authorities, restricting adherence to the law, which requires direct reporting.

Epidemiology of cytomegalovirus infection in pregnancy in Israel: Real-world data from a large healthcare organization

Congenital cytomegalovirus infection (cCMVi) is the leading cause of nonhereditary sensorineural hearing loss among newborns. Women newly acquiring cytomegalovirus infection (CMVi) during pregnancy have the highest risk of vertical transmission. This study aimed to describe the epidemiology of CMVi in pregnancy in a large healthcare database. A retrospective cohort study was performed using the Maccabi Healthcare Services database (Israel). Women aged 18-44 years old on July 1, 2013 with no record of pregnancy in the prior 6 months were followed through December 31, 2017 for first pregnancy occurrence. Pregnancy outcomes (live birth, spontaneous/therapeutic abortions, stillbirth, and uncertain outcomes) were captured. CMV test results were obtained to assess serostatus at the start of pregnancy (SoP) and primary CMV infection (CMVi) during pregnancy. Associations of demographic and reproductive factors with pCMVi were investigated (multivariable logistic regression). The study included 84 699 pregnant women (median age = 31 years; interquartile range = 28-35). Live birth, fetal loss, and uncertain pregnancy outcomes accounted for 76.8%, 18.2%, and 5.0%, respectively. The seroprevalence of CMV at the start of pregnancy in this cohort was 63.4% (95% confidence interval [CI]: 63.1-63.7). Among seronegative women with available test results (n = 10 657), CMVi incidence was 14.5 per 1000 (95% CI = 12.2-16.7). In multivariate logistic regression models adjusting for maternal age, CMVi was significantly associated with having one or more prior live births (odds ratio [OR]: 3.8 [95% CI: 2.6-5.4]) and having a child less than 6 years of age (OR: 4.3 [95%CI: 3.0-6.1]). One in three pregnant women in Israel is at risk for primary CMVi. This study demonstrates that real-world electronic healthcare data can be leveraged to support clinical management and development of interventions for congenital CMV by identifying women at high risk for CMVi during pregnancy.

The involvement of community pediatricians in the treatment of developmental-behavioral difficulties as perceived by directors of child development centers

Background

Developmental-behavioral issues are among the most frequent and disabling conditions of children and adolescents seen in ambulatory settings. Guidelines of the Israeli Pediatric Association and the Israeli Society for Developmental Pediatrics specify the role of the primary-care pediatrician in screening and early identification of mild developmental behavioral conditions and define the criteria for referral to child development institutes. The aims of this study were to examine and describe how directors of these institutes perceive the role and involvement of community pediatricians in child development.

Methods

Qualitative interviews of the directors of 22 child development institutes from the ministry of health and the four health plans.

Results

According to the interviewees, there is little involvement of community pediatricians in detecting developmental delays, and it is mainly nurses and preschool teachers who detect such delays. They report that the key barriers that deter community pediatricians from greater involvement in child development diagnosis and treatment are lack of time, lack of compensation, and insufficient clinical knowledge. The interviewees would like to see community pediatricians conducting the primary medical evaluation, providing parental guidance, referring to therapists in mild cases, exercising discretion before referring children to child development institutes and providing relevant information to the institutes in the referral process. The mechanisms that they proposed for increasing the involvement of community pediatricians were expansion of pediatricians’ training, increased pediatricians’ use of teleconsultation with child development specialists and incentives for thorough performance of developmental assessments.

Conclusions

Due to the importance of the Issue, we strongly recommend that policymakers require child development principles, evaluation, and providing appropriate parental guidance in the curriculum of the Israeli pediatric residency program. In addition, health plans should compensate pediatricians who need to conduct longer visits for children with developmental delays. The health plans should also develop teleconsultation channels for pediatricians with child development specialists to reduce unnecessary referrals to child development institutes.

Trauma, Post-Traumatic Stress Disorder, and Mental Health Care of Asylum Seekers

Asylum seekers in Israel from East Africa frequently experienced traumatic events along their journey, particularly in the Sinai Peninsula, where they were subjected to trafficking and torture. Exposure to trauma has implications for rights that are contingent on refugee status. This retrospective chart review aimed to characterize the types of traumas experienced by 219 asylum seekers (149 men) from Eritrea and Sudan who sought treatment at a specialized mental health clinic in Israel, and to compare the mental health of trauma victims (n = 168) with that of non-trauma victims (n = 53). About 76.7% of the asylum seekers had experienced at least one traumatic event, of whom 56.5% were diagnosed with post-traumatic stress disorder (PTSD). Most reported traumas were experienced en route in the Sinai, rather than in the country of origin or Israel. Few clinical differences were observed between trauma victims and non-trauma victims, or between trauma victims with and without a PTSD diagnosis. Our findings emphasize the importance of accessibility to mental and other health services for asylum seekers. Governmental policies and international conventions on the definition of human trafficking may need to be revised, as well as asylum seekers’ rights and access to health services related to visa status.

Low and High Ambient Temperatures during Pregnancy and Birth Weight among 624,940 Singleton Term Births in Israel (2010-2014): An Investigation of Potential Windows of Susceptibility

BACKGROUND

Exposure to heat during pregnancy has been associated with reduced fetal growth. Less is known about associations with cold and the potential for critical time windows of exposure.

OBJECTIVES

We aimed to evaluate, in a national retrospective cohort, critical windows of susceptibility during pregnancy to extreme temperatures (low and high) and fetal growth, among 624,940 singleton term births in Israel during the period 2010-2014.

METHODS

Temperature exposures were estimated using a spatially refined gridded climate data set with a 1-h and 1-km2 resolution. Percentiles of temperature were categorized by climatic zone for the entire pregnancy and by trimesters and weeks. Generalized additive models with the distributed lag nonlinear model framework were used to estimate unadjusted and adjusted associations between percentiles and categories of temperature and fetal growth markers: term [births after 36 weeks of gestational age (GA)] mean birth weight and term low birth weight (tLBW, term infants with birth weight below 2,500g).

RESULTS

After adjustment, extreme temperatures (percentiles) during the entire pregnancy were associated with a lower mean birth weight {≤10th vs. 41st-50th percentile: -56g [95% confidence interval (CI): -63g, -50g)]; >90th vs. 41st-50th percentile: -65g; 95% CI: -72g, -58g}. Similar inverse U-shaped patterns were observed for all trimesters, with stronger associations for heat than for cold and for exposures during the third trimester. For heat, results suggest critical windows between 3-9 and 19-34 GA-weeks, with the strongest association estimated at 3 GA-weeks (temperature >90th vs. 41st-50th percentiles: -3.8g; 95% CI: -7.1g, -0.4g). For cold, there was a consistent trend of null associations early in pregnancy and stronger inverse associations over time, with the strongest association at 36 GA-week (≤10th vs. 41st-50th percentiles: -2.9g; 95% CI: -6.5g, 0.7g). For tLBW, U-shape patterns were estimated for the entire pregnancy and third trimester exposures, as well as nonsignificant associations with heat for 29-36 GA-weeks. Generally, the patterns of associations with temperatures during the entire pregnancy were consistent when stratified by urbanicity and geocoding hierarchy, when estimated for daily minimum and maximum temperatures, when exposures were classified based on temperature distributions in 49 natural regions, and when estimated for all live births.

DISCUSSION

Findings from our study of term live births in Israel (2010-2014) suggest that exposure to extreme temperatures, especially heat, during specific time windows may result in reduced fetal growth. https://doi.org/10.1289/EHP8117.

Failure of Israeli pediatric residency curricula to cover child development and special education issues: results of a national survey on levels of knowledge

Background

There is an increasing prevalence of developmental difficulties among Israeli children. We aimed to assess whether pediatricians are equipped to diagnose and manage them.

Methods

We assessed the knowledge of basic child development issues and availability of services and content of special education systems among a randomly selected national sample of residents and senior Israeli pediatricians. This was done via an 70-itemed survey developed especially for this study which consisted of seven main subjects: developmental milestones, global developmental delay, autism spectrum disorder, attention deficit hyperactivity disorder, protocol for referring to a child development institute, availability and facilities of special education systems, and medical conditions associated with developmental delay.

Results

A total of 310 pediatricians (an 86 % usable response rate) participated. The total median knowledge score was 32.1 % (IQR 17.8–53.5 %). Knowledge was significantly better among senior pediatricians (p < .001), those working in an office-based setting (p < .001), and those who were parents (p < .001) or had a family history of a developmental condition (p = .003). Most responders (94 %) felt that their resident training in child development was inadequate, and that they do not have sufficient access to resources and guidelines about child development and special education systems (80 %).

Conclusions

The gap in knowledge on topics of child development and special education systems among Israeli pediatricians stems from inadequacies in the current curricula of pediatric residencies. The alarmingly low scores of our survey on these issues call for prompt revamping of the syllabus to include them.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13584-021-00480-y.

Addressing vaccine hesitancy and access barriers to achieve persistent progress in Israel's COVID-19 vaccination program

As of March 31, 2021, Israel had administered 116 doses of vaccine for COVID-19 per 100 population (of any age) - far more than any other OECD country. It was also ahead of other OECD countries in terms of the share of the population that had received at least one vaccination (61%) and the share that had been fully vaccinated (55%). Among Israelis aged 16 and over, the comparable figures were 81 and 74%, respectively. In light of this, the objectives of this article are: 1. To describe and analyze the vaccination uptake through the end of March 2021 2. To identify behavioral and other barriers that likely affected desire or ability to be vaccinated 3. To describe the efforts undertaken to overcome those barriers Israel's vaccination campaign was launched on December 20, and within 2.5 weeks, 20% of Israelis had received their first dose. Afterwards, the pace slowed. It took an additional 4 weeks to increase from 20 to 40% and yet another 6 weeks to increase from 40 to 60%. Initially, uptake was low among young adults, and two religious/cultural minority groups - ultra-Orthodox Jews and Israeli Arabs, but their uptake increased markedly over time.In the first quarter of 2021, Israel had to enhance access to the vaccine, address a moderate amount of vaccine hesitancy in its general population, and also address more intense pockets of vaccine hesitancy among young adults and religious/cultural minority groups. A continued high rate of infection during the months of February and March, despite broad vaccination coverage at the time, created confusion about vaccine effectiveness, which in turn contributed to vaccine hesitancy. Among Israeli Arabs, some residents of smaller villages encountered difficulties in reaching vaccination sites, and that also slowed the rate of vaccination.The challenges were addressed via a mix of messaging, incentives, extensions to the initial vaccine delivery system, and other measures. Many of the measures addressed the general population, while others were targeted at subgroups with below-average vaccination rates. Once the early adopters had been vaccinated, it took hard, creative work to increase population coverage from 40 to 60% and beyond.Significantly, some of the capacities and strategies that helped Israel address vaccine hesitancy and geographic access barriers are different from those that enabled it to procure, distribute and administer the vaccines. Some of these strategies are likely to be relevant to other countries as they progress from the challenges of securing an adequate vaccine supply and streamlining distribution to the challenge of encouraging vaccine uptake.

A nationwide analysis of population group differences in the COVID-19 epidemic in Israel, February 2020-February 2021

BACKGROUND

Social inequalities affect the COVID-19 burden and vaccine uptake. The aim of this study was to explore inequalities in the incidence and mortality rate of SARS-CoV-2 infection and vaccine uptake in various sociodemographic and population group strata in Israel.

METHODS

We analysed nationwide publicly available, aggregated data on PCR-confirmed SARS-CoV-2 infections and COVID-19 deaths between March 2020 and February 2021, as well as the first three months of COVID-19 immunisation according to sociodemographics, including population group and residential socioeconomic status (SES). We computed incidence and mortality rates of COVID-19. Comparisons between towns with predominantly Arab, ultra-Orthodox Jewish (the minorities), general Jewish populations, and according to SES, were conducted using generalised linear models with negative binomial distribution.

FINDINGS

Overall, 774,030 individuals had SARS-CoV-2 infection (cumulative incidence 84•5 per 1,000 persons) and 5687 COVID-19 patients had died (mortality rate 62•8 per 100,000 persons). The highest mortality rate was found amongst the elderly. Most (>75%) individuals aged 60 years or above have been vaccinated with BNT162b2 vaccine. The risk of SARS-CoV-2 infection was higher in towns with predominantly Arab and ultra-Orthodox Jewish populations than in the general Jewish population, and in low SES communities. COVID-19 mortality rate was highest amongst Arabs. Conversely, vaccine uptake was lower amongst Arab and ultra-Orthodox Jewish populations and low SES communities.

INTERPRETATION

Ethnic and religious minorities and low SES communities experience substantial COVID-19 burden, and have lower vaccine uptake, even in a society with universal accessibility to healthcare. Quantifying these inequalities is fundamental towards reducing these gaps, which imposes a designated apportion of resources to adequately control the pandemic.

FUNDING

No external funding was available for this study.

Associations of Feeding Practices in Early Life and Dietary Intake at School Age with Obesity in 10- to 12-Year-Old Arab Children

Understanding the role in pediatric obesity of early life feeding practices and dietary intake at school age is essential for early prevention. The study aimed to examine associations of early life feeding practices, environmental and health-related exposures, and dietary intake at school age as determinants of obesity in children aged 10-12 years. In an earlier study of 233 healthy infants in two Arab towns in northern Israel, neonatal history, feeding practices, and health information were obtained up to age 18 months. This follow-up study assessed dietary intake and anthropometric measurements at age 10-12 years using the 24 h recall method. Overall, 174 children participated in this study. Almost all (98%) the children were breastfed. The prevalence of obesity at school age was 42%. A multivariable model adjusted for energy intake and socioeconomic status showed positive associations of total fat intake and of weight-for-height z score, but not feeding practices in infancy, with obesity. Higher gestational age at birth was associated with lower odds of obesity at age 10-12 years. In conclusion, in a population with near universal breastfeeding, gestational age at birth, weight indicators but not feeding practices in infancy, and total fat intake at school age were associated with increased likelihood of obesity.

Vaccination timeliness and completeness among preterm and low birthweight infants: a national cohort study

Vaccinating premature and low birthweight (LBW) infants according to chronological age has been found safe and effective. Although these infants are susceptible to infections, vaccinations are often delayed. We estimated vaccination coverage (VC) in preterm and LBW infants compared to term infants in a cohort study (2016 Israel birth cohort, n = 181,543) using the National Immunization Registry. Vaccinations included Hepatitis B, Diphtheria-Tetanus-acellular Pertussis-IPV-Haemophilus influenzae B, Oral Polio Bivalent, Rotavirus, Pneumococcal Conjugate, Measles-Mumps-Rubella-Varicella and Hepatitis A. Inclusion criteria: (1) born in Israel; (2) having a unique identifier (allowing data matching); and (3) surviving to 24 months. VC at 24 months and timeliness of vaccine doses were evaluated according to infants' birthweight (BW) and gestational age (GA). Preterm infants (GA < 37 weeks) comprised 7.0% (n = 12,264); LBW infants (BW< 2500 g) were 7.7% (n = 13,950); BW was 1500-2499 g in 6.8%, 1000-1499 g in 0.6% and below 1000 g in 0.3%. Compared to normal birthweight (NBW) infants (BW≥2500 g), LBW infants showed delayed initiation of vaccinations. Odds ratio (OR) for delay: DTaP-IPV-Hib 1 OR = 1.26 [95%CI 1.19-1.33]; Rota 1, OR = 1.22 [95%CI 1.16-1.29]. Vaccination delay rates were higher among smaller new-borns (below 1000 g). At 24 months there was no significant difference regarding vaccination status. This national cohort VC analysis focused on preterm/LBW infants. Vaccinating preterm and LBW infants according to the recommended schedule induces protection against life-threatening infectious diseases. Vaccination initiation among LBW infants showed considerable delay. Health practitioners and parents should cooperate to improve timely vaccination initiation.

Between a woman and her fetus: Bedouin women mediators advance the health of pregnant women and babies in their society

INTRODUCTION

Bedouin women in Israel confront a challenging circumstance between their traditional patriarchal society and transition to modernity. In terms of reproductive health, they face grave disparities as women, pregnant women and mothers. In this article we aim to understand the challenges of Bedouin women who work as mediators in the promotion of Bedouin women's perinatal health. We explore their challenges with the dual and often conflictual role as health peer-instructors-mediators in mother-and-child clinics, and also as members of a Bedouin community, embodying a status as women, mothers, and family caretakers. Drawn upon a feminist interpretative framework, the article describes their challenges in matters of perinatal health. Our research question is: how do women who traditionally suffer from blatant gender inequality utilize health-promotion work to navigate and empower themselves and other Bedouin women.

METHODS

Based on an interpretive feminist framework, we performed narrative analysis on eleven in-depth interviews with health mediators who worked in a project in the Negev area of Israel. The article qualitatively analyses the ways in which Bedouin women mediators narrate their challenging situations.

RESULTS

This article shows how difficult health mediators' task may be for women with restricted education who struggle for autonomy and better social and maternal status. Through their praxis, women mediators develop a critical perspective without risking their commitments as women who are committed to their work as well as their society, communities, and families. These health mediators navigate their ways between the demands of their employer (the Israeli national mother and child health services) and their patriarchal Bedouin society. While avoiding open conflictual confrontations with both hegemonic powers, they also develop self-confidence and a critical and active approach.

CONCLUSIONS

The article shows the ways by which the mediator's activity involved in perinatal health-promotion may utilize modern perinatal medical knowledge to increase women's awareness and autonomy over their pregnant bodies and their role as caregivers. We hope our results will be applicable for other women as well, especially for women who belong to other traditional and patriarchal societies.

The measles outbreak in Israel in 2018-19: lessons for COVID-19 pandemic

During 2018-2019 Israel saw some 4300 measles cases in a country-wide epidemic. Increased measles incidence rates and considerable disease burden have been observed in under-vaccinated communities, predominantly Jewish ultraorthodox. The measles epidemic, despite proper public health handling, revealed susceptible population subgroups as well as gaps and lacking resources in the Israeli public health systems. In the COVID-19 pandemic in Israel, as of December 2020, the number of COVID-19 cases reported nationally was over 300,000 with approximately 3000 fatalities. Notably, minority groups such as the ultraorthodox Jewish community and the Arab community in Israel has been profoundly affected by the COVID-19 pandemic. We believe it is still possible to implement the key lessons from the measles outbreak in Israel that could aid in the COVID-19 response in Israel and elsewhere. These conceptions should include a social-based approach, investment in public health human resources and infrastructure, tackling root causes of inequalities, emphasis on trust and solidarity, proactive communication, need for political will, and proper use of epidemiological data as a basis for decision-making. In parallel to proper use of COVID-19 vaccines, when available, a 'social vaccine' is crucial as well as preparedness and response according to public health principles.

Adapting the Israeli national health insurance law to the 21st century- a report from the 19th Dead Sea Conference

Passage of the National Health Insurance Law (NHIL) in 1995 marked a turning point in the history of the Israeli healthcare system, ensuring sustainable, high-quality medical care to all eligible Israeli residents. Over 100 amendments have been made to the law over the years, yet additional adaptations are required to ensure the law’s relevance in years to come. In honor of the 25th anniversary of the passage of the law, the 19th annual Dead Sea Conference brought together prominent figures in the Israeli healthcare system for a discussion on “25 Years to the NHIL: Suggested Changes and Adaptations”. Key topics discussed in the conference were regulatory aspects related to the healthcare system, administration of medical services, and financial aspects pertinent to the NHIL. The following meeting report summarizes the insights and recommendations from this conference.

Area-level socioeconomic disparity trends in nutritional status among 5-6-year-old children in Israel

OBJECTIVE

This study aimed to assess area-level socioeconomic position (SEP) disparities in nutritional status, to determine whether disparities differed by sex and to assess whether nutritional status and disparities changed over time.

DESIGN

We used repeated cross-sectional data from a national programme that evaluates the quality of healthcare in Israel to assess children's nutritional status.

SETTING

The study included all Israeli residents aged 7 years during 2014-2018 (n=699 255).

METHODS

SEP was measured based on the Central Bureau of Statistics' statistical areas, and grouped into categories, ranging from 1 (lowest) to 10 (highest). We used multivariable multinomial regression to assess the association between SEP and nutritional status and between year and nutritional status. We included interactions between year and SEP to assess whether disparities changed over time.

RESULTS

Children in SEP 1, comprised entirely of children from the Bedouin population from Southern Israel, had drastically higher odds of thinness compared with those in the highest SEP (Girls: OR 5.02, 99% CI 2.23 to 11.30; Boys: OR 2.03, 99% CI 1.19 to 3.48). Odds of obesity were highest in lower-middle SEPs (OR_{SEP 5 vs 10} 1.84, 99% CI 1.34 to 2.54). Prevalence of overweight and obesity decreased between 2014 and 2018, normal weight increased and thinness did not change. SEP disparities in thinness decreased over time in boys but showed a reverse trend for girls. No substantial improvement was seen in SEP disparities for other weight categories.

CONCLUSIONS

Our study demonstrates the need to consider initiatives to combat the considerable SEP disparities in both thinness and obesity.

Child healthcare in Israel: current challenges

The article describes and discusses several key elements of the paediatric healthcare system in Israel, including paediatric training, family and community paediatrics, hospital-based paediatric services, preventive care services, and special programs such as the "Drop of Milk" (Tipat Halav) program. Although child care in Israel has gained several notable achievements, such as a low infant mortality rate, there are several significant challenges for the coming years. These include training of enough paediatricians and periodic updating of training programs to fulfil needs and provide an adequate preventive care from fetal life through infancy, childhood, and adulthood. In addition, paediatricians in Israel should continue to be involved in national public health programs to reduce health inequities among mothers and children and reduce health disparities among certain geographic areas and various populations. Graduates of paediatric residency are expected to be able to address the new technologies, the requirements for personal medicine and on-line medicine, and to be able to deal with both pure "medical" issues, and public health, lifestyle, and environmental issues.

A comparison of health indicators and social determinants of health between Israel and the Occupied Palestinian Territories

Despite the proximity and interconnections between Israel and the Occupied Palestinian Territories (oPt), great disparities persist in health status between these two regions. This disparity is seen in infant, child and maternal mortality, life expectancy, mortality rates for leading causes of death and measures of mental well-being. This paper compares health indicators between oPt and Israel and examines the social determinants of health that may be responsible for differences between them. Data on health indicators were obtained from publicly available publications or websites of the World Health Organization and The World Bank, as well as the database of the Global Burden of Disease Project of the Institute of Health Metrics and Evaluation. Data on the social determinants of health were obtained from publications and websites of the United Nations, the World Bank, the U.S. Central Intelligence Agency, Palestinian and Israeli government reports, reports from non-governmental organisations, peer-reviewed studies and news articles. The health disparities are due to a complex mix of factors involving economic conditions, food insecurity, environmental exposures, psychological trauma and stress, and access to health services, most of which can be related directly or indirectly to the Israeli military occupation of oPt.

Timeliness and completeness of routine childhood vaccinations in young children residing in a district with recurrent vaccine-preventable disease outbreaks, Jerusalem, Israel

BackgroundChildhood vaccination schedules recommend vaccine doses at predefined ages.AimWe evaluated vaccination completeness and timeliness in Jerusalem, a district with recurrent vaccine-preventable disease outbreaks.MethodsVaccination coverage was monitored by the up-to-date method (vaccination completeness at age 2 years). Timeliness of vaccination was assessed in children (n = 3,098, born in 2009, followed to age 48 months, re-evaluated at age 7 years) by the age-appropriate method (vaccine dose timeliness according to recommended schedule). Vaccines included: hepatitis B (HBV: birth, 1 month and 6 months); diphtheria, tetanus, acellular pertussis, polio, Haemophilus influenzae b (DTaP-IPV-Hib: 2, 4, 6 and 12 months); pneumococcal conjugate (PCV: 2, 4 and 12 months); measles-mumps-rubella/measles-mumps-rubella-varicella (MMR/MMRV: 12 months) and hepatitis A (HAV: 18 and 24 months).ResultsOverall vaccination coverage (2014 cohort evaluated at age 2 years) was 95% and 86% for MMR/MMRV and DTaP-IPV-Hib4, respectively. Most children (94%, 91%, 79%, 95%, 92% and 82%) were up-to-date for HBV3, DTaP-IPV-Hib4, PCV3, MMR/MMRV1, HAV1 and HAV2 vaccines at 48 months, but only 32%, 28%, 38%, 58%, 49% and 20% were vaccinated timely (age-appropriate). At age 7 years, the median increase in vaccination coverage was 2.4%. Vaccination delay was associated with: high birth order, ethnicity (higher among Jews vs Arabs), birth in winter, delayed acceptance of first dose of DTaP-IPV-Hib and multiple-dose vaccines (vs MMR/MMRV). Jewish ultra-Orthodox communities had low vaccination coverage.ConclusionsConsiderable vaccination delay should be addressed within the vaccine hesitancy spectrum. Delays may induce susceptibility to vaccine-preventable disease outbreaks; tailored programmes to improve timeliness are required.

Hidden Figures: Are Ultra-Orthodox Jewish Women Really so Different When it Comes to Health Care?

Incorporating the needs of at-risk populations into national health care initiatives is essential. Israel has identified ultra-Orthodox Jewish, or Haredi, women, as at risk of increased morbidity and mortality, yet actual data on this insular community are lacking. We reviewed published research on Israeli Haredi women's health status, behaviors and health care access and examined methodologies. Of 273 articles identified, 14 publications and four government reports were included. More research is needed on this community, essential not only to Israeli health care policy, but to that of the USA and the UK, who share the largest percentages of Haredi Jews.

Preconceptional diet quality is associated with birth outcomes among low socioeconomic status minority women in a high-income country

PURPOSE

Studies of the association between maternal nutrition and birth outcomes have investigated differing nutrients, maternal socioeconomic conditions, and timing within the reproductive cycle; and have produced inconsistent results. We evaluated the association of preconceptional maternal dietary intake with birth outcomes among low socioeconomic status ethnic minority women in a high-income country.

METHODS

In this prospective cohort study, habitual preconceptional dietary intake was assessed among pregnant Bedouin Arab women in Israel (n = 384), using a short culturally specific, targeted food frequency questionnaire. Multiple nutrients (protein, lysine, calcium, iron, zinc, folate, omega-3 fatty acids) were evaluated simultaneously via a diet quality score derived from principal component analysis. Multivariable logistic regression was used to test associations between the diet quality score and a composite adverse birth outcomes variable, including preterm birth, low birth weight and small for gestational age.

RESULTS

Sixty-nine women (18%) had adverse birth outcomes. Women with low preconceptional diet quality scores had low intakes of nutrient-rich plant foods, bioavailable micronutrients, and complete proteins. In multivariable analysis, a woman at the 10th percentile of the diet quality score had a 2.97 higher odds (95% CI 1.28-6.86) of an adverse birth outcome than a woman at the 90th percentile.

CONCLUSION

Low diet quality during the preconceptional period was associated with adverse birth outcomes among low socioeconomic status minority women in a high-income country. The results have implications for the development of appropriate intervention strategies to prevent adverse birth outcomes, and the promotion of adequate nutrition throughout the child-bearing years.

Health diplomacy through health entrepreneurship: using hackathons to address Palestinian-Israeli health concerns

The universally shared values of improving health and well-being of populations make health a suitable diplomacy tool that transcends populations. The role of entrepreneurship in improving health and contributing to sustainable development is increasingly used in conjunction with traditional health diplomacy. In this paper, we present healthcare entrepreneurship as an effective health diplomacy tool that can spur economic growth, improve healthcare and generate sustainable development in communities. Improvements in health require involvement of diverse stakeholders including healthcare and non-health professionals to generate and implement sustainable problem-focused solutions. We illustrate the utility of early-stage innovation events, such as hackathons, in sparking entrepreneurship, interdisciplinary collaboration, ideation and innovation around problems specific to a local community. Specifically, we describe a hackathon organised in Nazareth, Israel as a means to bridge multicultural communities to address common health issues across the population. We suggest that health entrepreneurship is an important component of health diplomacy, and a critical ingredient for improved health, economic growth and sustainable development.

Sex effect on growth faltering in an indigenous ethnic minority population of infants in Israel

OBJECTIVE

We examined sex effects on growth faltering in an indigenous population of Bedouin Arab infants born in Israel, an economically developed country.

DESIGN

Retrospective cohort study. Height-for-age Z-score (HAZ) at age 6, 12, 18 and 24 months was calculated for full-term, normal-birth-weight Bedouin infants born during years 2000-2009 and attending maternal and child health (MCH) clinics. Multivariate linear regression analysis (MLRA) was used to calculate the association between sex and HAZ, controlling for year of birth, birth weight (BW) and residence by type of settlement (established settlement (ES); non-established settlement (NES)).

SETTING

Bedouin are an indigenous poor community of semi-nomadic Arabs, with the highest infant mortality rate in Israel. Fifty per cent of Bedouin infants live in NES with inadequate access to running water, electricity, and rubbish and sewage disposal. All Bedouin receive free well-baby care in community-based MCH clinics.

PARTICIPANTS

Full-term, normal Bedouin infants (n 5426) born during 2000-2009 and attending computerized MCH clinics who had growth measurements at age 6, 12, 18 and 24 months.

RESULTS

At all ages, girls had significantly higher mean HAZ than boys (P < 0·05). Increasing birth year, residence in ES and increasing BW were positively associated with HAZ (P < 0·05) at all ages. In MLRA controlling for birth year, BW and type of settlement, sex still had a significant effect, with lower HAZ among boys at 6, 12, 18 and 24 months of age (P < 0·001 at all ages).

CONCLUSIONS

Our results indicated that sex effects on growth faltering can occur in an indigenous population with low socio-economic status within an economically developed country.

Preventive health services for young children in Israel: historical development and current challenges

PURPOSE

Pediatric preventive health services are delivered in many different formats throughout the world. In Israel, these services for young children are provided in designated Maternal Child Health Clinics (MCHC). The history and operation of Israel's MCHC have been described primarily in the Hebrew language medical literature with most of these reports being over a decade old. This paper provides an up to date summary of the evolution and current care in Israel's one-hundred-year old model for the provision of preschool preventive health services. As these clinics have been recognized by the World Organization as a model for emulation, it is important that such information be made available. Israel's MCHC provide universal care to infants and preschool children (0-6 years), free of charge. These community-based clinics provide developmental surveillance, growth monitoring, and routine childhood immunizations. Anticipatory guidance is offered to families on topics including nutrition, parenting and child safety. Screening is also performed for maternal postpartum depression and family violence. Care is given by public health nurses working in collaboration with physicians. The vast majority (> 96%) of the country's children receive care in this system. Immunization coverage rates through this system are in line with World Health Organization guidelines - over 95% overall average nationally. Unfortunately, the allocated funding has not increased in proportion to the population growth. There is ongoing debate on the role of the national government in health services: should it be that of a direct services provider or focus on guidance and regulation of the health system.

CONCLUSION

MCHC well child care can help assure widespread provision of pediatric preventive health care. For this model to function, both its funding and content needs to be updated on an ongoing basis to reflect current preventive health care needs.

Mean and variance of greenness and pregnancy outcomes in Tel Aviv during 2000–14: longitudinal and cross-sectional approaches

Background

Natural environments may have beneficial impacts on pregnancy outcomes. However, longitudinal evidence is limited and the associations with variance in surrounding greenness is unknown. Our objective was to evaluate these associations among 73 221 live births in Tel Aviv, Israel.

Methods

Longitudinal exposure to mean of greenness during pregnancy and trimesters were calculated using satellite-based Moderate Resolution Imaging Spectroradiometer (MODIS) Normalised Difference Vegetation Index (NDVI) data. In addition, exposure to mean and variation of NDVI from high-resolution satellite and percentage of tree cover [Vegetation Continuous Fields (VCF)] at 300-m buffer were evaluated in a cross-sectional approach. Generalized linear models were used to estimate the crude and adjusted associations. We explore the possible mediating role of ambient exposures and distance to ‘outdoor gyms’ located in parks.

Results

Crude beneficial associations between exposure to higher mean NDVI during pregnancy and pregnancy outcomes were observed [for birthweight, 3rd/1st tertile exposure increased the mean by 25.5 g, 95% confidence intervals (CIs): 15.4, 35.5] and decreased the odds of low birthweight, small for gestational age, preterm deliveries (PTD) and very PTD. Adjustment for individual and neighbourhood-level markers of socio-economic status (SES) attenuated all the associations. Strongest associations were observed during the first and second trimesters. Cross-sectional associations for mean greenness were similar with narrower CIs, and associations with NDVI were stronger than with tree cover and stronger for mean compared with variance of greenness. Associations were consistent for term births, different buffer sizes and for further adjustment to maternal education. Stronger associations were observed for lowest SES. Distance to ‘outdoor gyms’ and variance of greenness had the largest estimates of mediation.

Conclusion

This study adds to the limited information on when exposure to greenness is most beneficial, on the association with variance of greenness and the possible pathways. These observations require confirmation in other populations.

Risk and Protective Factors for Child Overweight/Obesity Among Low Socio-Economic Populations in Israel: A Cross Sectional Study

Background and Aims: Scientific evidence regarding protective factors that contribute to healthy weight in childhood is limited and is particularly scarce in lower socio-economic populations in different ethnic groups. This study aimed to assess the prevalence of biological, behavioral and psychosocial factors for child overweight/obesity in Jewish and Arab population groups in Israel, and to compare their associations with child overweight/obesity in the two groups. Methods: Children aged 5-6 years were randomly selected from 20 Mother and Child Health clinics in towns and villages of lowest socio-economic ranking in Northern Israel. Children and mothers were invited for a special "One Stop Shop-Preparation for School" visit which included growth measurements. Questionnaires were distributed to mothers for self-report on biological, SES, psychological and lifestyle factors. Perinatal and early nutritional data were retrieved from clinic records. Multivariate analyses using logistic regression models predicting child overweight/obesity were conducted separately for Jewish (N = 371) and Arab (N = 575) children. Results: Overweight/obesity (BMI ≥85th centile) rates were higher in Jewish (25%) than Arab (19%) children. In both Jewish and Arab groups, respectively, maternal BMI (OR = 1.10 [95%CI = 1.04, 1.17]; OR = 1.08 [95%CI = 1.04, 1.13]), and child birthweight (OR = 1.33 [95%CI = 1.04, 1.71]; OR = 1.39 [95%CI = 1.11, 1.73]) were significant risk factors for overweight/obesity, and maternal self-efficacy regarding child's lifestyle was significantly protective (OR = 0.49 [95%CI = 0.28, 0.85]; OR = 0.54 [95%CI = 0.34, 0.85]). Additionally, four other maternal psychological and child behaviors were significantly associated with overweight/obesity in the Jewish group and two child lifestyle behavior factors in the Arab group. Moreover, significant interactions indicating moderation effects were found only in the Jewish group: maternal education and maternal age moderated the effect of maternal BMI on child overweight/obesity. No other moderation of risk factors was found. Discussion: In this study of children from low SES families, protective factors contributed to healthy child weight alongside risk factors for overweight/obesity. They differed between the population groups, and fewer variables explained overweight/obesity in Arab children. Although further expansion of these findings is required they point at the relevance of protective factors, maternal self-efficacy in particular, for understanding childhood obesity in specific ethnic contexts and for planning culturally adapted prevention programs in disadvantaged populations.

Concurrent medical conditions among pregnant women - ignore at their peril: report from an antenatal anesthesia clinic

Background

Care of pregnant women with concurrent medical conditions can be optimized by multidisciplinary antenatal management. In the current study we describe women with concurrent medical conditions who attended our antenatal anesthesia clinic over a 14-year period, 2002–2015 and, based on the findings, we suggest new policies, strategies and practices to improve antenatal care.

Methods

In 2002, an antenatal anesthesia clinic was established in Hadassah Medical Center. Each consultation focused on the concurrent medical condition. A written anesthesia strategy according to the medical condition and its anesthesia considerations was discussed and given to the patient. Data regarding clinic visits were recorded.

Results

A total of 451 clinic women attended the antenatal anesthesia clinic. Maternal age was 31.7 ± 6.0 years (mean ± SD), with gestational age of pregnancy 33.0 ± 5.4 weeks at the clinic visit. Musculoskeletal conditions (23% of all the women seen) were the most frequent concurrent conditions, followed by anesthesia related concerns 20%, neurologic conditions 19%, and cardiac conditions 15%. Women were provided plans that were deliberated carefully rather than being concocted during labor.

Conclusions

A wide range of concurrent medical conditions was seen in the antenatal anesthesia clinic, however fewer women attended the clinic than expected according to known population frequencies of concurrent medical conditions. Women with concurrent medical conditions should have labor and anesthesia plans considered during the nine months of pregnancy, prior to delivery, and hospitals should have a means of obtaining this information in a timely manner. Finally, there is a need to develop additional antenatal anesthesia clinics.

Trends in Fetal Growth Between 2000 to 2014 in Singleton Live Births from Israel

Trends in birthweight and abnormal fetal growth, namely term low birthweight (LBW), macrosomia, small-for-gestational age (SGA) and large-for-gestational age (LGA), are important indicators of changes in the health of populations. We performed this epidemiological study to evaluate these trends among 2,039,415 singleton live births from Israel over a period of 15 years. Birth certificate data was obtained from the Ministry of Health. Multivariable linear and logistic regression models were used to evaluate crude and adjusted estimates compared to the baseline of 2000 and polynomial trends. During the study period we observed a significant decrease in the rates of infants born SGA and LGA (10.7% to 9.2%, 10.2% to 9.6% respectively). After adjustment, based on the imputed data set, term mean birthweight increased by 6.0 grams (95% CI: 2.9, 9.1), and term LBW odds decreased by 19% in 2014 compared to 2000 (adj ORs: 0.81; 95% CI: 0.77, 0.85). Significant decreases were also observed for adjusted SGA, LGA and macrosomia rates. The decrease in abnormal fetal growth rates were not entirely explained by changes in sociodemographic characteristics or gestational age and may imply real improvement in child intrauterine growth in Israel during the last 15 years, especially in the Jewish population.

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.

Israel: health and beyond

The principle that global human identity and dignity supersede other values is a broadly accepted conviction that guides practice and policies in the realm of human health in most of the world. An assessment of the level of success that Israel has achieved in health, in the face of formidable challenges, including rapid population growth, diverse and often divided ethnic affiliations, and existential security threats, leads us to propose that extension of this principle of global human identity and dignity, together with the objective of a decent society, as overriding values beyond health to other domains of human endeavour within Israel and in its relations with neighbouring peoples, represents an entirely achievable imperative. The result will be to further advance Israel's aspiration to serve as a model for societal decency with wide international acceptance and engagement. We have identified several determinants of Israel's advancement in health, including: articulation of a clear vision, national purpose, and long-term commitment that seeks to take the health of its citizens seriously; a multi-ethnic population that brings diversity and energy to national progress; a political democracy, which is characterised by robust debate and discussion about the nation's future; national legislation governing cardinal health-care processes; cultural and religious histories that respect and revere scholarship, learning, research, and charitable donation; an expanding economy, with recent but increasing appreciation of the economic, social, and political underpinnings of health and health inequalities; a strong base of international support from the Diaspora Jewish community; and a strong desire for acceptance by the international community in key arenas, especially science and health. As a result, despite the fewer than seven decades since its establishment, Israel has achieved important milestones in health. Nevertheless, this trajectory of achievement is threatened by several serious challenges, including the capacity to sustain high-quality universal health coverage, especially for an ageing population living with multiple comorbidities in the face of a stagnant level of the percentage of treasury funding to health care at a level that is well below the average of the Organisation for Economic Co-operation and Development; ever-increasing transfer of services and care covered by the mandatory public health services basket to private programmes; insufficient progress in resolving health disparities among and between communities, populations, and regions of the country congruent with disparities in income and employment; gender inequities; a looming increase in the already alarming shortfall in health-care professionals; and failure to match inpatient and acute care facilities to manage growing needs. These challenges within Israel are magnified in the context of health disparities with the neighbouring Palestinian population, a situation in which ongoing-but fragile and limited-health cooperation and training arrangements cannot stand in for a solution that will address Palestinian national aspirations. We come away from this Series with a great sense of optimism, but with specific recommendations that are based on the foregoing challenges. We believe that by increasing the investment in the health sector, which includes investing in the societal, political, educational, and environmental underpinnings of health, far more can be achieved to move Israel to a model international leadership position in health care, education, and research, and turn health into an engine for economic wellbeing and development. Religious leadership in Israel, with its formidable political influence, can be harnessed to promote health initiatives in areas ranging from smoking cessation and healthy diet to organ transplantation, and most of all condemnation of hostility and its replacement by peaceful resolution of even the deepest conflicts. Most of all, this Series showed that there is an enormous opportunity, which Israel can lead, to leverage the universally accepted principles of health as a sanctuary against conflict and inequity, to achieve a brighter future for a deeply troubled region of the world.