1 Dept of Health Education and Promotion Diane Levin-Zamir, MPH, CHES Director, Department of Health Education and Promotion Clalit Health Services

1Dept of Health Education

and Promotion

Diane Levin-Zamir, MPH, CHES

Director, Department of Health Education and Promotion

Clalit Health Services


and Promotion

Defining the terms

The Scope of the Issue

What is the Price?

When Culture Meets Culture

Promising Initiatives

Recommendations

Epilogue


and Promotion

Empowerment

The ongoing capacity of individuals or

groups to act on their own behalf to achieve

a greater measure of control over their lives

and destinies.

Staples LH, Powerful ideas about empowerment. 1990


and Promotion

Health Empowerment

Process by which the responsibility of the

individual for his health increases, including

the ability: To define problem/situation

To determine priorities for treatment

To seek possible alternatives

To choose and apply the appropriate alternative


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Foundations of Empowerment

• Health Information

• Self Efficacy

• Mechanism for Change


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Health Literacy

The development of the cognitive and social

skills which determine the motivation and ability

of individuals to gain access to, understand and

use information in ways which promote and

maintain good health.

WHO Health Promotion Glossary, 1998


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The degree to which individuals have the

capacity to obtain, process and understand

basic health information and services needed

to make appropriate health decisions.

Health Literacy

Healthy People, 2010.


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Health LiteracyHealth Literacy Typology Typology

• Functional - Communication of Information

• Interactive – Personal Skills

• Critical – Community Empowerment

Nutbeam, Health Promotion International 2000


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Ethnic Minorities

• Immigrants

• Migrants

• Co-existing cultures


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Health Literacy

Health

Empowerment

What is the Model?

Empowerment Health

Health Literacy Health

Empowerment Health Literacy


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HealthHealth

EmpowermentHealth Literacy


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What is the Price?

Health Disparities and Inequity

Use of Valuable Resources

Self Esteem and Shame


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What is the scope of the issue?

Canada: 22% of adult Canadians fall into

the lowest level of functional literacy

US: 90 million Americans face health

literacy challenges

61% of Spanish speaking community lack minimal health literacy skills

Baker DW, Parker RM, William MV, Pitkin K, Parikh NS, Coates W, Imara M. The Health Care Experience of Patients With Low Literacy, Arch Fam Med, 1996, 5, 329-334.


and Promotion

Inadequate health literacy increases with age…

01020304050607080

65-69 70-74 75-79 80-84 >=85

Marginal

Inadequate%

Gazmararian, et al. JAMA 1999


and Promotion

GNINAELC – Ot erussa hgih ecnamrofrep,

yllacidoirep naelc eht epat sdaeh dna

natspac revenehw uoy eciton na

noitalumucca fo tsud dna nworb-red edixo

selcitrap. Esu a nottoc baws denetsiom

htiw lyporposi lohocla. Eb erus on lohocla

sehcuot eht rebbur strap, sa ti sdnet ot yrd

dna yllautneve kcarc eht rebbur. Esu a

pmad tholc ro egnops ot naelc eht tenibac.

A dlim paos, ekil gnihsawhsid tnegreted,

lliw pleh evomer esaerg ro lio.


and Promotion

The Scope of the Issue

42% of the people didn’t understand the instructions for

taking medication on empty stomach. 26 % of the people didn’t understand the instructions for making appointments

43% didn’t understand the text concerning rights and responsibilities.

60% didn’t understand the text regarding informed consent

Baker DW, Parker RM, William MV, Pitkin K, Parikh NS, Coates W, Imara M. The Health Care Experience of Patients With Low Literacy, Arch Fam Med, 1996, 5, 329-334.


and Promotion

Shame and Self-Esteem

40% of low literacy people have

feelings of shame;

63% never told a spouse;

53% never told children


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Factors Determining Empowerment

and Health Literacy

Past experience with the health system

Cultural background

Age

Avenues of message communication

Complexity of information


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Foster’s Model of Medical Systems

Cause of disease Symptoms Diagnosis Treatment

In every culture there is a notion of


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Western Medicine

Cause (Specific or Non-specific)

Symptom Diagnosis Treatment/Cure

Time


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Cause

Treatment/Cure

Traditional Medicine

Symptom DiagnosisSocio-Cultural Identity


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Strategies to enhance health literacy…

Create a shame-free environment

Enhance assessment techniques

Module 3

• Improve interpersonal communication with patients• Create and use patient-friendly written materials.


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Health Literacy:

Presented by:American Medical Association Foundation & American Medical Association

Module 1:

Overview of Health Literacy

10/03

Help Your Patients UnderstandHelp Your Patients Understand


and Promotion


Module 2:

Creating A Shame-Free Environment

10/03

Health Literacy:



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Module 3:

Enhancing Patient Interaction and Communication

10/03

Health Literacy:



and Promotion

“Promising” Initiatives

“Refuah Shlemah” - A Cross-Cultural Program for

Promoting Health Among Ethiopian Immigrants

in the Primary Care Setting

Improving Diabetes Among Arab Diabetics in

Israel through Health Empowerment and

Health Literacy

Emmi - Using breakthroughs in technology

for health empowerment


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Population in Israel by Culture

Other2.34%

Jews living in

Israel more than 10 years

63.43%

Jews New

Immigrants 16. 01%

Moslem Arabs 14.80%

Druze1.64%

Christian Arabs1.77%


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Clalit Health Services

3.6 million members, 30,000 workers1,350 primary and specialized care clinics14 hospitals416 pharmacies40 diagnostic imaging centers67 laboratory centers83 physiotherapy units30 occupational therapy units87 diet & nutrition consultation units22 mental health clinics20 alternative medicine clinics70 dental clinics


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HospitalHospitalPrimaryPrimary

Care ServicesCare Services

PublicPublic

PrivatePrivate SectorSector CommunityCommunity

OrganizationsOrganizations

NGOsNGOs


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Since 1984, nearly 80,000 Ethiopians have

immigrated to Israel

A Cross-Cultural Program for Promoting Health Among Ethiopian Immigrants in the Primary Care Setting

Significant adjustment problems due to

cultural disparities exist particularly regarding

health and health care; navigation of the

primary health care system.

“Refuah Shlemah”


and Promotion

1. employing Ethiopian immigrant facilitators on a full

time basis, who have been trained to work as health

liasons and inter-cultural mediators between

patients and physicians

2. training clinical staff with the aim of changing their

attitudes and thus bridging inter-cultural gaps, by

increasing awareness and sensitivity regarding Ethiopian

perception of health and dis-ease causation

3. cooperatively implementing health

education activities for new immigrants

“Refuah Shlemah”


and Promotion

The program was effective in:

1. Improving physician-patient relations,

2. Improving availability and accessibility of

medical services and

3. Improving the ability to navigate the health

system

4. No significantly increase in expenditure on

services was incurred.

The Major Findings

Brookdale Institute, 2002


and Promotion

The results include:

improved perception of general health

status among the experimental clinics,

no perceived difference in perceived

well being among the diabetics and asthmatics.

some aspects of self care were more positive

as a result of the program, for example physical

activity, etc.

Second Phase of Evaluation

Brookdale Institute, 2002


and Promotion

1. A health mediator in primary care clinics can

significantly bridge the communication gap in a multi-

cultural setting supporting and empowering an

immigrant population.

2. Specific improvements for asthmatics and diabetes in

the present ecclectic model showed initial improvement.

3. A model is needed in which the health mediators

concentrate specifically on these groups with special

health needs.

Conclusion


and Promotion

Diane Levin-Zamir, MPH, CHES, Dr. Margalit Goldfracht, MD, Ofra Peled, MA, Shosh Gan-Noy MA, Rachel Meir, RN, Siham Badarne,

MPH, Dr. Muhamed Najami, Dr. Yunis Abu-Rabia, Nuha Zydan, Raid Ashtash, Dr. Napaz Nubani, Dr. Naim Shadi, Dr. Erwin Stern, Prof.

Menachem Shapira, Dr. Agbaria

Community Intervention for Diabetes Control Among Adult Arab

Population


and Promotion

Prevalence of Diabetes

Prevalence of Diabetes in Israel – 5.9% of

adult population

Prevalence of Diabetes – World – 5.1%

Prevalence of Diabetes in Israeli Arab

Population significantly higher

Basic FactsBasic Facts


and Promotion

The high prevalence of diabetes

among the Arab population in

Israel has been attributed to change

in lifestyles including physical

activity and nutrition.


and Promotion

Complications due to diabetes are also high due to cigarette smoking among males.

05

101520253035404550

Cigarette Smoking Rates

Jewish Males

Arab-IsraeliMales


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A national program for diabetes control

based on health promotion methodology

was planned, implemented and evaluated

by Clalit Health Services, based in primary

care clinics.


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The goals of the national intervention program:

1. To increase awareness of the Arab community

regarding diabetes and the importance of treatment,

while reducing the stigma held regarding chronic disease.

2. To develop and apply lifestyle change methodology,

culturally tailored to the the Arab community.

3. To promote change in health behaviors: nutrition,

physical activity, smoking, self care and foot care.


and Promotion

The national initiative included 4 main stages

1.1.Establishment of a national inter-disciplinary teamEstablishment of a national inter-disciplinary team:

to assess and define needs

to develop the strategy of the intervention program

from the fields of health promotion, family medicine,

diabetology, nursing and nutrition.


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2. Development of culturally appropriate health promotion tools on the topics of eating habits, physical activity, smoking cessation, self-monitoring and self-care.


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3. Program Implementation

The program, conducted from 2001-2003, was open to

the entire community living in Arab towns and villages,

as it focused on healthy lifestyle which is pertinent to

all, not only diabetics.

Program implementation in over 20 communities, in

which more that 6,000 residents participated.


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Program ComponentsProgram Components

Lectures and Discussions with Community Health Professionals


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Individual Lifestyle Individual Lifestyle InstructionInstruction


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According to the chronic disease register, Clalit treats 170,000 diabetics

9 % of adult diabetics participated in the health promotion program

ParticipationParticipation


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The evaluation of the program was

conducted by telephone interview of a

representative sample of the

participants regarding the following

indicators: change in health behavior,

attitudes towards diabetes, satisfaction

and change in HbA1C.

44 . .EvaluationEvaluation


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Attributed Contribution of the Event

010

203040

506070

8090

Nutrition Smoking General

ArabJewish

N=300


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Reported Behavior Change as a Result of Participation in the Program

0

10

20

30

40

50

60

70

80

Nutrition PhysicalActivity

Smoking Footcare

ArabJewish


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Diabetes according to HbA1C among Participants from the Arab Population in HP Program

23%

36%

27%

36%

27%

37%

0%

5%

10%15%

20%

25%

30%35%

40%

45%

<=77-9>=9

2001

2002

N= 154


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Perceived difficulty in leading a normal life

63

64

65

66

67

68

69

70

71

72

Percent

ArabJewish


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Expressed need for in-depth community programs, above and beyond community events.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

ArabJewish


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1. The Arab community in Israel is very interested in

ongoing health promotion interventions regarding

lifestyle and chronic disease prevention.

2. The primary care clinic is an appropriate setting for

health promotion events particularly regarding

chronic disease prevention.

3. Individual lifestyle counseling should be added to the

community initiative as well as in-depth behavior

change workshops.

The main conclusions of the initiative:


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All of the conclusions have been applied in the 2004 All of the conclusions have been applied in the 2004

national diabetes program strategy, emphasizing national diabetes program strategy, emphasizing

self-management and maintenanceself-management and maintenance..

Documents

1 Dept of Health Education and Promotion Diane Levin-Zamir, MPH, CHES Director, Department of Health Education and Promotion Clalit Health Services