Diane Levin-Zamir, MPH, CHES Director, Department of Health Education and Promotion

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

2. Defining the terms What is the Price? The Scope of the Issue When Culture Meets Culture Promising Initiatives Recommendations Epilogue

3. 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

4. Health Empowerment • To define problem/situation • To determine priorities for treatment • To seek possible alternatives • To choose and apply the appropriate alternative Process by which the responsibility of the individual for his health increases, including the ability:

5. Foundations of Empowerment • Health Information • Self Efficacy • Mechanism for Change

6. 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

7. Health Literacy The degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions. Healthy People, 2010.

8. Health Literacy Typology • Functional - Communication of Information • Interactive – Personal Skills • Critical – Community Empowerment Nutbeam, Health Promotion International 2000

9. Ethnic Minorities • Migrants • Immigrants • Co-existing cultures

10. What is the Model? Health Literacy Empowerment Health Empowerment Health Literacy Health Health Empowerment Health Literacy

11. Health Health Literacy Empowerment

12. What is the Price? • Health Disparities and Inequity • Use of Valuable Resources • Self Esteem and Shame

13. 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.

14. Inadequate health literacy increases with age… % Gazmararian, et al. JAMA 1999

16. 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.

17. Shame and Self-Esteem • 40% of low literacy people have feelings of shame; • 63% never told a spouse; • 53% never told children

19. Factors DeterminingEmpowerment and Health Literacy • Past experience with the health system • Complexity of information • Cultural background • Age • Avenues of message communication

20. Foster’s Model of Medical Systems • In every culture there is a notion of • Cause of disease • Symptoms • Diagnosis • Treatment

21. Western Medicine Cause (Specific or Non-specific) Symptom Diagnosis Treatment/Cure Time

22. Traditional Medicine Cause Diagnosis Socio-Cultural Identity Symptom Treatment/Cure

23. Module 3 Strategies to enhance health literacy… • Create a shame-free environment • Enhance assessment techniques • Improve interpersonal communication with patients • Create and use patient-friendly written materials.

24. Health Literacy: Presented by: American Medical Association Foundation & American Medical Association Help Your Patients Understand Module 1: Overview of Health Literacy 10/03

25. Health Literacy: Presented by: American Medical Association Foundation & American Medical Association Help Your Patients Understand Module 2: Creating A Shame-Free Environment 10/03

26. Health Literacy: Presented by: American Medical Association Foundation & American Medical Association Help Your Patients Understand Module 3: Enhancing Patient Interaction and Communication 10/03

27. “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

28. Population in Israel by Culture Druze Christian 1 . 64 % Other Arabs 2 . 34 % 1 . 77 % Moslem Arabs 14 . 80 % Jews living in Israel more Jews than 10 years New Immigrants . % 43 63 16 . 01 %

29. Clalit Health Services 3.6 million members, 30,000 workers 1,350 primary and specialized care clinics 14 hospitals 416 pharmacies 40 diagnostic imaging centers 67 laboratory centers 83 physiotherapy units 30 occupational therapy units 87 diet & nutrition consultation units 22 mental health clinics 20 alternative medicine clinics 70 dental clinics

30. Private Sector NGOs Community Organizations Hospital Primary Care Services Public

31. “Refuah Shlemah” A Cross-Cultural Program for Promoting Health Among Ethiopian Immigrants in the Primary Care Setting • Since 1984, nearly 80,000 Ethiopians have immigrated to Israel • Significant adjustment problems due to cultural disparities exist particularly regarding health and health care; navigation of the primary health care system.

32. “Refuah Shlemah” 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

33. The Major Findings The program was effective in: Improving physician-patient relations, Improving availability and accessibility of medical services and Improving the ability to navigate the health system No significantly increase in expenditure on services was incurred. Brookdale Institute, 2002

34. Second Phase of Evaluation 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. Brookdale Institute, 2002

35. Conclusion A health mediator in primary care clinics can significantly bridge the communication gap in a multi-cultural setting supporting and empowering an immigrant population. Specific improvements for asthmatics and diabetes in the present ecclectic model showed initial improvement. A model is needed in which the health mediators concentrate specifically on these groups with special health needs.

36. Community Intervention for Diabetes Control Among Adult Arab Population 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

37. Prevalence of Diabetes Basic Facts • 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

38. The high prevalence of diabetes among the Arab population in Israel has been attributed to changein lifestyles including physical activity and nutrition.

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

40. 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.

41. 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.

42. The national initiative included 4 main stages 1.Establishment 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.

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

44. 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.

45. Program Components Lectures and Discussions with Community Health Professionals

46. Individual Lifestyle Instruction

47. Participation According to the chronic diseaseregister, Clalit treats 170,000 diabetics 9 % of adult diabetics participated inthe health promotion program

48. 4. Evaluation 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.

49. Attributed Contribution of the Event N=300

50. Reported Behavior Change as a Result of Participation in the Program