Post on 11-Jan-2016
1Dept of Health Education
and Promotion
Diane Levin-Zamir, MPH, CHES
Director, Department of Health Education and Promotion
Clalit Health Services
2Dept of Health Education
and Promotion
Defining the terms
The Scope of the Issue
What is the Price?
When Culture Meets Culture
Promising Initiatives
Recommendations
Epilogue
3Dept of Health Education
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
4Dept of Health Education
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
5Dept of Health Education
and Promotion
Foundations of Empowerment
• Health Information
• Self Efficacy
• Mechanism for Change
6Dept of Health Education
and Promotion
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
7Dept of Health Education
and Promotion
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.
8Dept of Health Education
and Promotion
Health LiteracyHealth Literacy Typology Typology
• Functional - Communication of Information
• Interactive – Personal Skills
• Critical – Community Empowerment
Nutbeam, Health Promotion International 2000
9Dept of Health Education
and Promotion
Ethnic Minorities
• Immigrants
• Migrants
• Co-existing cultures
10Dept of Health Education
and Promotion
Health Literacy
Health
Empowerment
What is the Model?
Empowerment Health
Health Literacy Health
Empowerment Health Literacy
11Dept of Health Education
and Promotion
HealthHealth
EmpowermentHealth Literacy
12Dept of Health Education
and Promotion
What is the Price?
Health Disparities and Inequity
Use of Valuable Resources
Self Esteem and Shame
13Dept of Health Education
and Promotion
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.
14Dept of Health Education
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
15Dept of Health Education
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.
16Dept of Health Education
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.
17Dept of Health Education
and Promotion
Shame and Self-Esteem
40% of low literacy people have
feelings of shame;
63% never told a spouse;
53% never told children
18Dept of Health Education
and Promotion
19Dept of Health Education
and Promotion
Factors Determining Empowerment
and Health Literacy
Past experience with the health system
Cultural background
Age
Avenues of message communication
Complexity of information
20Dept of Health Education
and Promotion
Foster’s Model of Medical Systems
Cause of disease Symptoms Diagnosis Treatment
In every culture there is a notion of
21Dept of Health Education
and Promotion
Western Medicine
Cause (Specific or Non-specific)
Symptom Diagnosis Treatment/Cure
Time
22Dept of Health Education
and Promotion
Cause
Treatment/Cure
Traditional Medicine
Symptom DiagnosisSocio-Cultural Identity
23Dept of Health Education
and Promotion
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.
24Dept of Health Education
and Promotion
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
25Dept of Health Education
and Promotion
Presented by:American Medical Association Foundation & American Medical Association
Module 2:
Creating A Shame-Free Environment
10/03
Health Literacy:
Help Your Patients UnderstandHelp Your Patients Understand
26Dept of Health Education
and Promotion
Presented by:American Medical Association Foundation & American Medical Association
Module 3:
Enhancing Patient Interaction and Communication
10/03
Health Literacy:
Help Your Patients UnderstandHelp Your Patients Understand
27Dept of Health Education
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
28Dept of Health Education
and Promotion
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%
29Dept of Health Education
and Promotion
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
30Dept of Health Education
and Promotion
HospitalHospitalPrimaryPrimary
Care ServicesCare Services
PublicPublic
PrivatePrivate SectorSector CommunityCommunity
OrganizationsOrganizations
NGOsNGOs
31Dept of Health Education
and Promotion
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”
32Dept of Health Education
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”
33Dept of Health Education
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
34Dept of Health Education
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
35Dept of Health Education
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
36Dept of Health Education
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
37Dept of Health Education
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
38Dept of Health Education
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.
39Dept of Health Education
and Promotion
Complications due to diabetes are also high due to cigarette smoking among males.
05
101520253035404550
Cigarette Smoking Rates
Jewish Males
Arab-IsraeliMales
40Dept of Health Education
and Promotion
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.
41Dept of Health Education
and Promotion
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.
42Dept of Health Education
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.
43Dept of Health Education
and Promotion
2. Development of culturally appropriate health promotion tools on the topics of eating habits, physical activity, smoking cessation, self-monitoring and self-care.
44Dept of Health Education
and Promotion
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.
45Dept of Health Education
and Promotion
Program ComponentsProgram Components
Lectures and Discussions with Community Health Professionals
46Dept of Health Education
and Promotion
Individual Lifestyle Individual Lifestyle InstructionInstruction
47Dept of Health Education
and Promotion
According to the chronic disease register, Clalit treats 170,000 diabetics
9 % of adult diabetics participated in the health promotion program
ParticipationParticipation
48Dept of Health Education
and Promotion
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
49Dept of Health Education
and Promotion
Attributed Contribution of the Event
010
203040
506070
8090
Nutrition Smoking General
ArabJewish
N=300
50Dept of Health Education
and Promotion
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
51Dept of Health Education
and Promotion
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
52Dept of Health Education
and Promotion
Perceived difficulty in leading a normal life
63
64
65
66
67
68
69
70
71
72
Percent
ArabJewish
53Dept of Health Education
and Promotion
Expressed need for in-depth community programs, above and beyond community events.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
ArabJewish
54Dept of Health Education
and Promotion
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:
55Dept of Health Education
and Promotion
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..