Tamar Peled MSc, Michael Weingarten BM BCh, Noemi Varsano MSc, Andre Matalon MD, Adi Fuchs MD, Robert D. Hoffman MD, Charna Zeltcer MD, Ernesto Kahan MD MPH, Ella Mendelson PhD and Tiberio A. Swartz MD MPH
Background: Each winter influenza activity is a major cause of morbidity and mortality both in Israel and worldwide.
Objectives: To identify the influenza viruses active in Israel during the winter season and to assess the extent of influenza morbidity.
Methods: Information was collected on a population of 18,684 individuals enrolled in two community clinics in central Israel. It included the total number of visits for acute respiratory infection – including influenza and influenza-like illness (ARI/flu-like) – during a 20 week surveillance period (23 November 1997 to 27 March 1998) and the percent of influenza virus isolates in nasopharyngeal specimens from a sample of patients with ARI/flu-like collected on a weekly basis during the same period.
Results: A total of 5,947 visits for ARI/flu-like were recorded among 18,684 enrolled patients in two community clinics (18.1%). The progressive increase in the number of visits for ARI/flu-like reached a peak on week 2/98 with 597 visits and a rate of 31.95 visits per 1,000 population. After this, a decrease to the initial values was evident by week 12/98. Most affected patients were in the age groups 5–14 and 65 years and over, with a rate of 733.5 and 605.3 visits per 1,000 population, respectively. Influenza virus was isolated from 92 of the 426 nasopharyngeal specimens (21.6%). The most commonly detected strain was A/Sydney/5/97(H3N2) like (77.2%). The peak rate of isolates was recorded at the beginning of January (01/98).
Conclusions: A/Sydney/5/97(H3N2) like-strain was the dominant influenza virus. Its presence did not prevent the simultaneous activity of influenza A/H1N1 virus. The dynamic of the clinical disease as expressed by the weekly visit rate for ARI/flu-like was similar to the temporal pattern of the virological findings. The extent of morbidity suggests moderate epidemic activity.
Sophia Eilat-Tsanani MD, Mordechai Sorek MD, Nir Gay MD, Ora Chaimovitch MD, Lev Kulton MD and Hava Tabenkin MD MSc
Background: Breast cancer is the most common malignancy among women in Israel and throughout the world. Israeli women aged 50–75 years are advised to undergo a mammographic screening examination every 2 years. However, the lack of a structured referral system is reflected in the low utilization rate of mammography.
Objectives: To describe an innovative program in which family physicians in an urban clinic developed a model framework for referrals, coordinated with radiologists and surgeons, aimed at increasing compliance among women referred for mammography.
Methods: A community-based study was conducted, outside of the regular reception hours, in a neighborhood practice with a population of 527 women aged 50–75. A referral system under the supervision of family physicians was designed, and the women received appointments for mammography at specified days and hours. The results of the examination were sent to the physician who used dedicated time to continue the diagnostic and/or therapeutic process, as appropriate. At the physician’s instructions a research assistant contacted the women who did not keep their appointments and scheduled a second appointment.
Results: In 1993, the year prior to the study, when women referred themselves for mammography, the utilization rate was 9%. During the study year the utilization rate was 77%. Women born in Europe or America had higher compliance rates than women born in Asia or Africa (81% vs. 72%, respectively). Married women were more compliant than unmarried women (81% vs. 70%, respectively). No correlation was found between compliance and age, family history of cancer in general, or breast cancer in particular. Six new cases of breast cancer were detected.
Conclusions: The initiative of family physicians increased the utilization of mammography among women under their care. Family physicians allocated time outside of their regular reception hours for the program. A relatively large number of new malignancies were found, but this impression should be confirmed or negated by a large-scale study using the same methods.
Yaacov Fogelman MD and Ernesto Kahan MD MPH
Background: The prevalence of attention deficit-hyperactivity disorder and its pharmacologic treatment have increased dramatically in the past decade in the United States and Britain. We examined the use of methylphenidate hydrochloride for the treatment of ADHD in children in northern Israel.
Methods: We evaluated all prescriptions for methylphenidate filled in 1999 for children aged 5–18 years residing in northern Israel who were insured by Clalit Health Services, a health maintenance organization that covers approximately 70% of the population.
Results: Methylphenidate was prescribed to 1.45% of the children in northern Israel in 1999, an increase of 20% in the overall prevalence of methylphenidate use since 1992. Eighty-two percent were boys. The rate of prescription varied widely by type of settlement, from 0.2% in Arab cities and towns to 5.7% in kibbutzim. Primary care physicians wrote 78% of all the prescriptions.
Conclusions: The increase in methylphenidate use was much smaller in northern Israel than in most other developed regions and countries. More efforts at diagnosis and treatment of attention deficit disorders may need to be directed at Arab populations and those with inadequate medical services.
Sasson Nakar MD, Shlomo Vinker MD, Eliezer Kitai MD, Eli Wertman MD and Michael Weingarten MD
Background: Migration leads to changes in almost all areas of life including health. But how far are health beliefs also preserved, and how far are they affected by the process of acculturation to the host society?
Objectives: To examine the difference between behavior and attitudes towards conventional and traditional medicine among elderly Yemenite immigrants.
Methods: A community-based study was conducted in the Yemenite neighborhoods in the city of Rehovot. All inhabitants of Yemenite origin over the age of 70 were identified from the population register, excluding those who were institutionalized or demented. Social work students interviewed them at home. The questionnaire inquired after health problems in the preceding month. For each of these problems, the respondent was asked whether any mode of treatment had been employed – Yemenite folk remedies, conventional medical care, or other. Their attitudes towards Yemenite folk medicine and conventional medicine were recorded. Socioeconomic data included their current age, age at immigration, year of immigration, marital status, gender, religiosity, and education.
Results: A total of 326 elderly people were identified who fulfilled the selection criteria, of whom 304 (93%) agreed to be interviewed. Of these, 276 (91%) reported at least one health problem in the preceding month, providing 515 problems of which 349 (68%) were reported to a conventional medical doctor while 144 (28%) were treated by popular folk remedies. Fifty-nine problems (11.5%) were treated by specifically Yemenite traditional remedies, mostly by the respondents themselves (38/59) rather than by a traditional healer. Immigrants who arrived in Israel over the age of 30 years, as compared to respondents who immigrated at an earlier age and grew up in Israel, were more likely to use traditional Yemenite remedies (24.4% vs. 8.2%, P<0.005).
Conclusion: Aged Yemenite Jews in Israel prefer modern medicine. The earlier the immigrant arrived in Israel, the more positive the attitude towards modern medicine and the less use made of traditional Yemenite healing.
John Yaphe MD MClSc, Moshe Schein MB ChB MS and Pnina Naveh RN
Background: The recent influx of Ethiopian immigrants to Israel has created challenges for healthcare workers. Qualitative research methods have proven to be of value in providing useful data in cross-cultural medical settings.
Objective: To learn about parents' perception of the health of their children among a group of Ethiopian immigrants in Israel.
Methods: Ethiopian parents of children under age 3 registered with a family medicine clinic in Jerusalem were invited to participate in two focus groups. Transcripts of the group discussions were analyzed to reveal themes relating to children's health.
Results: Analysis of the transcripts revealed five themes relating to the health of children in two domains: the intra-familial and the extra-familial. Specific themes that emerged in the intra-familial domain were: the role of traditional medicine, gender-specific roles in child care, and decision-making in seeking extra-familial medical help. Themes in the extra-familial domain were recognition of illness and the meaning of symptoms, and notions of prevention and resistance to illness. The collected data found application in the daily clinical work of the researchers and enriched understanding of their patients.
Conclusions: Ethiopian immigrants to Israel share special perceptions of their children’s health that differ from prevailing beliefs in Israel. Focus groups provide health workers with a wealth of data on these beliefs that will enable them to offer more culturally sensitive care.
Howard Tandeter MD, Mirta Grynbaum MD and Jeffrey Borkan MD PhD
Background: Bloodletting is practiced in Ethiopia. Physicians in Israel engaging in transcultural encounters with Ethiopian immigrants are generally unaware of these ethnomedical beliefs and practices.
Objective: To assess the past and present use of bloodletting among Ethiopian immigrants in Israel.
Methods: We interviewed a sample of 50 adult patients of Ethiopian origin about present and past use of bloodletting. A second consecutive sample of 10 adult patients of Ethiopian origin who often asked their doctors to perform blood tests were identified and interviewed. Data analysis was performed by "immersion-crystallization" analysis.
Results: More than half of the interviewed patients reported the use of bloodletting. Scars were commonly present on their upper extremities. A qualitative analysis identified the different reasons for the use of bloodletting, the technique used and its appreciated efficacy. We also found an unexpected cultural synergy between traditional bloodletting and western medical blood sampling.
Conclusions: Some Ethiopian immigrants continue to perform traditional bloodletting in their new country of residency, a practice that local physicians may not be aware of. Bloodletting-type scars on the upper extremities may be common in these patients. Patients may ask for blood sampling as a culturally accepted way to perform bloodletting (synergy).
Orna Baron-Epel PhD MPH and G. Kaplan MA
Background: A mass influx of immigrants from the former Soviet Union to western countries and Israel followed the demise of the Soviet Bloc at the beginning of the 1990s. It was expected that these immigrants would have a higher morbidity and mortality rate similar to that in Russia.
Objectives: To measure and compare self-reported diseases, subjective health and health services utilization of a representative sample of veteran Israeli Jews and immigrants from the former USSR.
Methods: A cross-sectional survey of Israeli adults was performed by telephone interviews. The survey included 793 Israeli Jews, of whom 124 were immigrants from the former USSR who arrived in Israel after 1989 (response rate 52%).
Results: The immigrants reported a higher rate of diseases and sub-optimal health after adjustment for other variables. However, no excess in health services utilization was reported. A time trend of reporting sub-optimal subjective health was observed: the longer the immigrants spent in Israel the more their reporting patterns resembled those of immigrants who arrived in Israel before 1970. Those who arrived after 1994 more frequently reported having a chronic disease.
Conclusions: Acculturation seems to have been the main effect on the immigrants' health, together with a healthy migrant effect at the beginning of the 1990s. The immigrants' health was worse in the later years of the immigration wave, partially reflecting the poor state of health in Russia compared to Israel.
Rachel Dahan, MD, Shmuel Reis, MD, Doron Hermoni, MD and Jeffrey Borkan, MD
Rachel Dahan, MD, Shmuel Reis, MD, Doron Hermoni, MD and Jeffrey Borkan, MD
Paul E. Slater, MD, MPH and Alex Leventhal, MD, MPH, MPA
Israel Rabinowitz, MD and Shmuel Reis, MD
Yuri Viner, MD, Dan Miron, MD, Emanuel Gottfried, MD, Dora Segal and Anthony Luder, MBBS (UK)
Rasmi Abu-Ras, MD, Klari Felser, MD and Menachem Rottem, MD
Howard Tandeter, MD and Martine Granek-Catarivas, MD
In countries in which a primary care-oriented system has developed, general practitioners, family physicians, and other primary care doctors are the keystone of an approach that aims to achieve high quality and satisfaction with relatively low costs. Despite this new trend, medical schools still produce excessive numbers of sub-specialists rather than prinary care physicians. Among multiple reasons influencing a career choice either towards or away from primary care (institutional, legislative, and market pressures), the present article discusses ways in which medical school curricula may affect students in their perceptions of the role of primary care physicians. Since students are greatly influenced by the cultures of the institutions in which they train, the negative attitude of university towards family medicine may negatively affect the number of students going into this specialty. Examples from Israeli faculties are presented.