Associations of psychosocial factors, knowledge, attitudes and practices with hospitalizations in internal medicine divisions in different population groups in Israel.

BACKGROUND: Inequalities in healthcare utilization exist across ethnic groups; however, the contributions of health-related knowledge and psychosocial factors to these inequalities remain unclear. We examined associations of social determinants of health, psychological factors, knowledge, attitudes and health practices, with hospitalizations in internal medicine divisions, among Israeli adults, Jews and Arabs, with non-communicable diseases, in a setting of universal health insurance. METHODS: A retrospective study was undertaken among 520 Jews and Arabs aged 40 years or older with non-communicable diseases, members of a large health maintenance organization. Hospitalization (at least once during 2008) in an internal medicine division was determined based on documentation in electronic health records. Participants were randomly selected in strata of sex, population-group and hospitalization status (yes/no). Data were collected from medical records and via face-to-face interviews using a structured questionnaire. Main independent variables included comorbidity burden, health behaviors, mental health wellbeing and self-rated health. Scales measuring health knowledge and attitudes/beliefs were constructed using factor analysis. RESULTS: Comorbidity burden (OR 1.41 [95% CI 1.24-1.61]) and self-rated health (not good vs. good) (OR 1.88 [95% CI 1.13-3.12]) were positively associated with hospitalizations in an internal medicine division, while an inverse association was found with better mental health wellbeing (OR 0.98 [95% CI 0.96-0.99, for each 1-point score increase). Among Jewish participants, positive associations were found of the number of offspring, comorbidity burden and perceived difficulty, with hospitalizations. No significant associations were found with hospitalizations of other sociodemographics, health behaviors, knowledge and attitudes/beliefs. CONCLUSIONS: Comorbidity burden was the main risk factor of hospitalizations in internal medicine divisions. Psychosocial factors, such as self-rated health, a complex variable affected by social capital, mental wellbeing, the number of offspring, and perceived burden and difficulty, seem also to contribute. These findings suggest the involvement of broad family and social factors, beyond individual level characteristics and medical needs, in hospitalizations in internal medicine divisions. Interventions to reduce hospitalizations should be comprehensive and integrate aspects of mental health wellbeing; they should build on familial characteristics (e.g., number of offspring), factors related to social capital such as self-rated health, and perceived burden and difficulty.

Correlates of hospitalizations in internal medicine divisions among Israeli adults of different ethnic groups with hypertension, diabetes and cardiovascular diseases.

BACKGROUND: Disparities in non-communicable diseases (NCDs) may affect health care utilization. We compared the correlates of hospitalizations in internal medicine divisions, of adults with NCDs, between the main population groups in Israel. METHODS: A cross-sectional study was conducted among Jews (N = 17,952) and Arabs (N = 10,441) aged ≥40 years with diabetes, hypertension or cardiovascular diseases, utilizing the computerized database of the largest health maintenance organization in Israel. Information was retrieved on sociodemographics, background diseases, hospitalizations and utilizations of other health services. Multivariable log binomial regression models were performed. RESULTS: Overall, 3516 (12.4%) patients were hospitalized at least once during a one-year period (2008). Hospitalization in internal medicine divisions was more common among Arab than Jewish patients; prevalence ratio 1.24 (95% CI 1.14-1.35), and increased with age (P<0.001). An inverse association was found between residential socioeconomic status and hospitalization among Jewish patients, but not among Arab, who lived mostly in low socioeconomic status communities. In both population groups, congestive heart failure, arrhythmias, heart surgery, cardiac catheterization, kidney disease, asthma, neurodegenerative diseases, mental illnesses, smoking (in men) and disability were positively related to hospitalization in internal medicine divisions, which was more common also in patients who consulted any specialist and a specialist in cardiology. Emergency room visits, consulting with an ophthalmologist and performing cancer screening tests were inversely related to hospitalizations among Jewish patients only (P = 0.009 and P = 0.067 for interaction, respectively). CONCLUSIONS: In a country with universal health insurance, the correlates of hospitalizations included sociodemographics, multi-morbidity, health behaviors and health services use patterns. Socioeconomic disparities might account for ethnic differences in hospitalizations. Individuals with several NCDs, rather than one specific disease, disability and smoking should be targeted to reduce healthcare costs related to hospitalizations.

Cardiovascular health among two ethnic groups living in the same region: A population-based study.

BACKGROUND: Poor cardiovascular health (CVH) among ethnic/racial minorities, studied primarily in the USA, may reflect lower access to healthcare. We examined factors associated with minority CVH in a setting of universal access to healthcare. METHODS AND RESULTS: CVH behaviors and factors were evaluated in a random population sample (551 Arabs, 553 Jews) stratified by sex, ethnicity and age. More Jews (10%) than Arabs (3%) had 3 ideal health behaviors. Only one participant had all four. Although ideal diet was rare (≤1.5%) across groups, Arabs were more likely to meet intake recommendations for whole grains, but less likely to meet intake recommendations for fruits/vegetables and fish. Arabs had lower odds of attaining ideal levels for body mass index and physical activity. Smoking prevalence was 57% among Arab men and 6% among Arab women. Having four ideal health factors (cholesterol, blood pressure, glucose, smoking) was observed in 2% and 8% of Arab and Jewish men, respectively, and 13% of Arab and Jewish women. Higher prevalence of ideal total-cholesterol corresponded to lower high-density lipoprotein cholesterol among Arabs. No participant met ideal levels for all 7 metrics and only 1.8% presented with 6. Accounting for age and lower socioeconomic status, Arabs were less likely to meet a greater number of metric goals (odds ratio (95% confidence interval): 0.62 (0.42-0.92) for men, and 0.73 (0.48-1.12) for women). CONCLUSIONS: Ideal CVH, rare altogether, was less prevalent among the Arab minority albeit universal access to healthcare. Health behaviors were the main contributors to the CVH disparity.

Blood pressure level and hypertension awareness and control differ by marital status, sex, and ethnicity: a population-based study.

BACKGROUND: Population-based studies about factors associated with blood pressure (BP) levels and hypertension awareness and control are lacking in Israel. We aimed to identify covariables of BP level (across the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7) categories) and hypertension awareness and control. METHODS: Participants (n = 763; aged 25-74 years) were randomly selected from the population registry and stratified by sex, age, and ethnicity (Arab or Jewish). Sociodemographic, lifestyle, chronic morbidity, drug therapy, and measured anthropometric and BP data were collected. Hypertension was defined as physician diagnosis, antihypertension drug therapy, or systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg. RESULTS: Standardized hypertension prevalence was 32.5%. Age and body mass index were positively associated with being in a higher JNC-7 category. In multivariable analysis, the association between gender and JNC-7 category depended upon marital status. Of those with hypertension (n = 315), 66.0% were aware of their status, and 26.0% exhibited adequate BP control. Using "aware-and-controlled" as the outcome reference category, the odds ratio (OR) of being aware and uncontrolled was 1.9 (95% confidence interval (CI) = 1.3-2.9) for 10-year age increment. The OR of being unaware and uncontrolled was 5.6 (95% CI = 2.0-15.8) for Arabs vs. Jews, 5.6 (95% CI = 1.4-22.3) for single/divorced vs. married participants, 3.9 (95% CI = 1.7-9.2) for those with <3 visits to the family physician per year, and 0.1 (95% CI = 0.02-0.4) for those with self-reported cardiovascular disease. CONCLUSIONS: Sociodemographic factors and primary healthcare service utilization are associated with hypertension awareness and control. Specially focused outreach may be needed to improve hypertension awareness among Arabs, certain subgroups not traditionally considered to be at high risk, and those who have less contact with the healthcare system.

Jews and Arabs in the same region in Israel exhibit major differences in dietary patterns.

The Jewish majority and Arab minority populations in Israel exhibit disparities in nutrition-related chronic diseases, but comparative, population-based dietary studies are lacking. We evaluated ethnic differences in dietary patterns in a population-based, cross-sectional study of Arab and Jewish urban adults (n = 1104; age 25-74 y). Dietary intake was assessed with an interviewer-administered, quantified FFQ. We used principal-component analysis to identify 4 major dietary patterns: Ethnic, Healthy, Fish and Meat Dishes, and Middle Eastern Snacks and Fast Food. The Ethnic and Healthy patterns exhibited major ethnic differences. Participants in the top Ethnic intake tertile (97% Arab) had modified Mediterranean-style Arabic dietary habits, whereas those in the bottom Ethnic tertile (98% Jewish) had central/northern European-style dietary habits. The Arab participants with less strongly ethnicity-associated dietary habits were younger [OR for 10-y decrease = 1.42 (95% CI: 1.21-1.68)] and male [OR = 2.23 (95% CI: 1.53-3.25)]. Jews with less strongly ethnicity-associated dietary habits were less recent immigrants [OR = 8.97 (95% CI: 5.05-15.92)], older [OR for 10-y decrease = 0.80 (95% CI: 0.69-0.92)], had post-secondary education [OR = 2.04 (95% CI: 1.06-3.94)], and reported other healthy lifestyle behaviors. In relation to the Healthy pattern, Arabs were less likely than Jews to be in the top intake tertile, but the magnitude of the difference was less in diabetic participants. Participants reporting other healthy lifestyle behaviors were more likely to have a high intake of the Healthy pattern. Substantial differences were found between Arabs and Jews in dietary patterns and suggest a need for culturally congruent dietary interventions to address nutrition-related chronic disease disparities.

An association between Helicobacter pylori infection and cognitive function in children at early school age: a community-based study.

BACKGROUND: H. pylori infection has been linked to iron deficiency anemia, a risk factor of diminished cognitive development. The hypothesis on an association between H. pylori infection and cognitive function was examined in healthy children, independently of socioeconomic and nutritional factors. METHODS: A community-based study was conducted among 200 children aged 6-9 years, from different socioeconomic background. H. pylori infection was examined by an ELISA kit for detection of H. pylori antigen in stool samples. Cognitive function of the children was blindly assessed using Stanford-Benit test 5th edition, yielding IQ scores. Data on socioeconomic factors and nutritional covariates were collected through maternal interviews and from medical records. Multivariate linear regression analysis was performed to obtain adjusted beta coefficients. RESULTS: H. pylori infection was associated with lower IQ scores only in children from a relatively higher socioeconomic community; adjusted beta coefficient -6.1 (95% CI -11.4, -0.8) (P = 0.02) for full-scale IQ score, -6.0 (95% CI -11.1, -0.2) (P = 0.04) for non-verbal IQ score and -5.7 (95% CI -10.8, -0.6) (P = 0.02) for verbal IQ score, after controlling for potential confounders. CONCLUSIONS: H. pylori infection might be negatively involved in cognitive development at early school age. Further studies in other populations with larger samples are needed to confirm this novel finding.

Is the association between Helicobacter pylori infection and anemia age dependent?

BACKGROUND: The relationship between H. pylori infection and anemia in childhood is still unclear. The aim of the study was to examine the association between H. pylori infection and anemia or iron deficiency in school-age children and in infants. MATERIALS AND METHODS: Six- to 9-year-old Israeli Arab children (N = 202) and infants (N = 197) were examined for hemoglobin and ferritin levels. ELISA was used to detect H. pylori antigens in stool specimens collected from the participants. Household characteristics were obtained through personal interviews with the mothers. RESULTS: The prevalence of anemia was 15.5 versus 5.5% in H. pylori-positive and -negative school-age children, respectively and 34.5 versus 29.8% in H. pylori-positive and -negative infants, respectively. The Mantel-Haenszel age-adjusted prevalence ratio (PR) and 95% confidence intervals (CIs) were 1.6 (95%CI 1.0, 2.6). In multivariate analysis controlling for socioeconomic variables, H. pylori infection was associated with 2.8 higher prevalence of anemia only in school-age children: adjusted PR 2.8 (95% CI 0.9, 9.3). The adjusted mean difference in hemoglobin levels between H. pylori infected school-age children and uninfected ones was -0.372 gr/dL (95% CI -0.704, -0.039) (p = .04). The respective mean ferritin difference was -6.74 µg/L (95% CI -13.38, -.011) (p = .04). Such differences were not found in infants. CONCLUSIONS: H. pylori infection is associated with higher prevalence of anemia in school-age children independently of socioeconomic variables. Such association was not observed in infants. These findings are of clinical and public health importance.

Lifestyle intervention in obese Arab women: a randomized controlled trial.

BACKGROUND: Few randomized controlled trials on lifestyle interventions have been reported in non-Western populations; none have been reported in Arab populations. METHODS: From 2 Muslim Arab communities in Israel, obese, nondiabetic women aged 35 to 54 years with 1 or more components of the metabolic syndrome were randomized to either an intensive (n = 100) or a moderate (control) (n = 101) 12-month lifestyle intervention. Women in the intensive intervention had 11 individual and 11 group counseling sessions per year with a dietitian and 22 physical activity group sessions per year. Women in the moderate intervention had 3 individual and 2 group dietary counseling sessions per year and no guided physical activity. Cultural issues were addressed in the design and conduct of both interventions. The primary outcome measure was change in the metabolic syndrome and its components. RESULTS: At 12 months, the intensive intervention group had median declines of 3.0 mg/dL (to convert to millimoles per liter, multiply by 0.0555) in fasting plasma glucose and 4.5 mg/dL (to convert to millimoles per liter, multiply by 0.0113) in triglyceride levels compared with median increases of 1 mg/dL in fasting plasma glucose and 5.8 mg/dL in triglyceride levels in the moderate intervention group (P = .01 and P = .02, respectively). The median waist circumference decreased by 5.4 cm in the intensive intervention group and by 3.1 cm in the moderate intervention group (P = .10). The prevalence of the metabolic syndrome decreased by 4.0% in the intensive intervention group and increased by 5.2% in the moderate intervention group (P = .12). CONCLUSION: The 12-month culturally sensitive intensive lifestyle intervention was effective in improving some of the metabolic syndrome components in obese Arab women. Trial Registration clinicaltrials.gov Identifier: NCT00273572.

The prevalence of Parkinson's disease in an Arab population, Wadi Ara, Israel.

BACKGROUND: The prevalence of Parkinson's disease varies among ethnic and geographic groups around the world, being very low in China and high in Argentina. While the main etiology of the disease has yet to be determined, environmental, occupational and genetic factors seem to play important roles. OBJECTIVES: To estimate the prevalence of PD in an Arab Muslim population in Israel, using the drug tracer approach. METHODS: We studied a Muslim Arab population living in a well-defined geographic area in Israel, with the majority located in two towns and two large villages. Of the approximately 115,000 residents, about 38% are under the age of 15 and 7.75% are older than 65. Drug tracer methodology was applied in this study. All those who were on anti-PD medication were identified and examined by a neurologist to confirm the diagnosis. RESULTS: The overall crude prevalence of PD in this population was low, 43.24/100,000, while the prevalence in the age group above 65 years was 477.32/100,000. Below this age, the prevalence was very low, 12.29/100,000. PD prevalence was higher in males than in females (ratio 1.17); 63% of male patients smoked cigarettes. The prevalence was found to be twice as high among the residents of rural areas, where most inhabitants work in agriculture. CONCLUSIONS: The prevalence of PD among the Arab population in Israel is considered low and comparable to that reported in other Arab countries.

Presence of Helicobacter pylori in a sibling is associated with a long-term increased risk of H. pylori infection in Israeli Arab children.

BACKGROUND AND OBJECTIVES: We examined the dynamics of Helicobacter pylori infection between pre-school and school ages and compared the determinants of late acquisition of H. pylori infection with determinants of early and persistent H. pylori infection. METHODS: ELISA was used to detect H. pylori antigens in stool specimens collected from children at preschool age (3-5 years) and from their mothers and siblings in 2004. The children were tested again for H. pylori at school age (6-9 years) in 2007-2009. Household and socioeconomic characteristics were obtained by interviews. RESULTS: The prevalence of H. pylori infection increased from 49.7% (95% CI 42.8, 56.7) in 2004 to 58.9% (95% CI 51.8, 65.6) in 2007-2009. Among children tested in both examinations, 69 (49.3%) had persistent infection, 14 (10.0%) were new cases, 56 (40.0%) remained uninfected, and one (0.7%) had lost H. pylori infection. The approximate annual incidence of infection during 2004-2009 was 5%. Sibling's H. pylori positivity at baseline increased the risk for late acquisition of H. pylori infection; adjusted prevalence ratio (PR) 4.62 (95% CI 0.76, 28.23) (p = .09), while maternal education lowered the risk; adjusted PR 0.84 (95% CI 0.69, 1.01) (p = .06). Sibling's H. pylori positivity was the only significant variable associated with early and persistent H. pylori infection in multivariate analysis. CONCLUSIONS: Most H. pylori infections are acquired at preschool age and transient infection beyond this age is uncommon in this population. Helicobacter pylori-infected siblings are the major reservoir of H. pylori in early and late childhood demonstrating sustained intra-familial transmission of H. pylori.

Depression among Arabs and Jews in Israel: a population-based study.

INTRODUCTION: Depression is the second most common chronic disorder seen by primary care physicians. Risk factors associated with depression include medical and psychosocial factors. While in Israel, the rate and risk factors for depression are considered similar to those in other Western countries, population-based data are limited. The present study aims to estimate the prevalence of depression among Jews and Muslim Arabs, and to consider possible associations with demographic, socioeconomic, and health factors. METHODS: The study group (N = 872) was equally divided according to ethnicity, gender, and age group. Depression was measured by the Harvard Department of Psychiatry National Depression Screening Day Scale (HANDS). RESULTS: The rate of depression scores in the likely/very likely range was 2.5 times higher among Arabs than among Jews (24.9 vs. 10.6%; P < 0.001). Women were more likely to express symptoms of depressive episode than were men (22.0 vs. 13.6%; P = 0.001), and the depression rate increased with age, from 11.0% in the youngest group (26-35) to 25.0% in the oldest (P = 0.001). The rate of increase in depression by age was different for the genders, rising more steeply for women than for men. However, the age-gender differential was not identical for the two ethnic groups. The differences in depression prevalence between Arabs and Jews were maintained after controlling for confounding variables, except that when controlling for education, the difference between the ethnic groups was no longer significant. After adjusting for all variables in the analysis, no significant association remained between ethnicity and depression (OR = 0.80; 95% CI = 0.45-1.40).

Obesity among Arabs and Jews in Israel: a population-based study.

BACKGROUND: Arabs in Israel have high morbidity and mortality from diabetes and cardiovascular disease. Obesity is a risk factor for both conditions. OBJECTIVES: To investigate the prevalence of obesity (body mass index >30 kg/m2), subjects' knowledge and behaviors, and their reports on practices of health-care professionals regarding body weight among Arabs and Jews. METHODS: The study participants (n=880) were randomly sampled from the urban population of the Hadera district in Israel. Data on demographic, socioeconomic and lifestyle characteristics; reports on height, current body weight and body weight at the age of 18 years; knowledge and behavior; and health-care professionals' practices with regard to body weight were obtained by interview. Anthropometric measurements were performed subsequently. RESULTS: Information on BMI was available on 868 participants (49% Arabs, 49% women, median age 46 years). Although the median BMI did not differ significantly between Arabs and Jews at age 18, the prevalence of current obesity was 52% in Arab women compared to 31% in Jewish women (P < 0.001), and 25% in Arab men compared to 23% in Jewish men (P = 0.6). On multivariate analysis, obesity was significantly associated with age, BMI at the age of 18 years, leisure time physical activity and cigarette smoking, but not with ethnicity. Fewer Arabs reported measuring their body weight and Arab women were less frequently advised to maintain an active lifestyle. CONCLUSIONS: The high prevalence of obesity among Arab women may be explained by lifestyle characteristics. Prevention of obesity in Arabs should be directed at women and should start preferably before adulthood.