Municipal community centers as healthy settings: evaluation of a real-world health promotion intervention in Jerusalem.

BACKGROUND: This study presents an intervention designed to foster the implementation of health promotion programs within District Municipality Community Centers (DMCCs) in Jerusalem, and the creation of a peer network of healthy settings with a shared aspiration of collaborating and implementing health-promoting policies at the community level. We also present the evaluation strategy, based on the EQUIHP and RE-AIM frameworks. METHODS: Twenty DMCCs completed our program. This evaluation research involved a comprehensive seminar during the first year for DMCCs coordinators, teaching them the principles of health promotion. An educational kit was distributed during the second year. The evaluation strategy included a process evaluation and annual evaluations based on the EQUIHP and RE-AIM frameworks. The EQUIHP tool was divided into four dimensions of evaluation: 1) Framework of health promotion principles, 2) Project development and implementation, 3) Project management, and 4) Sustainability; while the RE-AIM domains included: 1)Reach, 2)Effectiveness, 3)Adoption, 4)Implementation and 5)Maintenance. RESULTS: The program led to high responsiveness among DMCCs and to the implementation of diverse health promotion initiatives, with a participation of approximately 29,191 residents. The EQUIHP evaluation showed an improvement in program quality in Year 2. The final RE-AIM evaluation presented a total median score of 0.61 for all domains, where 0 was non-performance and 1.0 was full performance. The 'Framework of health promotion principles' and 'Reach' components received the highest median score (0.83, 1.0 and 0.87), while the 'Sustainability and 'Maintenance' components received the lowest (0.5). CONCLUSIONS: This innovative program adapts the Healthy Cities approach (initiated by the World Health Organization in 1986) to the development of community center health-promoting settings within the larger municipal framework, training local community center staff members to assess and address local health concerns and build community capacity. The local focus and efforts may help community actors to create health promotion programs more likely to be adopted, feasible in the 'real-world' and able to produce public health impact in the communities where people live. Moreover, collaboration and cooperation among DMCCs may lead to a broader community health vision, forging coalitions that can advocate more powerfully for health promotion. TRIAL REGISTRATION: NIH trial registration number: NCT04470960. Retrospectively registered on: 14/07/2020.

A decade of progress: comparative evaluation of the Israel Healthy Cities Network.

Established in 1990, Israel's Healthy Cities Network (HCN) performed its first evaluation in 2003-2004. A decade later, the present evaluation was implemented to assess members' compliance with the European HCN requirements and to determine progress made since the initial evaluation. A total of 31 of the existing 42 HCN members participated in this mixed methods evaluation. Based on the Monitoring, Accountability, Reporting, and Impact assessment framework, the evaluation questionnaire integrated Healthy Cities' principles and strategies. Univariate and bivariate analyses were used to investigate municipality performance as well as associations between indicators and structural or process measures. Matched-paired t-tests were performed to compare HCN member cities' initial evaluation with the current evaluation. Qualitative analyses explored the processes involved in implementing the Healthy Cities approach. The current evaluation found that Israel's HCN complies with all European HCN requirements, except for producing a city health profile. Increased coordinators' time investment, maintaining municipal health steering committee meetings and attending HCN activities were positively associated with better score on all dimensions. There was no significant difference between the two evaluation scores for all HCN cities collectively; however, within city comparisons indicated significant change. Coordinators reported that there was added value in HCN membership and conveyed a need for better network facilities, publicity and improved public relations. This evaluation validates the previous evaluation's findings and informs decision makers and municipal leaders regarding potential areas to modify or expand, both on the municipality level and the network at large.

Established in 1990, Israel's Healthy Cities Network (HCN) performed its first evaluation in 2003­2004. A decade later, the present evaluation was implemented to assess members' compliance with the European HCN requirements and to determine progress made since the initial evaluation. A total of 31 of the existing 42 HCN members participated in this evaluation. Based on the Monitoring, Accountability, Reporting, and Impact assessment framework, the evaluation questionnaire integrated Healthy Cities' principles and strategies, integrating both closed and open-ended questions. The current evaluation found that Israel's HCN complies with all European HCN requirements, except for producing a city health profile. Increased coordinators' time investment, maintaining municipal health steering committee meetings and attending HCN activities were positively associated with better performance on dimensions of equity policy and management. There was no significant difference between the two evaluation scores for all HCN cities collectively; however, within city comparisons indicated significant change. Coordinators reported that there was added value in HCN membership and conveyed a need for better network facilities, publicity and improved public relations. This evaluation validates the previous evaluation's findings and informs decision makers and municipal leaders regarding potential areas to modify or expand, both on the municipality level and the network at large.

Do Patients Seek Women-Centered Cardiac Care? Patient Experience of an All-Female Multidisciplinary Heart Center for Women.

Purpose: Cardiovascular disease in women is frequently under-diagnosed and under-treated. Numerous heart centers for women have opened throughout the world to address these disparities; however, there is a paucity of data regarding participants' perspectives. The current study assesses motivation to participate and perceived benefits in attending a heart center for women (HCW) in Jerusalem, Israel. Methods: This study utilized qualitative methods to assess patients' motivation and perceived benefits to attending a women's heart center, particularly as they relate to gender medicine and single-sex staffing. A random sample of 42 clinic patients were asked to participate in interviews. Inclusionary criteria consisted of previous cardiovascular event, active cardiac symptom or three or more cardiovascular disease risk factors. Exclusionary criteria consisted of pregnancy, type 1 diabetes requiring insulin, psychiatric diagnosis that precluded participation, dementia, or other multidisciplinary clinic participation. Interviews were audio recorded and transcribed verbatim. Qualitative data analysis followed Braun and Clarke's methodology of thematic analysis. Results: The single-sex and gender medicine aspects did not motivate women to attend the HCW, although some participants perceived this as beneficial in retrospect. Women reported that the clinic visit enhanced their knowledge and awareness of issues related to heart disease in women as well as personal health benefits. They reported benefitting from the holistic approach, consideration of their lifestyle, the staff's expression of concern, personalized attention, common language, and feeling understood. Conclusion: This study describes the patient experience in an all-female HCW, highlighting their motivation for attendance and perceived benefits. While they did not actively seek women-centered care, women reported educational and care provision benefits to their attendance. The care attributes that women identified as beneficial typify the person-centered approach to care. These findings may inform both the design and evaluation of medical care facilities that aim to address the sex and gender disparities in cardiology as well as other medical specialties.

Cardiovascular disease risk factors and health behaviors of ultra-Orthodox Jewish women in Israel: a comparison study.

Objectives: Women from low socio-economic, culturally insular populations are at increased risk for cardiovascular disease (CVD). The ultra-Orthodox Jewish (UOJ) community in Israel is a rapidly growing low socio-economic, insular, cultural-ethnic minority with numerous obstacles to health. The current cross-sectional study investigates CVD-related health behaviors and risk factors in a sample of UOJ females, comparing sample characteristics with the general population. Design: Self-administered questionnaires completed by a cluster randomized sample of 239 UOJ women included demographics, CVD-related health behaviors (consumption of fruit, vegetables, and sweetened beverages; hours of sleep; secondhand smoke exposure; and physical activity engagement) and risk factors (BMI, reported diagnoses of diabetes, high blood pressure, and heart disease). Results: Compared with the general population, UOJ women were less likely to consume 5 fruits and vegetables a day (12.7% vs. 24.3%, p < .001); more likely to consume ≥ 5 cups of sweetened beverages a week (18.6% vs. 12.6%, p = .019), and more likely to sleep <7 hours a night (62.0% vs. 50.6%, p = .002). UOJ women also reported less secondhand smoke exposure (7.2% vs. 51.4%, p < .001) and higher rates of physical activity recommendation adherence (60.1% vs. 25.6%, p < .0001) than the general population. Obesity was higher in UOJ women (24.3% vs. 16.1%, p < .0001). Increased parity and reduced moderate physical activity were associated with increased BMI. Increased parity was also associated with reduced sleep. Grand multiparous women (a 68% prevalence rate), in particular, were more likely to be overweight or obese than women with less than 5 children. Conclusions: This study suggests that health promotion interventions in this population target healthy weight maintenance, nutrition, and physical activity.

Health ambassadors in the workplace: a health promotion intervention mobilizing middle managers and RE-AIM evaluation of outcomes.

BACKGROUND: The workplace provides an ideal setting for health promotion, as adults spend most of their day at work. Middle managers hold a strategic position to lead workplace health promotion. This study evaluates the outcomes of an intensive intervention training middle managers to promote health in the workplace. METHODS: A workshop was designed and conducted to train female middle management employees to construct, implement, and evaluate a health promotion program in their workplace. Semi-structured interviews were carried out post-intervention to assess workplace health promotion outcomes according to the RE-AIM framework, and identify variables contributing to success. Additionally, questionnaires were distributed pre and post-program assessing personal health and self-efficacy changes. RESULTS: Eighteen participants from 13 government offices, who serve 19,560 employees, completed the training course. Nine workplaces had workplace health promotion programs in progress 12 months after the course had ended, of which 8 made health promotion changes in organizational policy. Workplace RE-AIM scores showed that 8 workplaces were high or partial performers, and 5 were low or non-performers. Factors that increased the likelihood of successful interventions included management support, steering committee, comprehensive programming, conducting a needs assessment and flexibility in program implementation in the presence of challenges. Post course, participants reported increased health knowledge related to workplace health promotion (p < 0.001), and increased health promotion self-efficacy (p < 0.05). CONCLUSIONS: Training and continued guidance of middle managers resulted in the design and successful implementation of workplace health promotion interventions. A RE-AIM based assessment was found to be an effective method for evaluating multi-content workplace health promotion programs. Registered at ClinicalTrials.gov, https://www.clinicaltrials.gov , registration number: NCT03295136, registration date: 24/09/2017.

Two-Phase Evaluation of a Community-Based Lifestyle Intervention for Palestinian Women in East Jerusalem: A Quasi-Experimental Study Followed by Dissemination.

Palestinian-Arab women are at increased risk of cardiovascular disease due to high prevalence of diabetes and other risk factors. The current study investigates the effectiveness of an intensive group-based intervention on lifestyle habits that can prevent diabetes and cardiovascular disease. To that end, we conducted a group-based intervention based on the diabetes prevention program in two consecutive phases. The first phase consisted of a quasi-experimental study and the second phase included community-wide dissemination, with a 6-month follow-up. Findings from the quasi-experiment indicate increased consumption of fruit, vegetables and whole grains, weight reduction (-2.21 kg, p < 0.01), and a significant increase in the average daily steps in the intervention group (from 4456 to 6404). Findings from the dissemination indicate that average daily vegetables consumption increased from 1.76 to 2.32/day as did physical activity and average daily steps (from 4804 to 5827). There was a significant reduction in blood pressure, total cholesterol and LDL. These gains were sustained over 6 months following the intervention. This community-based, culturally adapted, health-promotion intervention led to improved nutrition and physical activity which were maintained after 6 months. Collaboration with community centers and local community partners created an effective channel for dissemination of the program to pre-clinical individuals.

Psychosocial Functioning, BMI, and Nutritional Behaviors in Women at Cardiovascular Risk.

Psychosocial factors such as depression, anxiety, and stress are associated with increased cardiovascular risk. Health behaviors may play a role in this relationship, as individuals experiencing elevated levels of anxiety, stress, and/or depression may be less likely to engage in risk-reducing behaviors such as diet and exercise. Some evidence suggests that this relationship is particularly relevant for women. This study explored the relationship between levels of anxiety, depression, stress, and specific nutritional behaviors in a sample of 187 women at cardiovascular risk. BMI was explored as a possible moderator of these relationships. Higher levels of depression in patients with high BMI was associated with increased fruit consumption, whereas this was not seen in highly depressed patients with normal BMI. The reverse pattern was seen for consumption of sweet drinks. Anxiety was found to have a complex relationship with consumption of sweetened drinks and white bread, with higher consumption at moderately elevated levels of anxiety and reduced consumption at the highest levels. Possible interpretations of these findings, as well as their implications for lifestyle interventions with this population are discussed. These findings suggest a number of questions for further research.

Integration of Mixed Methods in Community-Based Participatory Research: Development of a Disease Prevention Intervention for Ultra-Orthodox Jewish Women.

PURPOSE: To describe the development of the first disease prevention intervention with ultra-Orthodox Jewish (UOJ) women in Israel using mixed methods and community-based participatory research (CBPR). DESIGN: This collaborative, 7-staged development process used an exploratory sequential mixed methods design integrated into a community-based participatory approach. SETTING: The UOJ community in Israel, a high-risk, low socioeconomic, culturally insular minority that practices strict adherence to religious standards, maintains determined seclusion from mainstream culture and preserves traditional practices including extreme modesty and separation between the sexes. PARTICIPANTS: Women from a targeted UOJ community in Israel with distinct geographic, religious, and cultural parameters. These included 5 key informant interviewees, 5 focus groups with 6 to 8 participants in each, a cluster randomized sample of 239 questionnaire respondents (an 87% response rate), and 11 steering committee participants. METHOD: Qualitative data were analyzed through Interpretative Phenomenological Analysis by 2 researchers. Quantitative data were collected via questionnaire (designed based on qualitative findings) and analyzed utilizing descriptive statistics. RESULTS: Barriers to health behavior engagement and intervention preferences were identified. The final intervention included walking programs, health newsletters, community leader trainings, teacher and student trainings, and health integration into schools. CONCLUSION: Utilizing mixed methods in CBPR improved cultural tailoring, potentially serving as a model for intervention design in other difficult to access, low socioeconomic, and culturally insular populations.

Cardiovascular health literacy and patient-physician communication intervention in women from disadvantaged communities.

BACKGROUND: For many women in low socioeconomic status communities, limited health literacy is an obstacle to following medical guidance and engaging in health-promoting behaviours. Low health literacy skills are also associated with an increased risk of cardiovascular disease. DESIGN: A health literacy intervention was designed through focus groups with women in low socioeconomic status communities. The primary health literacy issue identified was communication challenges at doctors' visits. A unique intervention tailored to the participants' preferences was designed consisting of three workshops conducted in community women's groups in low socioeconomic status Jerusalem communities. The intervention aimed to increase patient-physician communication skills through doctor visit preparation and better visit management, improve perceived efficacy in patient-physician interaction and expand cardiovascular disease knowledge. METHODS: Questionnaires were completed before and 3 months after the intervention, assessing knowledge of cardiovascular disease risk factors and symptoms, self-report of behaviours in preparations for a doctor's visit, and perceived efficacy in patient-physician interaction. RESULTS: A total of 407 women from low socioeconomic status communities completed questionnaires. Post-intervention, the percentage of women that reported preparing for doctors' visits increased significantly. Women with initially low levels of perceived efficacy in patient-physician interaction showed a significant increase in perceived efficacy, while initially higher perceived efficacy in patient-physician interaction participants showed a decrease. Participants also demonstrated an increase in knowledge of several risk factors for cardiovascular disease and heart attack symptoms. CONCLUSIONS: A community-based cardiovascular health literacy intervention improved cardiovascular knowledge and reported doctor visit preparation in low socioeconomic status women as well as increased perceived efficacy in patient-physician interaction among participants with low baseline perceived efficacy in patient-physician interaction. This may lead to improved health care utilisation, preventing chronic illness. Registered at ClinicalTrials.gov, https://www.clinicaltrials.gov , registration number: NCT03203018.