The association of medical, social, and normative factors with the implementation of end-of-life care practices.

BACKGROUND: End-of-life (EoL) care practices (EoLCP) are procedures carried out at the EoL and bear directly on this stage in the patient's life. Public support of these practices in Israel is far from uniform. Previous studies show that while ∼30% of participants support artificial respiration or feeding of terminally ill patients, 66% support analgesic treatment, even at the risk of shortening life. This study aimed to create a typology of six end-of-life care practices in Israel and assess the association of medical, social, and normative factors with the implementation of those practices. These practices included mechanical ventilation, artificial feeding, deep sedation, providing information to the patient and family caregivers, including family caregivers in EoL decision-making, and opting for death at home. METHODS: This cross-sectional study was performed as an online survey of 605 adults aged 50 or more in Israel, of which ~ 50% (n = 297) reported supporting a dying terminally ill relative in the last 3 years. Participants were requested to provide their account of the EoL process of their relative dying from a terminal illness in several aspects, as well as the EoL care practices utilized by them. RESULTS: The accounts of the 297 interviewees who supported a dying relative reveal a varied EoL typology. The utilization of end-of-life care practices was associated with the socio-normative beliefs of family caregivers but not with their socioeconomic status. Strong correlations were found between family caregiver support for three key practices (mechanical ventilation, artificial feeding, and family involvement in EoL) and the actual utilization of these practices in the care of dying patients. CONCLUSIONS: The findings portray an important image of equity in the utilization of EoLCP in Israel, as the use of these practices was not associated with socioeconomic status. At the same time, the study found substantial diversity in family caregivers' preferences regarding EoL care practices use not related to socioeconomic status. We believe that differences in preferences that do not lead to problems with equity or other important societal values should be respected. Accordingly, policymakers and health system leaders should resist calls for legislation that would impose uniform EoL practices for all Israelis. Instead, they should take concrete steps to preserve and enhance the widespread current practice of practitioners to adapt EoL care to the varied needs and preferences of Israeli families and cultural, social, and religious subgroups. These steps should include providing frameworks and tools for family caregivers to support their loved ones close to their deaths, such as educational programs, seminars, supportive care before and during the end of life of their loved ones, etc.

Polarization in public attitudes toward end-of-life decisions in Israel - A cross-sectional study.

OBJECTIVES: End-of-life (EoL) processes are a complex socio-normative and ethical phenomenon. This study aimed to generate a database of public opinion in Israel concerning EoL processes and decisions and to identify differences in attitudes across subgroups in the population, particularly based on experience as a family caregiver of a dying patient. METHODS: This cross-sectional study was performed in late March 2022. The study utilized an online sample of 605 adults over the age of 50 including those who accompanied a loved one to their death in the last 3 years. Participants were requested to provide their opinions and attitudes on several aspects of EoL decisions, including truth-telling, medically assisted dying, EoL procedures, pre-death actions, and family caregivers' engagement. RESULTS: While only 27% and ∼30% of participants support artificial respiration or feeding (respectively) of terminally ill patients, 66% support analgesic treatment, even at the risk of shortening life. The data show an association between religiosity and agreement with life-extending procedures. For example, while 83% of seculars support medically assisted dying, only 59% and 26% of traditional and religious respondents support it. However, no statistically significant differences were observed in support of family involvement in EoL process in any sociodemographic variable. SIGNIFICANCE OF RESULTS: The results of this study suggest that the Israeli public is relatively polarized on several issues about EoL processes, specifically patient autonomy and medically assisted dying. Yet, at the same time, there is a consensus among the Israeli public about certain EoL elements, particularly the importance of family caregivers in the EoL decision-making process.

Agencies Displayed by Patients, Medical Teams, and Caregivers at the End of Life from the Perspectives of Family Members - A Qualitative Study.

Background: End-of-life (EoL) Care is challenging for terminally-ill patients and their caregivers. This research is aimed to examine the relational agencies of the patients, the caregivers, and the medical teams in the context of EoL care, with a particular emphasis on the caregivers. Methods: This study is based on the qualitative analysis of interviews with 12 individuals who were closely supported a loved one to their death from a terminal illness. Results: Information collected revealed several agency-related themes. Family caregivers are significant entities in managing the 'case' of a seriously ill individual. At the final or more advanced stages of the EoL process, caregivers gradually shift from a supportive role to being active agents, but not always backed by the necessary experience, knowledge, or the requisite emotional resilience. Conclusions: Based on recognizing their agentic proactivity, a clear and elaborate articulation of the family caregivers' roles is needed.

Overcoming the effect of pandemic fatigue on vaccine hesitancy-Will belief in science triumph?

PURPOSE: The study aims to examine the factors that impact vaccination uptake and additional protective behavior during the fourth wave of the pandemic in Israel, whereas the "pandemic fatigue" phenomenon has been identified as a hurdle to adherence to protective health behaviors against coronavirus disease 2019 (COVID-19). DESIGN: A cross-sectional, structured questionnaire was utilized for this investigation in September 2021, during the fourth wave of the pandemic. METHODS: A sample of the adult (18+) Israeli population was employed for the study. Recruiting participants for the study was conducted through an online internet panel company that consists of over 100,000 members, representing all geographic and demographic sectors of the Israeli population. RESULTS: Our findings indicate that pandemic fatigue has begun to have cascading effects on vaccination efforts. In particular, this study found that at this stage of the COVID-19 pandemic, trust in authorities, and even threat perception components, such as concern and fear of contracting the disease, are incapable of predicting vaccination uptake. Instead, perception of the importance of the vaccine and its effectiveness are predictive of vaccination uptake. CONCLUSION: The findings indicate that at this stage of the pandemic, focusing on the robustness of the science behind the vaccine is more important than trying to regain public trust. The findings also suggest that risk communication employing fear tactics is losing its capacity to generate motivation for vaccination. CLINICAL RELEVANCE: The findings of this study reveal lessons learned from the COVID-19 global pandemic. Specifically, the study reveals how in times of prolonged crisis, we can currently and, in the future, prepare improved strategies for public communication in order to promote uptake of protective health behavior, such as vaccination.

Disaffiliation from Jewish Ultra-Orthodox Communities: Life Trajectories Shaped by the Axes of Rigidity-Fluidity and Alterity-Inclusion.

Increasing numbers of young Israelis annually leave the enclave of the ultra-Orthodox Jewish community. Relying on 16 in-depth interviews, we examine the effects of this disaffiliation on life trajectories and identity reconstruction of individuals who left their society of origin two decades ago. This unveiled a multistep longitudinal process, characterized by moving in and out of various structural stages, coupled with disaffiliates' agency to highlight specific sociocultural characteristics or the more universal nature of the human condition. The life course of disaffiliates begins with a phase of early struggle with the immediate tolls of disaffiliation, followed by a formative period marked by two steps: military service and acquisition of higher education. Here disaffiliates practice adoption of increasingly inclusive identities, in which the past and present are enmeshed. The formative period is followed by three alternative trajectories: (a) adherence to restrictive Israeli conformity, (b) ongoing search for singularity, and (c) integration of ultra-Orthodox heritage with contemporary Israeli realities. The disaffiliation trajectory from the ultra-Orthodox society is embedded in particular sociocultural, political, and historical contexts. However, narratives of disaffiliates adhere to frameworks of cultural Jewish-Israeli particularism, as much as to those of human universalism, plugging in to certain universal themes of the human condition, namely rigidity, fluidity, alterity, and inclusion.

The Effects of Sociocultural Transitioning on Accessibility to Healthcare: The Case of Haredi Jews Who Leave Their Communities.

Minority groups and immigrants encounter complex issues when attempting to access healthcare. This study examines factors affecting access to healthcare by a group of individuals in Israel who decided to leave their Haredi Jewish communities. We conducted 23 semi-structured interviews with individuals disaffiliating from Haredi communities in Israel in order to identify hurdles encountered during the process of seeking healthcare. We focused on specific steps in this process, including recognizing the need for help, deciding to actually turn to the health system, interaction with the system, and behavior after referring to the health system. We identified approximately 20 factors which can be either barriers or catalysts affecting healthcare access at the various stages. These were then traced to religious upbringing, hurdles of sociocultural transition, and unique characteristics of individuals reshaping their lives. The findings can be instrumental in designing culturally adapted health programs for individuals leaving the Haredi community. Moreover, the methodology that we are proposing can serve other investigations studying access to healthcare among various groups undergoing sociocultural transitions.

Assisted life termination and truth telling to terminally ill patients - a cross-sectional study of public opinions in Israel.

BACKGROUND: End-of-life decisions are highly complex socio-normative and ethical phenomena. The goal of this study was to provide an assessment of public opinions in Israel concerning aspects of end-of-life decisions. METHODS: An online cross sectional study was performed in February 2020. The primary tool including items pertaining to death assistance and truth telling to patients. A sample of 515 participants representative of the adult Israeli population was obtained. RESULTS: The majority of participants (71%) supports telling the entire truth to patients even in harsh conditions. Support for truth telling decreases with affiliation to religion, with as little as 40% support among ultra-orthodox. People with vocational education are the least supportive of truth telling. Concerning doctor assisted death, almost half (49%) of the sample were supportive. Opposition is positively associated with religiosity, with 90% of ultra-orthodox and 58% of religious participants opposing doctor-assisted death, compared to only 18% among seculars. Non-Jews were 3.35 times (95%CI: 1.90, 5.91) more likely to oppose doctor assisted death than Jews (p < .0001). An Interrelationship analysis crossing between attitudes revealed that the largest group (39%) was comprised of participants who support both ("autonomists"). CONCLUSIONS: Israelis are overwhelmingly supportive of truth telling to patients. In contrast, Israeli public opinions on doctor assisted death are divided. For both attitudes, religiousness plays a crucial role as a catalyst for conservatism and opposition to change. Almost a half of the public is also supportive of an autonomist approach that would allow patients to decide on ending their own lives.

Prosocial polio vaccination in Israel.

Regions with insufficient vaccination have hindered worldwide poliomyelitis eradication, as they are vulnerable to sporadic outbreaks through reintroduction of the disease. Despite Israel's having been declared polio-free in 1988, a routine sewage surveillance program detected polio in 2013. To curtail transmission, the Israel Ministry of Health launched a vaccine campaign to vaccinate children-who had only received the inactivated polio vaccine-with the oral polio vaccine (OPV). Determining the degree of prosocial motivation in vaccination behavior is challenging because vaccination typically provides direct benefits to the individual as well as indirect benefits to the community by curtailing transmission. However, the Israel OPV campaign provides a unique and excellent opportunity to quantify and model prosocial vaccination as its primary objective was to avert transmission. Using primary survey data and a game-theoretical model, we examine and quantify prosocial behavior during the OPV campaign. We found that the observed vaccination behavior in the Israeli OPV campaign is attributable to prosocial behavior and heterogeneous perceived risk of paralysis based on the individual's comprehension of the prosocial nature of the campaign. We also found that the benefit of increasing comprehension of the prosocial nature of the campaign would be limited if even 24% of the population acts primarily from self-interest, as greater vaccination coverage provides no personal utility to them. Our results suggest that to improve coverage, communication efforts should also focus on alleviating perceived fears surrounding the vaccine.

Truth-telling and doctor-assisted death as perceived by Israeli physicians.

BACKGROUND: Medicine has undergone substantial changes in the way medical dilemmas are being dealt with. Here we explore the attitude of Israeli physicians to two debatable dilemmas: disclosing the full truth to patients about a poor medical prognosis, and assisting terminally ill patients in ending their lives. METHODS: Attitudes towards medico-ethical dilemmas were examined through a nationwide online survey conducted among members of the Israeli Medical Association, yielding 2926 responses. RESULTS: Close to 60% of the respondents supported doctor-assisted death, while one third rejected it. Half of the respondents opposed disclosure of the full truth about a poor medical prognosis, and the others supported it. Support for truth-telling was higher among younger physicians, and support for doctor-assisted death was higher among females and among physicians practicing in hospitals. One quarter of respondents supported both truth-telling and assisted death, thereby exhibiting respect for patients' autonomy. This approach characterizes younger doctors and is less frequent among general practitioners. Another quarter of the respondents rejected truth-telling, yet supported assisted death, thereby manifesting compassionate pragmatism. This was associated with medical education, being more frequent among doctors educated in Israel, than those educated abroad. All this suggests that both personal attributes and professional experience affect attitudes of physicians to ethical questions. CONCLUSIONS: Examination of attitudes to two debatable medical dilemmas allowed portrayal of the multi-faceted medico-ethical scene in Israel. Moreover, this study, demonstrates that one can probe the ethical atmosphere of a given medical community, at various time points by using a few carefully selected questions.

On the implications of desexualizing vaccines against sexually transmitted diseases: health policy challenges in a multicultural society.

Two vaccines against sexually transmitted infections are included in many national vaccination programs: Hepatitis B Virus (HBV) vaccine and Human Papilloma Virus (HPV) vaccine. The trajectories of the implementation of these two programs were marked by differences in the way the sexual context of risk was communicated to the public. These trajectories fluctuated between full accounts of the sexual nature of the infection and attempts to desexualize the vaccines. Vaccine desexualization can be achieved by withholding information of sexual context, blurring information, and distancing the age of vaccination from the age of sexual debut. Desexualization may be advantageous in promoting public health and personal health of people who believe that HPV vaccination leads to increased promiscuity, people who believe that protection against STD is not relevant to their children, and people who are not comfortable discussing the sexuality of their children. On the other hand, desexualizing may be disadvantageous for children to parents who tend to express passiveness towards vaccination, parents who attribute importance to sex education, and teenagers with homosexual orientations. The ethical analysis of vaccine desexualization reveals a complex interplay of considerations related to utility, causation of harm, duty of transparency, right to know, and right not to know. This analysis suggests that the moral merits of applying desexualization are questionable. Lastly, a sociopolitical consideration of the matter, suggests that decisions on vaccine desexualization can have implications on the interrelationships between various social groups and subgroups composing a certain population, and may highlight intercultural schisms. All this indicates that shaping the sexual framework of vaccination programs bears implications far beyond the practical considerations of vaccine promotion.

Vaccine hesitancy as self-determination: an Israeli perspective.

Vaccine hesitancy can be portrayed as a broad spectrum of phenomena, ranging from a genuine call for help to complete defiance of authorities. The emphasis here is made on mid-spectrum hesitancy; hesitancy as an act of personal exploration and deliberation whether to get vaccinated or not. This form of vaccine hesitancy can be identified in the attitude of the Israeli public towards routine childhood vaccination programs, seasonal flu vaccination, newly introduced vaccines, such as human papilloma virus vaccine, as well as towards the emergency vaccination programs against poliovirus and H1N1 pandemic influenza. Vaccine hesitancy in Israel appears to be a process where individuals exercise self-determination and self-empowerment and make their own decisions based on assessment, reflection, choosing between various options and dealing with considerable complexities. Addressing this form of vaccine hesitancy could be challenging, but ultimately fruitful. This would require change of attitudes on the part of policymakers. The first steps should involve the realization that deliberative hesitancy is here to stay, and that hesitant individuals should be respected. This could pave the way for designing appropriate intervention strategies for convincing the hesitant public about the advantages of vaccination.

Using the social structure of markets as a framework for analyzing vaccination debates: The case of emergency polio vaccination.

The framework of the social structure of markets was used to analyze an online debate revolving around an emergency poliovirus vaccination campaign in Israel. Examination of a representative sample of 200 discussions revealed the activity of three parties: authoritative agents promoting vaccinations, alternative agents promoting anti-vaccination, both representing sellers, and the impartial agents, representing the customers-the general public deliberating whether to comply with vaccination or not. Both sellers interacted with consumers using mechanisms of luring and convincing. The authoritative agents conveyed their message by exhibiting professionalism, building trust and offering to share information. The alternative agents spread doubts and evoked negative emotions of distrust and fear. Among themselves, the alternative agents strived to discredit the authoritative agents, while the latter preferred to ignore the former. Content analysis of discussions conducted by the general public reveal reiteration of the messages conveyed by the sellers, implying that the transaction of pro and anti-vaccination ideas indeed took place. We suggest that the framework of the market as a social structure can be applied to the analysis of other vaccination debates, and thereby provide additional insights into vaccination polemics.

Analysis of public responses to preparedness policies: the cases of H1N1 influenza vaccination and gas mask distribution.

BACKGROUND: During several months in 2009-2010, the Israeli population was asked to take part in two preparedness programs: Acquisition of gas masks against a potential chemical-warfare attack, and vaccination against the A/H1N1 influenza pandemics. Compliance with the first request was moderate and did not attract much attention, whereas compliance with the second request was very low and was accompanied by significant controversy. The aims of this study are to compare the public's attitudes towards these two preparedness campaigns, and to explore the roles of trust, reasoned assessment, and reflexive reactions in the public's response to governmental preparedness policies. METHODS: The comparative analysis was based on a telephone survey of 2,018 respondents representing a cross-section of the adult Israeli population. Univariate analysis to describe associations of public response and attitude was performed by Chi-square tests. FINDINGS: A set of queries related to actual compliance, trust in credibility of authorities, personal opinions, reasons for non-compliance, and attitudes towards uncertainties was used to characterize the response to mask-acquisition and vaccination. In the case of mask-acquisition, the dominant response profile was of trusting compliance based on non-conditional belief in the need to adhere to the recommendation (35.6% of respondents). In the case of vaccination, the dominant response profile was of trusting non-compliance based on a reflective belief in the need for adherence (34.8% of respondents). Among the variables examined in the study, passivity was found to be the major reason for non-compliance with mask-acquisition, whereas reasoned assessment of risk played a major role in non-compliance with vaccination. Realization of the complexity in dealing with uncertainty related to developing epidemics and to newly-developed vaccines was identified in the public's response to the H1N1 vaccination campaign. CONCLUSIONS: The newly identified profile of "trusting-reflective-non-complier" individuals should be of concern to policy makers. The public is not accepting governmental recommendations in an unconditional manner. This is not driven by lack of trust in authorities, but rather by the perception of the responsibility of individuals in confronting forthcoming risks. Nevertheless, under certain conditions the public may respond in a non-reflective way and delegate this responsibly to authorities in an uncontested manner. This leaves the policy makers with the complex challenge of interacting with a passive non-involved public or alternatively with an opinionated, reflexive public.

Individualism, acceptance and differentiation as attitude traits in the public's response to vaccination.

The attitude of the general public to vaccination was evaluated through a survey conducted on a representative sample of the Israeli population (n = 2,018), in which interviewees were requested to express their standpoints regarding five different vaccination programs. These included: pandemic influenza vaccination, seasonal influenza vaccination, travel vaccines, Human Papilloma Virus vaccine and childhood vaccinations. Analysis of the responses reveal three major attitude traits: a) acceptance, characterized by the opinion that targets should be vaccinated; b) individualism, characterized by the opinion that vaccination should be left to personal choice; and c) differentiation, characterized by the tendency to express different attitudes when addressing different vaccination programs. Interestingly, direct opposition to vaccination was found to be a minor attitude trait in this survey. Groups within the population could be defined according to their tendency to assume these different attitudes as Acceptors, Judicious-acceptors, Differentiators, Soft-individualists, and Hard-individualists. These groups expressed different standpoints on all five vaccination programs as well as on other health recommendations, such as screening for early detection of cancer. Attitude traits could be also correlated, to a certain extent, with actual compliance with vaccination programs. Interestingly, attitudes to vaccination were not correlated with social profiles related to income or education, although younger individuals exhibited higher degrees of individualism and differentiation. Taken together, all this is in accordance with the current social settings, underlining the individual's tendency for critical evaluation and self-stirring. This should be taken into consideration by health authorities involved in vaccination programs.

Acceptance on the move: public reaction to shifting vaccination realities.

This review examines four events related to vaccination that have occurred in recent years: (a) the ongoing recovery from the MMR/Autism scare in the UK, (b) the upgrading of the Varicella vaccine to a universal childhood vaccine, (c) the major effort of authorities to provide a vaccine for A/H1N1 influenza and its rejection by the public, and, d) the current attempts to change the HPV vaccine target from girls only to boys and girls. All of these changes have been met with shifts in the public acceptance of the relevant vaccine. These shifts are characterized not only by the number of people willing to be vaccinated, but also by the attitudes and the motives related to acceptance. Examination of the interrelationship between changes in vaccination realities, and changes in acceptance patterns suggests that today, the public has a better understanding of vaccination, is acting in a more reflexive way, and is capable of changing attitudes and behavior. All together, changes in vaccination enhance debates and dialogues about vaccines, and lead to higher awareness and more conscious acceptance.

Major motives in non-acceptance of A/H1N1 flu vaccination: the weight of rational assessment.

Recent efforts of health authorities to promote vaccination against influenza A/H1N1 were met with low compliance rates in most industrialized countries. Here we analyzed the attitudes of the Israeli public towards A/H1N1 vaccination based on a telephone survey conducted several months after the peak of the outbreak. The findings attest to the low uptake of the A/H1N1 vaccine (17%) in Israel, and identify the socio-demographic characteristics associated with non-compliance. In addition, the survey reveals passiveness, fear and distrust as motives leading to non-compliance. Most importantly, the study identified the substantial weight of reflective assessment in the attitude of lay individuals towards the A/H1N1 vaccine. As many as 30% of the non-vaccinated responders provided reasoned arguments for rejecting the vaccine, based mainly on assessment of threat versus actual risk. These observations highlight the need to consider the opinion of the lay public when implementing new vaccination programs.

The involvement of IL-17A in the murine response to sub-lethal inhalational infection with Francisella tularensis.

BACKGROUND: Francisella tularensis is an intercellular bacterium often causing fatal disease when inhaled. Previous reports have underlined the role of cell-mediated immunity and IFNgamma in the host response to Francisella tularensis infection. METHODOLOGY/PRINCIPAL FINDINGS: Here we provide evidence for the involvement of IL-17A in host defense to inhalational tularemia, using a mouse model of intranasal infection with the Live Vaccine Strain (LVS). We demonstrate the kinetics of IL-17A production in lavage fluids of infected lungs and identify the IL-17A-producing lymphocytes as pulmonary gammadelta and Th17 cells. The peak of IL-17A production appears early during sub-lethal infection, it precedes the peak of immune activation and the nadir of the disease, and then subsides subsequently. Exogenous airway administration of IL-17A or of IL-23 had a limited yet consistent effect of delaying the onset of death from a lethal dose of LVS, implying that IL-17A may be involved in restraining the infection. The protective role for IL-17A was directly demonstrated by in vivo neutralization of IL-17A. Administration of anti IL-17A antibodies concomitantly to a sub-lethal airway infection with 0.1xLD(50) resulted in a fatal disease. CONCLUSION: In summary, these data characterize the involvement and underline the protective key role of the IL-17A axis in the lungs from inhalational tularemia.

Next generation OP-bioscavengers: a circulatory long-lived 4-PEG hypolysine mutant of F338A-HuAChE with optimal pharmacokinetics and pseudo-catalytic characteristics.

We have shown previously that conjugation of polyethylene glycol (PEG) chains to recombinant human acetylcholinesterase (rHuAChE) results in the extension of its residence time in the circulation of mice and monkeys [1,2]. By profiling the pharmacokinetic behavior of an array of well-defined hypolysine human mutant AChE molecules following PEGylation, we now determine that the duration of these enzyme forms in the circulation of rhesus macaques correlates with their number of appended PEG moieties, and is influenced by the actual location of the PEG chains at the molecule surface, as well. These findings, which concur with those we have previously established in mice, indicate that a common set of rules dictates the circulatory fate of PEGylated HuAChEs in rodents and non-human primates. In addition to its effect on circulatory residence, PEGylation reduces the ability of the rHuAChE bioscavenger to elicit an immune response in the heterologous mouse animal system. Thus, an inverse relationship between anti-AChE antibody production and PEG loading was observed following repeated administration of the different PEGylated hypolysine human AChEs to mice. We note however, that in rhesus macaques, the essentially homologous (human) AChE does not induce specific anti-AChE antibodies after repeated administration of high doses of the enzyme in its PEGylated form, and even in its non-PEGylated form. Taken together, these findings indicate that PEG acts by veiling enzyme-related epitopes, which would otherwise interact with host circulatory elimination pathways and immune system. The barring of such interactions by obstructive PEGs, confers the enzyme molecule with both extended circulatory residence and mitigated immunogenic properties. Further modulation by incorporation of the F338A mutation into the PEGylated hypolysine rHuAChE enzyme mold, resulted in the generation of an OP-bioscavenger that displayed reduced aging rates and could effectively protect mice against repeated exposure to CW agents. This selected 4-PEG F338A-AChE can serve as a paradigm for new generation OP-bioscavengers, specifically tailored for prophylactic treatment against toxic OP-agents.