1. Clalit Health Services
Diane Levin-Zamir, MPH, CHES
Director, Department of Health Education and Promotion
Clalit Health Services

2. Defining the terms
The Scope of the Issue
What is the Price?
When Culture Meets Culture
Promising Initiatives
Recommendations
Epilogue

3. 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

4. Health Empowerment To define problem/situation
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

5. Foundations of Empowerment
Health Information
Self Efficacy
Mechanism for Change

6. 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

7. Health Literacy
The degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions.
Healthy People, 2010.

8. Health Literacy Typology
Functional - Communication of Information
Interactive – Personal Skills
Critical – Community Empowerment
Nutbeam, Health Promotion International 2000

9. Ethnic Minorities
Migrants
Immigrants
Co-existing cultures

10. What is the Model? Health Literacy Empowerment Health Empowerment

11. Health
Empowerment
Health Literacy

12. What is the Price? Health Disparities and Inequity
Use of Valuable Resources
Self Esteem and Shame

13. 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,

14. Inadequate health literacy increases with age…%
The prevalence of inadequate health literacy steadily increases with age.
Of note, patients were screened for dementia in this study and those with any signs of dementia excluded.
We do not know why this happens. There are many theories. Many adults in America over 80 grew up in the Depression years and never completed 8th grade and may not have ever had these sophisticated literacy skills. Or this may be a “use it or lose it” phenomenon. Older individuals may read less as they age and spend more time in passive activities such as watching TV.
While we do not know why this happens, we do know that those with the greatest need to read and understand health care information (those taking multiple medications for multiple conditions) have the poorest skills and the greatest burden of low health literacy.
Transition: There has been a substantial amount of research on literacy in the last decade……
Reference: Gazmararian JA, Baker DW, Williams MV. Health literacy among Medicare enrollees in a managed care organization. JAMA, 1999; 281:
Gazmararian, et al. JAMA 1999

16. 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,

17. Shame and Self-Esteem
40% of low literacy people have feelings of shame;
63% never told a spouse;
53% never told children

19. Past experience with the health system
Factors Determining Empowerment
and Health Literacy
Past experience with the health system
Complexity of information
Cultural background
Age
Avenues of message communication

20. Foster’s Model of Medical Systems
In every culture there is a notion of
Cause of disease
Symptoms
Diagnosis
Treatment

21. Cause (Specific or Non-specific)
Western
Medicine
Cause (Specific or Non-specific)
Symptom
Diagnosis
Treatment/Cure
Time

22. Socio-Cultural Identity
Traditional Medicine
Cause
Socio-Cultural Identity
Diagnosis
Symptom
Treatment/Cure

23. Strategies to enhance health literacy…
Module 3
Create a shame-free environment
Enhance assessment techniques
Improve interpersonal communication with patients
Create and use patient-friendly written materials.
Facilitator: Use this slide to remind participants where they are in the course of the workshop, if appropriate. You may choose not to use this slide if it is redundant.
Note about special effects: Most of the slides in this presentation are set to “build”. This means that you need to click to see each bullet point on the slide. The idea is to cover one point at a time and then click to advance to the next point. We suggest that you rehearse this in the “Slide Show” view so that you feel comfortable with it.
The previous module (Module 2) addressed strategies for creating a shame-free environment, including ways to enhance assessment techniques with your patients.
In this module our focus will be on the strategies related to verbal and written communication…..

24. Help Your Patients Understand
Health Literacy:
Help Your Patients Understand
Module 1:
Overview of Health Literacy
NOTE TO FACILITATOR: Special directions or ideas for the facilitator, like these, are in italics. The non-italicized notes are examples of things to say about the slide. As a facilitator, you should be familiar with the notes for each slide. However, the notes are not meant to be read word for word. Practice out loud in your own words until you are comfortable. We encourage you to add your own stories and experiences. Please follow the suggested times as closely as possible.
(0:00)
Welcome everyone to the session. Introduce yourself and other faculty, as appropriate.
Check that each person has a Participant Guide and explain that they will use it during the workshop as a reference.
Check that each person has a copy of the Power Point slides (3 per page) and explain they can use it to take notes.
Explain: This workshop is part of a series developed by the AMA Foundation to increase clinician awareness of health literacy issues.
Module 3: (Total Time = 60 min.) (For facilitator information only.)
0:00 Introduction….Slides 1-6 (4 min.)
0:04 NALS….Slides 7-9 (4 min.)
0:08 Activity…..Slides (3 min.)
0:11 Implications….Slides (10 min.)
0:21 Video…..Slide 27 (23 min.)
0:44 Video Discussion….Slide 28 (5 min.)
0:49 Barriers….Slides (5 min.)
0:54 Guiding Priniciples/Strategies/What other docs have tried….Slides (3 min.)
0:57 Resources/Evaluations….Slides (3 min.)
0:60 End
Presented by:
American Medical Association Foundation & American Medical Association
10/03

25. Help Your Patients Understand
Health Literacy:
Help Your Patients Understand
Module 2:
Creating A Shame-Free Environment
NOTE TO FACILITATOR: Special directions or ideas for the facilitator, like these, are in italics. The non-italicized notes are examples of things to say about the slide. As a facilitator, you should be familiar with the notes for each slide. However, the notes are not meant to be read word for word. Practice out loud in your own words until you are comfortable. We encourage you to add your own stories and experiences. Please follow the suggested times as closely as possible.
(0:00)
Welcome everyone to the session. Introduce yourself and other faculty, as appropriate.
Check that each person has a Participant Guide and explain that they will use it during the workshop as a reference.
Check that each person has a copy of the Power Point slides (3 per page) and explain they can use it to take notes.
Explain: This workshop is part of a series developed by the AMA Foundation to increase clinician awareness of health literacy issues.
Module 3: (Total Time = 75 min.) (For facilitator information only.)
0:00 Introduction….Slides 1-3 (2 min.)
0:02 The shame of low literacy….Slides 4-6 (3 min.)
0:05 Where to start/Red flags…..Slides (5 min.)
0:10 Social history/Shame-free communication….Slides (5 min.)
0:15 Medication Reviews…..Slides (15 min.)
0:30 Shame-Free Environment/”Identifying Barriers” Activity ….Slides (15 min.)
0:45 Staff Involvement….Slide (5 min.)
0:50 Activity: “Designing a Shame-Free Environment”…Slide 28 (20 min.)
0:70 Learning Review/Resources/Evaluations….Slides (5 min.)
0:75 End
Presented by:
American Medical Association Foundation & American Medical Association
10/03

26. Help Your Patients Understand
Health Literacy:
Help Your Patients Understand
Module 3:
Enhancing Patient Interaction and Communication
NOTE TO FACILITATOR: Special directions or ideas for the facilitator, like these, are in italics. The non-italicized notes are examples of things to say about the slide. As a facilitator, you should be familiar with the notes for each slide. However, the notes are not meant to be read word for word. Practice out loud in your own words until you are comfortable. We encourage you to add your own stories and experiences. Please follow the suggested times as closely as possible.
(0:00)
Welcome everyone to the session. Introduce yourself and other faculty, as appropriate.
Check that each person has a Participant Guide and explain that they will use it during the workshop as a reference.
Check that each person has a copy of the Power Point slides (3 per page) and explain they can use it to take notes.
Explain: This workshop is part of a series developed by the AMA Foundation to increase clinician awareness of health literacy issues.
Module 3: (Total Time = 60 min.) (For facilitator information only.)
0:00 Introduction….Slides 1-5 (5 min.)
0:05 Step 1….Slides 6 (3 min.)
0:08 Step 2…..Slides 7-8 (3 min.)
0:11 Step 3….Slides (13 min.)
0:24 Step 4…..Slide 13 (4 min.)
0:28 Step 5….Slides (5 min.)
0:33 Review/Activity: Putting It All Together….Slides (22 min.)
0:55 Key Learnings/Resources/Evaluations….Slides (5 min.)
0:60 End
Presented by:
American Medical Association Foundation & American Medical Association
10/03

27. “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

28. Population in Israel by Culture
Druze
Christian 1 . 64 %
Other
Arabs 2 . 34 % 1 . 77 %
Moslem
Arabs 14 . 80 %
Jews
living in
Israel more
Jews
than 10
New
years
Immigrants 63 . 43 % 16 . 01 %

29. Clalit Health Services
3.6 million members, 30,000 workers
1,350 primary and specialized care clinics
14 hospitals
416 pharmacies
40 diagnostic imaging centers
67 laboratory centers
83 physiotherapy units
30 occupational therapy units
87 diet & nutrition consultation units
22 mental health clinics
20 alternative medicine clinics
70 dental clinics

30. Hospital Primary Care Services Public Private Sector NGOs
Community
Organizations
NGOs

31. “Refuah Shlemah”
A Cross-Cultural Program for Promoting Health Among Ethiopian Immigrants in the Primary Care Setting
Since 1984, nearly 80,000 Ethiopians have immigrated to Israel
Significant adjustment problems due to cultural disparities exist particularly regarding health and health care; navigation of the primary health care system.

32. “Refuah Shlemah”
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

33. The Major Findings The program was effective in:
Improving physician-patient relations,
Improving availability and accessibility of medical services and
Improving the ability to navigate the health system
No significantly increase in expenditure on services was incurred.
Brookdale Institute, 2002

34. Second Phase of Evaluation
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.
Brookdale Institute, 2002

35. Conclusion
A health mediator in primary care clinics can significantly bridge the communication gap in a multi-cultural setting supporting and empowering an immigrant population.
Specific improvements for asthmatics and diabetes in the present ecclectic model showed initial improvement.
A model is needed in which the health mediators concentrate specifically on these groups with special health needs.

36. Diane Levin-Zamir, MPH, CHES, Dr. Margalit Goldfracht, MD,
Community Intervention for Diabetes Control Among Adult Arab Population
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

37. Prevalence of Diabetes
Basic Facts
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

38. The high prevalence of diabetes among the Arab population in Israel has been attributed to change in lifestyles including physical activity and nutrition.

39. Complications due to diabetes are also high due to cigarette smoking among males.

40. 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.

41. 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.

42. The national initiative included 4 main stages
1.Establishment 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.

43. 2. Development of culturally appropriate health promotion tools on the topics of eating habits, physical activity, smoking cessation, self-monitoring and self-care.

44. 3. Program Implementation
The program, conducted from , 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.

45. Program Components
Lectures and Discussions with Community Health Professionals

46. Individual Lifestyle Instruction

47. Participation
According to the chronic disease register, Clalit treats 170,000 diabetics
9 % of adult diabetics participated in the health promotion program

48. 4. Evaluation
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.

49. Attributed Contribution of the Event

50. Reported Behavior Change as a Result of Participation in the Program

51. N= 154

52. Perceived difficulty in leading a normal life

53. Expressed need for in-depth community programs, above and beyond community events.

54. The main conclusions of the initiative:
The Arab community in Israel is very interested in ongoing health promotion interventions regarding lifestyle and chronic disease prevention.
The primary care clinic is an appropriate setting for health promotion events particularly regarding chronic disease prevention.
Individual lifestyle counseling should be added to the community initiative as well as in-depth behavior change workshops.

55. All of the conclusions have been applied in the 2004 national diabetes program strategy, emphasizing self-management and maintenance.