'A war of a different kind': local municipalities' experiences in managing the COVID-19 pandemic in Israel-a qualitative study.

OBJECTIVES: In Israel, in 2020, 57/257 local municipalities were part of the Healthy Cities Network (HCN). HCN municipalities have a strong political commitment to health promotion and reducing health inequalities. This research aimed to (1) explore local municipalities' management of the pandemic and (2) assess whether belonging to the HCN impacted this management. DESIGN, SETTING AND PARTICIPANTS: Fourteen municipalities were chosen-seven HCN municipalities, matched to seven non-HCN municipalities. In each municipality, semistructured telephone interviews were conducted with three to four officials. Interviews were recorded, transcribed and analysed using inductive thematic coding, both in general and specifically to compare HCN and non-HCN municipalities. RESULTS: Forty-two interviews were conducted, with five main themes: (1) relationship with the government; with the transference of information to the local municipalities found to be challenging and a strong need for more independence at the local level; (2) contact with residents which was divided into several actions, such as mapping the city population, supporting vulnerable populations and managing volunteers; (3) relationships within the municipality which included a sense of collaboration and community but also a feeling of wear out; (4) difference between the first lockdown compared with following lockdowns; within these themes, no significant differences were found between HCN municipalities and non-HCN municipalities and (5) the role of the Healthy City (HC) coordinator which was critical in several municipalities. They served as brokers, had a pre-existing intersectoral network and held a broader vision of health. CONCLUSIONS: Local municipalities in Israel played an important role in the pandemic response. Municipalities requested a central information source and more independence at the local level. Challenges and responses were similar across municipalities and residents, regardless of their HCN status. However, in some municipalities, the role of the HC coordinator was crucial for the pandemic response due to pre-existing interprofessional and intersectoral networks.

Neighborhood violence and health: the mediating role of loneliness among two ethnic groups in Israel.

Neighborhood violence is associated with poor health, but the mechanisms explaining this association are still unknown. This study seeks to examine the role of loneliness as a mediator of the association between neighborhood violence and health among two ethnic groups (Arabs and Jews) in Israel. A representative survey was conducted among adult residents (1903 Arabs and 2726 Jews) of four Israeli towns: two Arab towns, one Jewish town and one mixed town. A stratified sample of households by residential area, age and sex, was selected in each town. Mediation models were tested using Hayes' PROCESS procedure. Traffic violations, juvenile delinquency and vandalism were reported by more than 50% of Arab residents, relative to about 25-30% of Jewish residents. Loneliness mediated the association between neighborhood violence and health, with a full serial mediation for mental health and a partial serial mediation for physical health. Findings indicate that Arab towns are characterized by severe neighborhood violence. The association between neighborhood violence and physical health was fully dependent on the mediators among both ethnic groups. Future studies should use prospective designs with objective measures of health and violence to validate our cross-sectional findings.

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.

Teacher Training and Engagement in Health Promotion Mediates Health Behavior Outcomes.

School-based health promotion interventions have been shown to lead to measurable changes in the nutrition and physical activity behaviors. This study examines whether the impact of an intervention program on students' healthy eating and physical activity was mediated by teacher training and engagement in health promotion. The trial was conducted in three phases: needs assessment of the baseline survey of teachers, mothers' and children; intervention among seven randomly selected schools that included teacher training in healthy eating and physical activity; and a post-intervention evaluation survey. The SPSS PROCESS for Hayes (Model8) was used to determine moderation and mediation effects. The difference in difference (DID) was calculated for the three main outcomes of the study: eating breakfast daily (DID = 17.5%, p < 0.001); consuming the recommended servings of F&V (DID = 29.4%, p < 0.001); and being physically active for at least 5 days/week (DID = 45.2%, p < 0.001). Schoolchildren's eating breakfast daily was mediated by their teachers' training in nutrition (ß = 0.424, p = 0.002), teachers' engagement (ß = 0.167, p = 0.036), and mothers preparing breakfast (ß = 1.309, p < 0.001). Schoolchildren's consumption of F&V was mediated by teachers' engagement (ß = 0.427, p = 0.001) and knowing the recommended F&V servings (ß = 0.485, p < 0.001). Schoolchildren's physical activity was mediated by their teachers' training in physical activity (ß = 0.420, p = 0.020) and teachers' engagement (ß = 0.655, p < 0.001). Health behavior changes in the school setting including improvements in eating breakfast, consuming the recommended F&V and physical activity was mediated by teacher training and engagement. Effective teacher training leading to teacher engagement is warranted in the design of health-promotion interventions in the school setting.

Social Capital as a Mediator and Moderator in the Association between Loneliness and Health, Israel as a Case Study.

Loneliness has been associated with poor health. Social capital (SC) could possibly prevent the ill effects of loneliness. The study aims to assess the association of loneliness with physical and mental health in four different communities in Israel and study the impact of structural and cognitive SC on that association. A cross-sectional face-to-face survey with 4620 adults in four towns was conducted. The questionnaire included self-rated health (SRH), mental health (MH), loneliness, cognitive and structural SC and socioeconomic characteristics. Logistic regression analysis and mediation and moderation effects were calculated. Loneliness was associated with worse SRH (OR = 0.4-0.5) and worse MH (OR = 2.0-10). Both SC variables were associated with health. However, towns differ in these associations. Structural SC serves as a significant mediator between loneliness and SRH in all towns and is a mediator between loneliness and MH in two towns. Cognitive social capital was a moderator between loneliness and MH in two towns. This study suggests that increasing SC could possibly compensate for loneliness and buffer its effect on health. The study reinforces the need for the performance of separate health profiles to assess possible interventions for each community, as not always can we generalize these results to all communities.

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.

Associations between density and quality of health promotion programmes and built environment features across Jerusalem.

BACKGROUND: Health promotion programmes (HPPs) have the potential to influence individual health, depending on their quality and characteristics. Little is known about how they interact with built environment features and neighbourhood demographics in cities with substantial health disparities. METHODS: Using the European Quality Instrument for Health Promotion (EQUIHP), we assessed the quality of HPPs, operating between 2016 and 2017, among adults aged 18-75 in Jerusalem. Areas were characterized by ethnicity and area socioeconomic level. Health information (body mass index, physical activity level) was obtained from the city profile survey. Geospatial information on the location and length of walking paths and bicycle lanes was obtained. Spearman correlations were used to assess associations among variables. RESULTS: Ninety-three HPPs operating in 349 locations in Jerusalem were identified. Programmes were unevenly distributed across urban planning areas (UPAs), with the highest density observed in the southwest, areas populated mainly by non-orthodox Jewish residents. However, the best performing HPPs based on EQUIHP score were in the north and east UPAs, inhabited primarily by Arab residents. At a neighbourhood level, characteristics of the built environment positively correlated with higher total EQUIHP scores: the ratio between walking lane length to the neighbourhood's population size (r = 0.413, P < 0.001) and length of bicycle lane per population (r = 0.309, P = 0.5). Median EQUIHP score negatively correlated with the number of programmes per neighbourhood size (m2) (r = -0.327, P = 0.006) and neighbourhood average socioeconomic status (SES; r = -0.266, P = 0.027). CONCLUSIONS: Our findings suggest that higher quality HPPs were preferentially located in areas of lower SES and served minority populations in Jerusalem.

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.

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.

A city-wide health promotion programme evaluation using EQUIHP: Jerusalem Community-Academic Partnership (J-CAP).

BACKGROUND: While health promotion initiatives are common, too little is known about their quality, impact and sustainability. Fragmentation between sectors exists and programme evaluation initiatives lack consistency, making comparison of outcomes challenging. METHODS: We used a 'snowball' methodology to detect health promotion programmes (HPPs) in the Municipality of Jerusalem, excluding those in schools. The European Quality Instrument for Health Promotion (EQUIHP) was adapted and used to examine programme quality. The tool was pre-tested among stakeholders, and translated into Hebrew and Arabic between March and December 2017. Trained research assistants collected information on four domains using in-person interviews: (i) compliance with international principles of HPPs, (ii) development and implementation, (iii) project management and (iv) sustainability of programmes. RESULTS: Overall, 93 programmes, including 33 670 participants, were ascertained and evaluated. The majority of HPPs (54.8%) addressed nutrition and physical activity, with 58.1% targeting the non-orthodox Jewish population and 68.8% aimed at both sexes. Cronbach's alpha scores were 0.968 for the entire EQUIHP tool and 0.802, 0.959, 0.918 and 0.718 for the subdomains of Framework, Project Development, Project Management and Sustainability, respectively. Median domain scores were 0.83, 0.61, 0.76 and 0.75. Median score of the entire tool was 0.67. HPPs operated by the Municipality scored lower than those of non-governmental organizations and health providers/organizations in every domain except for Project Management. CONCLUSION: A systematic city-wide evaluation of HPPs is feasible and uncovers strengths and weaknesses, including sustainability and variability by programme provider. Academic-community partnerships may assist planning and improving HPPs in the city.

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.

Determinants of health behavior inequalities: a cross-sectional study from Israel.

Health behaviors are shaped by the opportunities people have; and the choices they make according to these opportunities. Inequality in economic, cultural and social resources causes disparities in health and health behaviors. Jerusalem has a multiethnic structure, mainly made up of Jews and Arabs. Arabs and Ultra-Orthodox Jews are disadvantaged in terms of socio-economic and health indicators. The purpose of this study is to determine the factors associated with three health behaviors: physical activity (PA), fruit and vegetable consumption, and smoking. This cross-sectional study was conducted among 1682 adults from a stratified sample by age, sex and neighborhood from 2011 to 2015, in accordance with the Healthy Cities project. Univariate analyses were conducted by Chi-square test of independence; and multivariate analyses by logistic regression models. Of the total population, 12% do adequate amounts of PA; 17.6% consume adequate amounts of fruits/vegetables; and 19.4% are current smokers. Multivariate analyses indicates for both genders: ethnicity/religion and education level is associated with doing PA; ethnicity/religion, education and income level is associated with fruit/vegetable consumption; and ethnicity/religion, and age is associated with smoking. However, gender significantly modifies the effect of ethnicity/religion for all the three health behaviors. Gender disparities regarding health behaviors are higher among Arabs and Ultra-Orthodox Jews. In similar economic, cultural and social circumstances, men and women have similar health behaviors; and unequal opportunity to education and income creates a vicious gender inequality cycle. Therefore, to reduce health behavior inequalities, besides economic and cultural inequalities, social and gender inequalities should also be reduced.

Feeding young infants with their head in upright position reduces respiratory and ear morbidity.

The influence of feeding position of the infant in the pathogenesis of ear and airway diseases has not been well established. We investigated the influence of instructing mothers to feed their 3-month old infants with their head in an upright position on ear and respiratory morbidity during a one-year follow-up. Mothers of 88 infants were instructed by trained nurses to feed their infants with their head in upright position (intervention group). The control group consisted of 75 mothers of infants of similar socioeconomic background who fed their infants without special instructions. Both groups were followed at Maternal-Child-Health clinics. Feeding position was evaluated at the beginning and the end of the twelve-month study, and parent reported morbidity data of both groups were evaluated at every 3-month's follow-up meeting. Infants from the intervention group were fed at a more upright head position. Parameters of parent reported morbidity evaluated as area under the curve were significantly lower in infants from the intervention group concerning ear diseases, respiratory diseases, prolonged fever episodes, need of bronchodilator inhalations and antibiotic courses compared to the control group. Instructing mothers to feed infants with their head in upright position was accompanied with less morbidity and treatment burden.

A smoke-free medical campus in Jerusalem: data for action.

BACKGROUND: Establishing smoke-free environments is a major component of tobacco control policy. The introduction of a smoke-free policy in medical campuses may serve as a role model for other educational and health institutions but little has been published about their prevalence or impact. In 2012, the Faculty of Medicine at Hebrew University-Hadassah in Jerusalem, Israel launched a smoke-free Medical Campus initiative. This study examined smoking behaviours, cigarette smoke exposure and attitudes towards the smoke-free campus policy among students and employees. METHODS: Using a self-administered questionnaire, data was collected from medical, dental and pharmacy students, as well as employees of the school of pharmacy. We approached the entire target population in 2013 (N = 449), with a response rate of 72.5 % (N = 313). RESULTS: The rate of smoking was 8.3 % (95 % CI 5.5-11.9 %). Most participants reported daily exposure or exposure several times a week to cigarette smoke (65.8 %). Overall, 98.0 % had reported seeing people smoke in open campus areas and 27.2 % indoors. Most participants supported the smoking ban inside buildings (94.2 %) but fewer supported (40.8 %) a complete ban of smoking throughout the campus, including outside areas. Only 18.4 % agreed that a policy prohibiting smoking was unfair to smokers. A multivariable analysis showed that support for a complete ban on smoking on campus was higher among non-smokers than for smokers (OR = 9.5, 95 % CI 2.2-31.5, p = 0.02). CONCLUSIONS: The smoke-free policy does not have total compliance, despite the strong support among both students and employees for a smoke-free medical campus. The data collected will assist policy makers move towards a total smoke-free medical campus and will aid tobacco control efforts in Israel and other countries.

Disparities in assessments of asthma control between children, parents, and physicians.

OBJECTIVE: Assessment of asthma control in children by physicians, patients and their parents was compared, assuming parents may underestimate symptoms in asthmatic children and exploring whether physicians tend to agree with them. DESIGN: Asthma control perception was assessed in 4- to 11-year-old asthmatic children and their parents, using C-ACT, during 2011-2012. Pediatric pulmonologists used GINA guidelines for their assessment; pediatricians, not having spirometry, used the information given in addition to physical examination. The C-ACT scores given by the children and their parents were further analyzed separately, and compared with their physicians' assessment. Statistical methods, which also measured possible influence of different variables, included kappa, Chi-square, linear-by-linear association, McNemar test and logistic regression. PATIENT SELECTION: The study comprised 354 parents and children aged 4-11 years with moderate-severe asthma; 129 (36.4%) were treated by 23 pediatricians; 225 (63.6%) by 11 pediatric pulmonologists. RESULTS: The C-ACT was generally found valid in assessing asthma control (P < 0.001; κ 0.529; CI 0.441, 0.617) and showed that in 229/354 (53%) of children the asthma was uncontrolled. Nevertheless, of the 229 children who indicated their asthma was uncontrolled, 124 (54.1%) of their parents (κ 0.245; CI 0.15, 0.34) and 96 (41.9%) of their physicians believed it to be controlled (κ 0.331; 0.24, 0.43). Comparing the physician-child discordance vis-à-vis the parents, the significant difference was when 96/229 children (41.9%) and 34/126 parents (27.0%) indicated the asthma was uncontrolled while the physician determined it controlled (OR 1.95; 1.19, 3.24). There were no significant differences between pediatric pulmonologists and pediatricians. CONCLUSIONS: In addition to increasing awareness of parents to symptoms in their asthmatic children, physicians should question the child appropriately, as well as using the children's responses to C-ACT as an information source for properly assessing asthma control.

[School health services: parents' and teachers' opinions].

BACKGROUND: Although School Health Services (SHS) are an efficient way of providing health care to children and adolescents, in recent years they have been curtailed in Israel. OBJECTIVES: To study parents' and teachers' knowledge about the content of SHS, their use and importance, and their preferred way of delivering these services. METHODOLOGY: From December 2006 - January 2007, teachers (n=304) of 2nd-12th-grade pupils and the pupils' parents (n=808) in state schools of the Hebrew education system (both secular and religious) were interviewed by phone. Parents were located by random dialing (response rate 63%), and the teachers from a Ministry of Education list (response rate 70%). RESULTS: About 70% of parents and teachers knew that SHS provide immunizations; 70% and 80% respectively, reported they provided first aid. Only 8% of the parents and 13% of the teachers reported that a nurse came at least three days a week to the school and most of them preferred that the nurse should come every day. Most respondents said that the SHS did important work. About a third of parents and 40% of teachers preferred that all health care services be provided in the schools by doctor and nurse; 40% of parents and teachers wanted the nurse to provide counseling and that the rest of SHS content be provided by the regular primary health care providers; 20% of parents and 14% of teachers preferred other options. CONCLUSIONS: Parents and teachers rate SHS as important and are prepared to consider alternatives for their delivery. This should be considered when re-organizing the SHS.

Implementation of the Healthy Cities' principles and strategies: an evaluation of the Israel Healthy Cities network.

The Israel network of Healthy Cities has been operating since 1990, and the first evaluation of its performance was carried out in 2004. The objectives were to evaluate the level of implementation of the 'Healthy Cities' principles and strategies in each network city and to assess the contribution of the network to its member cities. Coordinators of 18 active healthy cities participated in the study by completing a questionnaire with the aid of key informants in the municipality. The survey covered six dimensions of Healthy Cities' principles and strategies, and each was analyzed as a sum of scores of separate components and measures, converted to a 0-10 scale. Cities were found to differ in their performances. The dimension of intersectoral collaboration received the highest mean score (8.0 +/- 1.6), while the environmental protection dimension received the lowest one (4.5 +/- 2.2). Time investment by the coordinator of > 20 h a week is significantly associated with a higher score on the management dimension (7.8 versus 4.4 where the coordinator invests 20 h a week or less, P < 0.001). Previous work experience in either public health or community work was associated with higher scores of the community participation and intersectoral partnership dimensions (6.9 versus 5.2 and 8.5 versus 6.8, respectively, P < 0.05). Political support was associated with the city equity policy dimension (8.1 versus 4.8 in cities with high versus low political support, P < 0.01). Coordinator's participation in the network's activities is associated with better scores on all the dimensions except for environmental protection. It appears that political commitment and support is a significant enabling condition, which, together with the capacity building of the coordinator, may lead to better implementation of Healthy Cities' policy. Environmental issues should be incorporated into training sessions to enhance the environmental protection dimension.