Do differences exist in cross-cultural caregivers' respect for the autonomy/dignity of people with dementia? Real-time field observations in nursing homes.

BACKGROUND: Although published studies have examined the perceptions of caregivers who are attending to older adults with dementia concerning the values of human dignity and/or autonomy in institutional settings, none have explored the possible differences in actual behavior that relates to these values for caregivers from diverse ethno-cultural backgrounds. AIMS: Explore how caregivers with varied cultural backgrounds may differ in their real-time behavior regarding the autonomy and dignity of older adults with dementia and thereby determine whether that real-time behavior reveals new aspects of respect and disrespect for both the autonomy and dignity of those older adults. RESEARCH DESIGN AND METHODS: A qualitative research based on non-participatory observations, was meticulously recorded using a written journal and a rigorous microanalysis to analyze the collected data. We made 58 shift-based observations (morning and evening) of 29 caregivers from 3 ethno-cultural groups working in 3 nursing homes in Israel. These groups included Israeli-born Jews (Sabras), Israeli Arab-Muslims (Arabs), and immigrants from the Former Soviet Union (IFSU). RESULTS: (1) IFSU caregivers demonstrated more respect for autonomy and dignity, but also demonstrated disrespect for these values. (2) the main difference between the IFSU caregivers and other caregiver groups pertained to respect for their autonomy. The main specific facets of autonomy where IFSU caregivers surpassed their colleagues were information provision and persuasion. (3) toward both autonomy and dignity of these older adults, previously unaccounted for in the models we used, were discovered among the varied groups of caregivers, with only minor gaps between these groups. DISCUSSION AND IMPLICATIONS: This study-the first of its kind to focus on the real-time behaviors of caregivers from diverse ethno-cultural backgrounds-reveals the potential effects of culture on applying practices related to dignity and autonomy during daily care. The findings may have important implications for caregiver training in multicultural societies.

Reasons for and insights about HPV vaccination refusal among ultra-Orthodox Jewish mothers.

BACKGROUND: Vaccination against human papillomavirus (HPV) is a pivotal tool for preventing a significant cause of cervical cancer. One particular culturally recognized context associated with negative attitudes toward the HPV vaccine is the religiousness of parents. However, relatively speaking, there remains a scarcity of studies that have focused specifically on religious groups, especially non-Christian groups. PURPOSE: To better understand the basis for members of an ultra-Orthodox Jewish community to object to the HPV vaccine and how such objections can and cannot be reduced, thereby improving cultural competence-namely, the cultural understanding and ethical addressing of HPV vaccination refusal. METHODS: This qualitative study conducted semi-structured interviews with ten Israeli ultra-Orthodox mothers who are opposed to administering the HPV vaccine to their daughters. The content analysis addressed these results and extracted the major issues arising from these particular interviews. RESULTS: Four main novel insights were found pertaining to the negative stance toward HPV vaccination among mothers in an ultra-Orthodox Jewish community: (a) lack of knowledge about the HPV vaccine is not part of the reasoning against it; (b) rabbinical authority might have a lesser influence than expected for the moderation of HPV vaccine refusal; (c) complicated viewpoints regarding childhood vaccination may be the larger non-moderating context for HPV vaccination refusal; and (d) cultural competence is important for the ability to change the negative attitudes toward HPV vaccination. CONCLUSIONS: The study may improve cultural competence regarding HPV vaccination and contribute to decreasing objections to the HPV vaccine in ultra-Orthodox communities.

To debate or not to debate? Examining the contribution of debating when studying medical ethics in small groups.

BACKGROUND: Medical ethics is a significant learning topic for medical students, and often studied through small group learning (SGL) to encourage critical thinking (CT) and tolerance for ambiguity, both considered particularly important when coping with medical ethics dilemmas. However, a previous study about CT and tolerance for ambiguity in medical ethics SGL produced mixed results. Debating is a pedagogical tool known to enhance CT but never used before in medical ethics learning. This paper examines whether the use of debate may enhance medical ethics SGL by contributing to the CT of students and their tolerance of ambiguity. METHODS: Intervention study using the qualitative microanalysis research method, based on videotaped observations that were analyzed through Kamin's model of CT and non-CT. The study was conducted at Bar-Ilan University's Faculty of Medicine in the years 2017-2019. Forty-four students and 4 facilitators participated, equally split between 4 small groups. Twenty-four medical ethics SGL sessions at the beginning and end of the year were videotaped, 2 groups - with no intervention, 1 group included partial debate intervention and 1 group fully used debates. Results were compared for changes in CT and ambiguity before and during the intervention period. RESULTS: The full intervention (debating) group had the highest increase in utterances reflecting CT, thus actually doubling the median number of CT utterances at the end of the year in comparison to the median number at the beginning of the year. In a similar manner, the debate group exhibited the only group in which there was an increase in the median utterances of tolerance to ambiguity. Nevertheless, the debate group also exhibited the largest increase in the median non-CT utterances and the lowest decrease of intolerance to ambiguity, when comparing the end of the year to the beginning of the year sessions. CONCLUSIONS: Debating is an important enhancement to SGL in medical ethics; however, it does not guarantee a complete absence of non-CT.

Healthcare Provider's Culture and Its Impact on End-Of-Life Discussions.

To examine the openness to communication in end-of-life care of three major ethno-cultural groups of healthcare providers (HCPs) (in Israel: Israeli Arabs (Arabs), Israeli Jews (Sabras), and Immigrants from the Soviet Union (Russians). An anonymized set of three questionnaires was distributed among 240 physicians and nurses (HCPs) from the three ethno-cultural groups, yielding a response rate of 91% (and 82% when including hospital division). Sabra ethno-cultural group was more open to communicating about and relating to end-of-life with terminally ill patients. While recent exposure to death and external locus of control decreased the effect of ethno-cultural background, the latter remained statistically significant. Gender, age, marital status, and specialty were not found to be influential factors.This research highlights the importance of increasing awareness and responses to the effects of HCPs' culture on end-of-life care as varied cultures and medico-legal requirements come into contact in society.

What can European Principlism Teach about Public Funding of IVF? The Israeli Case.

Fertility treatments, which are part of "assisted reproductive technologies" (ART), mainly undertaken through in vitro fertilization (IVF), offer the opportunity to infertile couples to conceive. IVF treatments are undertaken in Israel in significantly higher numbers than in the rest of the world. As such, Israel provides an important case-in-point for examining the validity of the actual claims used to justify the more generous public funding of IVF treatments at the policy level. In this article, we utilize an analytical philosophy approach to conduct this examination. First, we highlight two fundamental concepts that were used at the Israeli public policy level in order to justify the generous public funding of IVF treatments. These concepts are "emotional vulnerability" and the "worthlessness of the childless," where the latter emphasizes the infinite value of children. Then, by applying the perspective of the European model of Bioethical Principlism, and focusing the attention to these two concepts we show that these justifications are invalid. Specifically, it is suggested that these concepts are on the one hand both relying on and expressing the principles of vulnerability, dignity, and integrity; yet on the other hand, these concepts are also undermining the very principles of bioethics they are supposed to express and rely on. Based on this suggested criticism, we offer two "take home" messages informed by our analysis of the Israeli case, but reaching beyond it.

Challenges to effective and autonomous genetic testing and counseling for ethno-cultural minorities: a qualitative study.

BACKGROUND: The Arab population in Israel is a minority ethnic group with its own distinct cultural subgroups. Minority populations are known to underutilize genetic tests and counseling services, thereby undermining the effectiveness of these services among such populations. However, the general and culture-specific reasons for this underutilization are not well defined. Moreover, Arab populations and their key cultural-religious subsets (Muslims, Christians, and Druze) do not reside exclusively in Israel, but are rather found as a minority group in many European and North American countries. Therefore, focusing on the Arab population in Israel allows for the examination of attitudes regarding genetic testing and counseling among this globally important ethnic minority population. METHODS: We used a qualitative research method, employing individual interviews with 18 women of childbearing age from three religious subgroups (i.e., Druze, Muslim, and Christian) who reside in the Acre district, along with focus group discussions with healthcare providers (HCPs; 9 nurses and 7 genetic counselors) working in the same geographical district. RESULTS: A general lack of knowledge regarding the goals and practice of genetic counseling resulting in negative preconceptions of genetic testing was identified amongst all counselees. Counselors' objective of respecting patient autonomy in decision-making, together with counselees' misunderstanding of genetic risk data, caused uncertainty, frustration, and distrust. In addition, certain interesting variations were found between the different religious subgroups regarding their attitudes to genetic counseling. CONCLUSIONS: The study highlights the miscommunications between HCPs, particularly counselors from the majority ethno-cultural group, and counselees from a minority ethno-cultural group. The need for nuanced understanding of the complex perspectives of minority ethno-cultural groups is also emphasized. Such an understanding may enhance the effectiveness of genetic testing and counseling among the Arab minority group while also genuinely empowering the personal autonomy of counselees from this minority group in Israel and other countries.

Reprogenetics, reproductive risks and cultural awareness: what may we learn from Israeli and Croatian medical students?

BACKGROUND: Past studies emphasized the possible cultural influence on attitudes regarding reprogenetics and reproductive risks among medical students who are taken to be "future physicians." These studies were crafted in order to enhance the knowledge and expand the boundaries of cultural competence. Yet such studies were focused on MS from relatively marginalized cultures, namely either from non-Western developing countries or minority groups in developed countries. The current study sheds light on possible cultural influences of the dominant culture on medical students in two developed countries, potentially with different dominant cultures regarding reprogenetics and reproductive risks: Israel and Croatia. METHODS: Quantitative-statistical analyses were employed, based on anonymous questionnaires completed by 150 first year medical students in Israel and Croatia. The questionnaires pertained to the knowledge and attitudes regarding genetics, reproduction and reproductive risks. These questionnaires were completed before the students were engaged in learning about these topics as part of the curriculum in their medical school. RESULTS: Substantial differences were revealed between the two groups of medical students. Israeli medical students were less tolerant regarding reproductive risks and more knowledgeable about genetics and reproductive risks than Croatian medical students. For example, while nearly all Israeli medical students (96%) disagreed with the idea that "Screening for reproductive risks in prospective parents is wrong," less than 40% of their Croatian counterparts shared a similar stance. Similarly, all (100%) Israeli medical students correctly observed that "A carrier of a recessive genetic disease actually has the disease" was wrong, as opposed to only 82% of Croatian students. CONCLUSIONS: By linking applicable theoretical literature to these findings, we suggest that they may reflect the hidden influence of the dominant culture in each country, disguised as part of the "culture of medicine." Acknowledging and learning about such influence of the dominant culture, may be an important addition to the training of medical students in cultural competence, and specifically their cultural awareness. Such an acknowledgement may also pave the road to drawing the attention of existing physicians regarding a less known yet an important aspect of their cultural competence, insofar as the cultural awareness component is concerned.

What Can Be Learned from Health-Related Tensions and Disparities in Ultra-Orthodox Jewish Families?

Promoting healthy lifestyle from early childhood is a key objective in public health, yet health behaviors are often culturally driven, especially in closed-religious communities. This study aims to reveal key cultural-religious aspects of attitudes and behaviors regarding lifestyle in one such closed community-the ultra-orthodox Jewish community. In-depth interviews were conducted with 20 participants: religious leaders, educational figures, psycho-medical professionals from two major ultra-orthodox communities in Israel. A thematic analysis was used to reveal key themes in the interviews. We found tensions between conflicting themes in the parenting, nutrition and physical activity domains, while the sleep domain illustrated cultural solution for a tension. By illuminating the perceptional components of lifestyle, the study contributes to better foundations of health promotion in closed-religious communities.

"I Treat Him as a Normal Patient": Unveiling the Normalization Coping Strategy Among Formal Caregivers of Persons With Dementia and Its Implications for Person-Centered Care.

INTRODUCTION: Currently, 47 million people have dementia, worldwide, often requiring paid care by formal caregivers. Research regarding family caregivers suggests normalization as a model for coping with negative emotional outcomes in caring for a person with dementia (PWD). The study aims to explore whether normalization coping mechanism exists among formal caregivers, reveal differences in its application among cross-cultural caregivers, and examine how this coping mechanism may be related to implementing person-centered care for PWDs. METHOD: Content analysis of interviews with 20 formal caregivers from three cultural groups (Jews born in Israel [JI], Arabs born in Israel [AI], Russian immigrants [RI]), attending to PWDs. RESULTS: We extracted five normalization modes, revealing AI caregivers had substantially more utterances of normalization expressions than their colleagues. DISCUSSION: The normalization modes most commonly expressed by AI caregivers relate to the personhood of PWDs. These normalization modes may enhance formal caregivers' ability to employ person-centered care.

Autonomy and dignity of patients with dementia: Perceptions of multicultural caretakers.

BACKGROUND: A key message in the World Health Organization's report on dementia emphasizes the need to improve public and professional attitudes to dementia and its understanding, while acknowledging the fact that the workforce in dementia care is becoming increasingly diverse culturally. OBJECTIVES: To explore possible differences among formal caretakers from varied cultural background in their attitudes toward the autonomy and human dignity of patients with dementia. RESEARCH DESIGN: Semi-structured interviews and content analysis, utilizing two fictional vignettes for eliciting caretakers' attitudes toward dignity and autonomy of their patients. Participants and context: A total of 20 formal caretakers of patients with dementia from three different cultural groups in Israel ("Sabras," "Arabs," and "Russians"), working in nursing homes and a hospital. Ethical consideration: Approvals of relevant research ethics committees were obtained and followed. FINDINGS: In comparison with the other groups, most Arab caretakers offer markedly richer perceptions of human dignity and autonomy. Their human dignity's conceptualization emphasizes "person-centered approach," and their perception of patients' autonomy includes provision of explanations and preservation and encouragement of independence. DISCUSSION: The differences found in the attitudes toward the meaning of autonomy and human dignity between the Arab caretakers and the other caretakers stand in contrast to previous studies regarding human dignity, emphasizing the common nature of these attitudes. Offering a linkage (theoretical and empirical) between the Arab perceptions of dignity and autonomy, the study strengthen and further the importance attributed in existing literature to person-centered care in enhancing the quality of care for patients with dementia. CONCLUSION: The conceptualization of human dignity may vary among different cultural groups. It may also influence the extent to which the caretaker holds a full-fledged perception of the patients' autonomy.

Human dignity and autonomy in the care for patients with dementia: differences among formal caretakers from various cultural backgrounds.

OBJECTIVES: To explore whether gaps exist between caretakers from different ethno-cultural groups (Israeli-born Jews [Sabras], Israeli Arabs [Arabs], and migrants from Russia [Russians]) regarding their perceptions of autonomy and human dignity of patients with dementia. DESIGN: A mixed-methods research scheme was used, comprised of qualitative and quantitative methods, utilizing semi-structured interviews and self-reported questionnaires. Twenty formal caretakers participated in the qualitative portion, and approximately 200 caretakers were included in the quantitative portion. All participants were recruited from three nursing homes and one hospital in the Galilee region (Israel). RESULTS: The qualitative portion of the study yielded eight themes encapsulated in the concept of autonomy and ten themes entailed within human dignity, in the context of care for patients with dementia. By utilizing these themes in the quantitative portion, substantial differences in nursing homes were found in the attitudes to autonomy and dignity of patients with dementia between Russian and Arab as well as Sabra caretakers (index score for autonomy: 2.97, 4.07, and 4, respectively; index score for dignity: 3.17, 4.1, and 4.07). A multi-variable regression, focusing on caretakers from nursing homes, showed the most significant influencing variables on the indexes of autonomy and dignity were ethno-culture Arab/Russian (0.84, 0.62) and the patient's family (0.29, 0.30). Regarding the autonomy index, being a female caretaker also had a significant influence (0.24). In the hospital, no influence emerged for the ethno-culture variables, and neither type of institution showed any influence of religion or religiousness as well as societal or community norms. CONCLUSIONS: Contrary to past research, in nursing homes, significant differences were found between certain ethno-cultural groups (Arabs and Russians) regarding their stance toward the dignity and autonomy of patients with dementia. Arab caretakers' fostering of more encompassing conceptions of dignity and autonomy, irrespective of institutional setting, provides better grounds for person-centered care.

Correction to: More than visual literacy: art and the enhancement of tolerance for ambiguity and empathy.

CORRECTION: Following publication of the original article [1], the authors reported that the corrections they had requested for Table 3 had not been implemented, and that the title for Table 2 included an unnecessary indication for remark/reference ("a" in a superscript font) at the end of the title. Also, the affiliation of the authors had not been clearly stated: it should read 'Faculty of Medicine, Bar-Ilan University, Safed Campus, P.O.Box 1589, Safed, Israel'.

More than visual literacy: art and the enhancement of tolerance for ambiguity and empathy.

BACKGROUND: Comfort with ambiguity, mostly associated with the acceptance of multiple meanings, is a core characteristic of successful clinicians. Yet past studies indicate that medical students and junior physicians feel uncomfortable with ambiguity. Visual Thinking Strategies (VTS) is a pedagogic approach involving discussions of art works and deciphering the different possible meanings entailed in them. However, the contribution of art to the possible enhancement of the tolerance for ambiguity among medical students has not yet been adequately investigated. We aimed to offer a novel perspective on the effect of art, as it is experienced through VTS, on medical students' tolerance of ambiguity and its possible relation to empathy. METHODS: Quantitative method utilizing a short survey administered after an interactive VTS session conducted within mandatory medical humanities course for first-year medical students. The intervention consisted of a 90-min session in the form of a combined lecture and interactive discussions about art images. The VTS session and survey were filled by 67 students in two consecutive rounds of first-year students. RESULTS: 67% of the respondents thought that the intervention contributed to their acceptance of multiple possible meanings, 52% thought their visual observation ability was enhanced and 34% thought that their ability to feel the sufferings of other was being enhanced. Statistically significant moderate-to-high correlations were found between the contribution to ambiguity tolerance and contribution to empathy (0.528-0.744; p ≤ 0.01). CONCLUSIONS: Art may contribute especially to the development of medical students' tolerance of ambiguity, also related to the enhancement of empathy. The potential contribution of visual art works used in VTS to the enhancement of tolerance for ambiguity and empathy is explained based on relevant literature regarding the embeddedness of ambiguity within art works, coupled with reference to John Dewey's theory of learning. Given the situational nature of the tolerance for ambiguity in this context, VTS provides a path for enhancing ambiguity tolerance that is less conditioned by character traits. Moreover, the modest form of VTS we utilized, not requesting a significant alteration in the pre-clinical curricula, suggests that enhancing the tolerance of ambiguity and empathy among medical students may be particularly feasible.

Process factors facilitating and inhibiting medical ethics teaching in small groups.

PURPOSE: To examine process factors that either facilitate or inhibit learning medical ethics during case-based learning. METHODS: A qualitative research approach using microanalysis of transcribed videotaped discussions of three consecutive small-group learning (SGL) sessions on medical ethics teaching (MET) for three groups, each with 10 students. RESULTS: This research effort revealed 12 themes of learning strategies, divided into 6 coping and 6 evasive strategies. Cognitive-based strategies were found to relate to Kamin's model of critical thinking in medical education, thereby supporting our distinction between the themes of coping and evasive strategies. The findings also showed that cognitive efforts as well as emotional strategies are involved in discussions of ethical dilemmas. Based on Kamin's model and the constructivist learning theory, an examination of the different themes within the two learning strategies-coping and evasive-revealed that these strategies may be understood as corresponding to process factors either facilitating or inhibiting MET in SGL, respectively. CONCLUSIONS: Our classification offers a more nuanced observation, specifically geared to pinpointing the desired and less desired process factors in the learning involved in MET in the SGL environment. Two key advantages of this observation are: (1) it brings to the forefront process factors that may inhibit and not merely facilitate MET in SGL and (2) it acknowledges the existence of emotional and not just cognitive process factors. Further enhancement of MET in SGL may thus be achieved based on these observations.

Dignity and autonomy in the care for patients with dementia: Differences among formal caretakers of varied cultural backgrounds and their meaning.

BACKGROUND: A key message in the World Health Organization report on dementia (2012) emphasizes this disease as a top priority in public health and the need to improve professional attitudes to patients with dementia, while acknowledging that the workforce in dementia care is becoming increasingly diverse culturally. AIMS: To trace whether there are substantial gaps between formal caretakers from different cultural groups (Israeli born Jews [Sabras], Israeli Arabs [Arabs] and migrants from Russia [Russians]) regarding their stances on the human dignity and autonomy of patients with dementia, as well as understand the meaning of these gaps. DESIGN & METHOD: quantitative analysis utilizing questionnaires that were filled-out by approximately 200 caretakers from the different cultural groups, working in a nursing home or a hospital. RESULTS: In nursing homes, substantial differences were found in the attitudes to human dignity and autonomy of patients with dementia between Russian and Arab as well as Sabra caretakers. In the hospital, there was no influence for the ethno-culture variable on dignity or autonomy. CONCLUSION: Contrary to past research, in nursing homes, significant differences were found between certain ethno-cultural groups (Arabs and Russians) regarding their stance towards the dignity of patients with dementia. Arab caretakers hold a conception of dignity and autonomy that resonates strongly with person-centered care and outweighs institutional settings as well as may be related to the fostering of virtues.

The Enemy as a Patient: What can be Learned from the Emotional Experience of Physicians and Why does it Matter Ethically?

This qualitative research examines the influence of animosity on physicians during clinical encounters and its ethical implications. Semi-structured interviews were conducted with ten Israeli-Jewish physicians: four treated Syrians and six treated Palestinian terrorists/Hezbollah militants or Palestinian civilians. An interpretive phenomenological analysis was used to uncover main themes in these interviews. Whereas the majority of physicians stated they are obligated to treat any patient, physicians who treated Syrians exhibited stronger emotional expression and implicit empathy, while less referring to the presence of the Israeli-Arab conflict. In contrast, physicians who treated enemy combatants or Palestinian civilians showed the exact opposite. Linking these results to the "Implicit Bias" theory, the role of empathy and the beneficence principle in medical ethics, we argue that: (a) the unconscious decreased emotional involvement among the latter group of physicians is a deficiency that needs to be recognized; and (b) this deficiency undermines the principle of beneficence, thereby possibly influencing the fulfillment of the commitment to treat patients. Acknowledging and addressing the potential emotional and ethical deficiencies entailed in encounters with the so-called enemy-patients are of importance to the global medical community, since such encounters are increasingly an integral part of the current political realities faced by both the developed and developing worlds.