Health locus of control in cancer patient and oncologist decision-making: An exploratory qualitative study.

OBJECTIVE: To investigate how cancer patients' and family members' perspective and health locus of control are presented in clinical encounter decision-making. METHODS: Semi-structured in-depth interviews were carried out with 16 cancer patients and 6 family members living in Israel (n = 22). Interviews were transcribed verbatim, and data were analyzed using thematic analysis. RESULTS: Following the health locus of control model, the findings were divided into an external and internal locus of control themes, and we added a theme regarding shared decision-making. Internal locus of control sub-themes included asking for a second opinion, negotiating with the doctor, asking questions, looking for information, and fighting for their rights. External locus of control sub-themes included powerful others, oncologists, and fate. The dominant approach of most of the interviewees was an external locus of control. Women demonstrated more external locus of control than men. On the direct question of who should decide on treatment-the doctor, the patient, or both jointly-the answers ranged from only the doctor (n = 8) to together (n = 7) to only the patient (n = 8). CONCLUSIONS: This study provides insights into different aspects of locus of control in the clinical encounter involving cancer patients. The findings reflect the need to devote comprehensive attention to cancer patients' perceptions and experiences in the clinical encounter. A patient-centered care approach and a personalized framework for decision-making in cancer care are essential to achieving better treatment outcomes. Further research can engage in the development and validation of an up-to-date health locus of control questionnaire for cancer patients based on the findings of this study.

Factors associated with seasonal influenza and HPV vaccination uptake among different ethnic groups in Arab and Jewish society in Israel.

BACKGROUND: Parents in the Arab population of Israel are known to be "pro-vaccination" and vaccinate their children at higher rates than the Jewish population, specifically against human papilloma virus (HPV) and seasonal influenza. OBJECTIVES: This study seeks to identify and compare variables associated with mothers' uptake of two vaccinations, influenza and HPV, among different subgroups in Arab and Jewish society in Israel. METHODS: A cross-sectional study of the entire spectrum of the Israeli population was conducted using a stratified sample of Jewish mothers (n = 159) and Arab mothers (n = 534) from different subgroups: Muslim, Christian, Druse and Northern Bedouins. From March 30, 2019 through October 20, 2019, questionnaires were distributed manually to eighth grade pupils (13-14 years old) who had younger siblings in second (7-8 years old) or third (8-9 years old) grades. RESULTS: Arab mothers exhibited a higher rate of uptake for both vaccinations (p < .0001, HPV - 90%; influenza - 62%) than Jewish mothers (p = 0.0014, HPV - 46%; influenza - 34%). Furthermore, results showed that HPV vaccination uptake is significantly higher than seasonal influenza vaccination uptake in both populations. Examination of the different ethnic subgroups revealed differences in vaccination uptake. For both vaccinations, the Northern Bedouins exhibited the highest uptake rate of all the Arab subgroups (74%), followed by the Druse (74%) and Muslim groups (60%). The Christian Arab group exhibited the lowest uptake rate (46%). Moreover, the uptake rate among secular Jewish mothers was lower than in any of the Arab groups (38%), though higher than among religious/traditional Jewish mothers, who exhibited the lowest uptake rate (26%). A comparison of the variables associated with mothers' vaccination uptake revealed differences between the ethnic subgroups. Moreover, the findings of the multiple logistic regression revealed the following to be the most significant factors in Arab mothers' intake of both vaccinations: school-located vaccination and mothers' perceived risk and perceived trust in the system and in the family physician. These variables are manifested differently in the different ethnic groups. CONCLUSIONS: This research shows that all Arabs cannot be lumped together as one monolithic group in that they exhibit major differences according to religion, education and access to information. Ranking of variables associated with uptake of the two vaccines can provide decision-makers an empirical basis for tailoring appropriate and specific interventions to each subgroup to achieve the highest vaccine uptake rate possible. Media campaigns targeting the Arab population should be segmented to appeal to the various sub-groups according to their viewpoints, needs and health literacy.

Recommending Unfunded Innovative Cancer Therapies: Ethical vs. Clinical Perspectives among Oncologists on a Public Healthcare System-A Mixed-Methods Study.

Over the past decade, there has been a growing development of innovative technologies to treat cancer. Many of these technologies are expensive and not funded by health funds. The present study examined physicians' perceptions of the ethical and clinical aspects of the recommendation and use of unfunded technologies for cancer treatment. This mixed-methods study surveyed 127 oncologists regarding their perceptions toward using unfunded innovative cancer treatment technologies, followed by in-depth interviews with 16 oncologists. Most respondents believed that patients should be offered all treatment alternatives, regardless of their financial situation. However, 59% indicated that they often face dilemmas regarding recommending new unfunded treatments to patients with financial difficulties and without private health insurance. Over a third (38%) stated that they felt uncomfortable discussing the cost of treatment with patients. A predictive model found that physicians facing patients whose medical condition worsened due to an inability to access new treatments, and who expressed the opinion that physicians can assist in locating funding for patients who cannot afford treatments, were more likely to recommend unfunded innovative therapies to patients (F = 5.22, R2 = 0.15, p < 0.001). Subsequent in-depth interviews revealed four key themes: economic considerations in choosing therapy, patient-physician communication, the public healthcare fund, and discussion of treatment costs. Physicians feel a professional commitment to offer patients the best medical care and a moral duty to discuss costs and minimize patients' financial difficulty. There is a need for careful and balanced use of innovative life-prolonging technologies while putting patients at the center of discourse on this complex and controversial issue. It is essential to develop a psychosocial support program for physicians and patients dealing with ethical and psychosocial dilemmas and to set guidelines for oncologists to conduct a comprehensive and collaborative physician-patient discourse regarding all aspects of treatment.

The physician as a neoliberal subject - A qualitative study within a private-public mix setting.

Research on neoliberalism in health care has insufficiently explored the intermediary role of physicians in neoliberal subjectification. This paper studies the construct of the physician as a neoliberal subject in the Israeli health care system, using qualitative data from in-depth interviews with 21 medical specialists. We interviewed physicians from specialties in which private practice is both less common (infectious disease and intensive care) and more common (orthopedics, cardiology, and cardiothoracic surgery). Our analysis focused on two key issues: the physician's role in society and the value placed on health care. We found a spectrum of views. At one end, some perceived themselves as entrepreneurs, managing themselves both as an enterprise and a product, and perceived health care as a commodity. At the opposite end, we found a professional ethos that considered the physician as a public servant, and health care as a human right. Both views were in constant tension with neoliberal subjectivity. Further research should investigate the association between institutional belonging, whether public or private, and the internalization of the main characteristics of the neoliberal worldview.

A Comparison Between Two Screening Approaches for ASD Among Toddlers in Israel.

Systematic screening of autism spectrum disorder (ASD) can improve early diagnosis of ASD. We compared the efficacy of two ASD screening methods, the Global Developmental Screening (GDS), and the Modified Checklist for Autism in Toddlers-Revised, with Follow-Up (M-CHAT/F) in 1591 toddlers of ages 18-36 months from 35 government-funded clinics in south Israel. The M-CHAT/F performed better than the GDS in detecting toddlers with ASD (sensitivity: 70.0% vs. 50.0%, and specificity: 98.2% vs. 96.6% respectively). Both methods had an equivalent performance in detecting other forms of developmental delays (sensitivity = 63%; and specificity ~ 98%). In addition, remarkable inter-nurse variation was observed in the GDS referral decisions. Thus, employment of the M-CHAT/F in the Israeli health system may improve early detection of ASD among toddlers.

Seroprevalence of measles, mumps and rubella among young adults, after 20 years of universal 2-dose MMR vaccination in Israel.

Evidence-based vaccination policy is important for the global and local efforts of achieving control over measles. In 2007, the first Israeli birth cohort to be twice vaccinated during childhood with Measles-Mumps-Rubella vaccine reached adulthood. In parallel, Israel experienced its largest measles outbreak since 1994. We aimed to assess the seroprevalence of measles IgG antibodies and concordance with rubella and mumps seroprevalence among young Israeli adults born 1988-9 in comparison to previous birth cohorts, in order to inform evidence based prevention policy. We conducted a seroprevalence study of IgG antibodies among 439 Israeli adults born in 1988-9, based on a representative sample of sera collected at age 18-19 upon recruitment to mandatory military service in 2007. In total, 85.7% were seropositive for measles as compared with 95.6% in the 1996 recruitment (P < 0.001). The absolute decline was significant both for males (8.8%, P = 0.001) and females (12.1%, P < 0.001). There were no significant differences in seropositivity by gender, years of education, country of birth or smoking status. Rubella seropositivity among measles seropositives was 90.4%, significantly (P < 0.001) higher than 72.1% among measles seronegatives. Mumps seropositivity among measles seropositives was 87.0%, significantly (P < 0.001) higher than 62.3% among measles seronegatives. Results were similar for Israeli-born only. Our findings indicate that measles seroprevalence decreased after the last change in vaccination policy and reach sub-optimal level. Until global eradication is reached, a proactive vaccination program to supplement routine childhood vaccination program should be considered in Israel and in other countries.

Health status, behavior, and care of lesbian and bisexual women in Israel.

INTRODUCTION: Lesbian and bisexual women (LBs) have unique health needs compared with heterosexual women (HW). AIM: This study aimed to associate the health status of LB, their health behavior, disclosure of sexual orientation (SO), and avoidance of health care with that of HW. METHODS: Participants in this cross-sectional study completed anonymous questionnaires, which were distributed in Internet sites and public venues in Israel, comparing health behaviors and outcomes between LB and HW. MAIN OUTCOME MEASURES: Health outcomes included subjective health status, general practitioner or gynecologist visit in the last 6 months, and satisfaction from the Israeli healthcare system. RESULTS: In 2012, 681 (34.4%) lesbians, 242 (13.5%) bisexual women, and 937 (52.1%) HW completed the questionnaire. In comparison with HW, LBs were more commonly single, used drugs/alcohol, smoked, experienced eating disorders, and reported an earlier sexual debut. In comparison with all women, lesbians performed less physical activities and were more satisfied with their body weight, whereas bisexuals had riskier sexual behavior and reported more verbal/physical abuse. LB reported more emergency room visits, more visits to psychiatrists, yet underwent Pap smears less frequently compared with HW. In a multivariate analysis, lesbians had fewer gynecologists' visits and were less satisfied with the healthcare system than HW, whereas bisexuals visited their general practitioner or gynecologist less frequently and were less satisfied with the primary healthcare system. Lesbians were more likely to disclose their SO with their doctors than bisexuals and were satisfied with the disclosure. Nondisclosure of SO was correlated with poor subjective health status. The interaction between being bisexual and nondisclosure of SO was strong. CONCLUSIONS: LB utilized health care less frequently than HW, resulting in unmet medical needs. SO disclosure was associated with better healthcare utilization and health outcomes, especially among bisexuals. Providers should be trained about LB's unique health needs and improve their communication skills to encourage SO disclosure.

Seroepidemiology of Epstein-Barr virus and cytomegalovirus among Israeli male young adults.

PURPOSE: To assess the seroprevalence and seroconversion of Epstein-Barr virus (EBV) and cytomegalovirus (CMV) Immunoglobulin G (IgG) antibodies and identify associated socioeconomic and smoking variables among male young adults in Israel, to explore health disparities and aid prevention efforts. METHODS: A population-based seroprevalence study of EBV and CMV IgG antibodies in a systematic sample of Israeli males upon recruitment to mandatory military service during 1994-2004. Associations between socioeconomic and smoking variables and the seroprevalence of EBV/CMV were evaluated, controlling for possible confounders. A subset of seronegative subjects was assessed for seroconversion upon discharge from military service. RESULTS: Overall seroprevalence rates were 87% for EBV and 59% for CMV. An association between the seroprevalence of EBV and CMV was observed. Seroconversion was 56% for EBV as compared with 31% for CMV. Lower paternal education was found to be associated with both EBV and CMV seroprevalence. Lower socioeconomic status, North African origin, and urban residence were found to be associated with CMV seropositivity, as was smoking for EBV seropositivity. CONCLUSIONS: Socioeconomic disparities exist in the seroprevalence rates of CMV and EBV among Israeli male young adults. The results of the study could aid public health efforts and determine target populations when a vaccine becomes available.

[Second medical opinions].

Second opinion is a decision-support tool for ratification or modification of a suggested treatment, by another physician. Second opinion may have a critical influence on the diagnosis, treatment and prognosis. The patient can benefit from treatment optimization and avoid unnecessary risks. The physician can benefit from less exposure to legal claims, and healthcare organizations can benefit from increased treatment, quality assurance and costs saving from unnecessary surgery and treatments. Nevertheless, injudicious use of this tool can provoke unnecessary medical costs. In recent years, many patients prefer to seek a second opinion on their disease and available treatments. Private and public insurance companies are trying to control surgery costs by urging and even demanding a second opinion before surgery. Although second opinions are common in medical practice, relatively little is known on this subject. Most of the studies reviewed in this article evaluated the clinical benefit of second opinions, the reasons patients seek a second opinion and the characteristics of these patients, as well as technological interventions to promote second opinions, and ethical or legal issues related to second opinions. Yet, there are opportunities for further studies about physicians attitudes and barriers towards second opinions, their effect on patient-physician communication and cost-effectiveness analyses of second opinions. Due to the relevance of second opinions for public heath, this review aims to summarize the current research on second opinions.

[Physician's role in health promotion: healthy lifestyle counseling in the clinical encounter].

Health promotion is the foundation to prevent disease-related risk factors. It is a multi-discipLinary activity including several professions. Within this complex, the physician has an important role in prevention and counseling on heaLthy lifestyLe in order to reduce morbidity and mortality. Nevertheless, there are many factors impeding the physician's involvement in health promotion counseling. This review aims to investigate the physician's role in health promotion during the clinical encounter. The authors focus on a healthy lifestyle, especially on diet, smoking cessation and physical activity. The article presents the evidence related to physicians' ability and self efficacy in health promotion, the type of counseling to be provided, time allocated, efficiency of counseling, model employed during the clinical encounter and factors impeding or promoting the counseling. The understanding of attitudes, strength of the evidence available regarding the efficacy of counseling and the factors promoting or impeding physicians in providing health promotion advice will help to remove existing barriers and to develop training programs to encourage physicians to be involved in primary and secondary prevention during the clinicaL encounter.

Public health, racial tensions, and body politic: mass ringworm irradiation in Israel, 1949-1960.

In this essay, we analyze the case study of mass ringworm irradiation conducted in Israel during its first years of existence and its consequences. We analyzed the case study of ringworm irradiation in the framework of racial construction of illness and its treatment, showing the elasticity of race and ethnicity as medical and social categories.

Identification of risk factors for infection in an outbreak of Mycoplasma pneumoniae respiratory tract disease.

BACKGROUND: Mycoplasma pneumoniae is one of the most common pathogens that causes community-acquired respiratory tract infection. Outbreaks are well known, and all age groups are susceptible. An outbreak in an army training unit afforded an opportunity to identify possible risk factors for morbidity. METHODS: An outbreak of respiratory illness that occurred in a unit comprising 91 trainees was investigated and analyzed as a cohort study. M. pneumoniae infection was suspected on clinical grounds and was confirmed by polymerase chain reaction, culture, and serologic testing. Data regarding medical history, symptoms, signs, and laboratory tests were collected. RESULTS: During a period of 12 days, 41 soldiers (45.1%) had respiratory illnesses, of which 10 (11.0%) were pneumonia. Comparison of symptomatic and asymptomatic individuals revealed that smoking was associated with higher rates of disease (risk ratio, 2.1; 95% confidence interval [CI], 1.3-3.2; P<.005) and seroconversion (risk ratio, 2; 95% CI, 1.2-3.4; P=.03). In multivariate analysis, both lower acute immunoglobulin G values (adjusted odds ratio, 7.8; 95% CI, 1.4-42.5; P=.018) and smoking (adjusted odds ratio, 5.6; 95% CI, 1.5-20.4; P=.01) were associated with symptomatic infection; stratification according to smoking status revealed that immunoglobulin G levels among nonsmokers were protective. Patients who had pneumonia had lower lymphocyte counts (1400+/-258 vs. 2000+/-465 cells/microL; P=.001). CONCLUSIONS: Smoking and lower preexisting immunoglobulin G levels were strongly associated with M. pneumoniae respiratory infection. These findings emphasize the importance of immunity and cessation of smoking for the prevention of disease. The high attack rate emphasizes the extent of infection transmission among healthy persons living in close contact.

Comparative double blind clinical study on round versus shaped cohesive gel implants.

BACKGROUND: Highly cohesive round or shaped implants are used today by most plastic surgeons performing breast augmentation outside North America. OBJECTIVES: This study was conducted to (1) compare aesthetic outcomes of round versus shaped implants in breast augmentation by defining the preferences of the general female population and plastic surgeons towards two groups of augmented breasts (implanted with either round or shaped devices); and (2) to determine whether or not plastic surgeons could identify the type of implant used in each patient based on the postoperative appearance. METHODS: The study surveyed 30 breast augmentation patients, 15 with shaped implants and 15 with round devices. Two cohort categories evaluated the postoperative photographs of the patients: the first group comprised 235 female lay respondents and the second group included 11 male plastic surgeons. The lay respondents were asked to score breast beauty and naturalness, and to assess the upper pole. The plastic surgeons were asked similar questions and were additionally asked to try to identify the implant type. RESULTS: With respect to "breast beauty," both respondent categories scored round and shaped implant patients similarly. With regard to "naturalness," both groups scored round implant patients significantly higher (P < .001). Concerning upper pole assessment, the round implant group was scored higher and better than the shaped implant group (P < .001). The plastic surgeons' correct identification rate was 64% for round implants, and 47% for shaped implants. CONCLUSIONS: We believe that in the hands of an experienced surgeon who takes all soft tissue variables into consideration, the aesthetic result may not be differentiable when using round versus shaped implants in well-selected patients.

Disease-modifying effects of postexposure hepatitis A active immunization.

BACKGROUND: Several studies have demonstrated the efficacy of hepatitis A virus (HAV) active vaccine in the prevention of secondary HAV infection when administered shortly after exposure. METHODS: We describe six new recruits with unknown HAV infection, of whom three received late postexposure prophylaxis with the active HAV vaccine and three were not vaccinated. RESULTS: Results indicated that the vaccinated patients had a longer period from exposure to onset of symptoms (p < 0.05), shorter hospitalization, and lower liver enzyme levels. CONCLUSIONS: It appears that late administration of the active HAV vaccine has a disease-modifying effect. These findings, combined with earlier reports, may have important implications for immunization policies.

Reliability of self-reported smoking history and age at initial tobacco use.

BACKGROUND: Many studies use questionnaires to determine smoking status and age of smoking onset. This study aimed to determine the reliability of self-reported smoking history and age of smoking initiation. METHOD: The proportion of inconsistent answers and correlation coefficients of reported age of initial smoking were measured by an answer-reanswer analysis of questionnaires in an ongoing, two-step, population-based survey of health behavior. Interviews were conducted on the day of recruitment to and the day of discharge from mandatory military service in Israel among a sample of 25,437 young men and women recruited between 1986 and 2000. RESULTS: Of 7276 participants reporting current or past smoking upon recruitment, 559 (7.7%) reported never having smoked upon discharge, thus demonstrating prima facie inconsistency. Variables significantly associated with reliable reporting in a multivariate logistic regression model were female gender (P = 0.04) and more than 4 years of military service (P < 0.01). 6010 subjects who reported a positive smoking history at both recruitment and discharge were available for analysis of reliability of reported age at smoking onset. Intraclass correlation coefficients for recruitment/discharge consistency in reported age at first cigarette were 0.73 (95% CI: 0.71-0.74) and 0.76 (95% CI: 0.74-0.78) for men and women, respectively. Eastern origin, lower subject education level, and lower paternal education level were also associated with lower reliability. CONCLUSIONS: Our results showed a relatively high level of answer-reanswer reliability, with some variance attributable to personal characteristics. These results suggest that self-reported age at onset of tobacco use is practical and reliable in normative, young adult populations. However, time elapsed between questionnaires and demographic and lifestyle characteristics may affect reliability rates, and thus should be carefully regarded in future studies.

Secular trends in age at menarche, smoking, and oral contraceptive use among Israeli girls.

INTRODUCTION: The improved nutrition and socioeconomic status of the population in industrialized countries has resulted in a decrease in the mean age at menarche. This trend raises the question of whether cigarette smoking and the use of oral contraceptives, health behaviors often adopted during adolescence, may also be starting at a younger age. Cigarette smoking and use of oral contraceptives are a public health concern because they pose an increased risk for development of chronic diseases, particularly in combination. This study was designed to identify secular trends in age at menarche, at first cigarette, and at first use of oral contraceptives among a large population-based sample of young Israeli women and to assess whether these trends are associated with sociodemographic factors. METHODS: A systematic, population-based survey used data obtained from female recruits to the Israel Defense Force from 1986 to 2000. During the study period, 11,392 questionnaires were collected from Jewish women aged 18 to 19 years. Participants were interviewed concerning geographic origin and level of education, father's geographic origin and level of education, current smoking status, use of oral contraceptives, and recalled age at first menstruation, first cigarette, and first use of oral contraceptives. RESULTS: Reported mean age (-/+ D) at menarche showed a monotonic trend of decreasing over time, from 13.41 (-/+ .30) years for women born before 1970 to 13.03 (-/+ 1.28) years for those born after 1978 (P < .001). Women born after 1978 were twice as likely to experience menarche by the age of 11 as those born prior to 1970 (odds ratio 2.0; 95% confidence interval, 1.41-2.82). Significant trends toward younger age at first use were observed for cigarettes and oral contraceptives. CONCLUSION: The trends of earlier age at menarche, first cigarette, and first use of oral contraceptives suggest health behaviors among young women that may herald increased chronic disease morbidity in the future. These trends indicate the need for further investigation and preventive measures aimed at this population.