"I'm 'just' a community pediatrician" views and challenges of pediatricians working in the community in Israel.

BACKGROUND: There are ongoing changes around the world in the training and practice of pediatricians who work in the community. These changes are driven by the understanding that pediatricians are required to provide not only acute primary care but also to address more comprehensive concerns, particularly the 'new morbidities'. The present study examines the professional identity of Israeli pediatricians in the community in light of these changes, the barriers and challenges to their work and professional adaptations in the field. METHODS: We used a mixed-methods approach, collecting the perspectives of 137 pediatricians who work in the community through an anonymous online survey, followed by in-depth semi-structured interviews with 11 community pediatricians. RESULTS: The survey results show that community pediatricians in Israel have limited knowledge on a variety of developmental, behavioral and emotional issues; that they lack working relationships with medical or other professionals; and are rarely engaged with other community services. Three main themes arose from the interviews that support and deepen the survey results: perceptions of the profession (pediatrics in the community vs. community pediatrics), the stature of pediatricians in the community (during residency, the choice to work in the community, their daily work) and barriers and change in community pediatrics (isolation, limited resources and challenges arising from the nature of community work). CONCLUSIONS: The present study sheds light on the professional identity and the day-to-day challenges and successes of pediatricians working in the community. Continuing medical education, providing a supportive framework and professional community, better resources, more time with patients, and tools and opportunities for professional development would help pediatricians who work in the community to overcome some of these challenges. The research findings reinforce the need for policy change in the field of community pediatrics with a specific community training curriculum, provision of more resources and ongoing support for pediatricians. This requires partnership between the HMOs, the Ministry of Health, the Scientific Council (Israel Medical Association, professional organizations) and NGOs in order to turn individual-level solutions into system-level and policy-changing solutions.

A social ecological approach to promote learning health disparities in the clinical years: impact of a home-visiting educational program for medical students.

BACKGROUND: There is consensus that medical schools have a duty to educate students about social determinants of health (SDOH) and equip them with skills required to ameliorate health disparities. Although the National Academy of Medicine (NAM) urged the development of experiential long term programs, teaching is usually conducted in the pre-clinical years or as voluntary courses. ETGAR a required health disparities course, based on the social ecological model, was initiated to answer the NAM call. This study aimed to ascertain the course impact on students learning of SDOH and health disparities. METHODS: Students during their first clinical year cared for four patients in their transition from hospital back home, one patient in each internal medicine, surgery, pediatrics and obstetrics/gynecology rotation. The students home-visited their patients after meeting them in hospital and preparing a plain language discharge letter. Training session prior to the course, a tutorial in each rotation, and structured feedback gave the educational envelope. Mixed methodology was employed to evaluate the course impact. Quantitative data collected by students during the home-visit: patients' characteristics and quality and safety of the transition back home using the Medication Discrepancy Tool and Care Transition Measure questionnaire. Stakeholders' views were collected via interviews and focus groups with students representing all affiliated hospitals, and interviews with heads of departments most involved in the course. RESULTS: Three hundred six students in three academic years, between October 2016-July 2019, completed home visits for 485 disadvantaged patients with improvement in patients' knowledge of their treatment (3.2 (0.96) vs 3.8 (0.57), Z = -7.12, p < .0001) and identification of medication discrepancies in 42% of visits. Four themes emerged from the qualitative analysis: contribution to learning, experience-based learning, professional identity formation, and course implementation. CONCLUSIONS: ETGAR was perceived to complement hospital-based learning, making students witness the interaction between patients' circumstances and health and exposing them to four patients' environment levels. It provided a didactic framework for promoting awareness to SDOH and tools and behaviors required to ameliorate their impact on health and health disparities. The course combined communication and community learning into traditionally bio-medical clinical years and serves as a model for how social-ecology approaches can be integrated into the curriculum.

Teaching plain language to medical students: improving communication with disadvantaged patients.

BACKGROUND: Low health literacy underpins health inequality and leads to poor adherence to medical care and higher risk of adverse events and rehospitalization. Communication in plain language, therefore, is an essential skill for health professionals to acquire. Most medical education communication skill programs focus on verbal communication, while written communication training is scarce. ETGAR is a student delivered service for vulnerable patients after hospital discharge in which, amongst other duties, students 'translate' the medical discharge letters into plain language and share them with patients at a home visit. This study ascertains how this plain language training impacted on students' written communication skills using a tool designed for purpose. METHODS: Students, in pairs, wrote three plain language discharge letters over the course of a year for patients whom they encountered in hospital. The students handed over and shared the letters with the patients during a post-discharge home visit. Structured feedback from course instructors was given for each letter. An assessment tool was developed to evaluate students' ability to tell the hospitalization narrative using plain and clear language. First and last letters were blindly evaluated for the entire cohort (74 letters; 87 students). RESULTS: Students scored higher in all assessment categories in the third letters, with significant improvement in overall score 3.5 ± 0.8 vs 4.1 ± 0.6 Z = -3.43, p = 0.001. The assessment tool's reliability was high α = 0.797, it successfully differentiated between plain language categories, and its score was not affected by letter length or patient's medical condition. CONCLUSIONS: Plain language discharge letters written for real patients in the context of experience-based learning improved in quality, providing students with skills to work effectively in an environment where poor health literacy is prevalent. ETGAR may serve as a model for learning written communication skills during clinical years, using the assessment tool for formative or summative evaluation.

Development of a novel social incubator for health promoting initiatives in a disadvantaged region.

BACKGROUND: Bottom-up approaches to disparity reduction present a departure from traditional service models where health services are traditionally delivered top-down. Raphael, a novel bottom-up social incubator, was developed in a disadvantaged region with the aim of 'hatching' innovative health improvement interventions through academia-community partnership. METHODS: Community organizations were invited to submit proposals for incubation. Selection was made using the criteria of innovation, population neediness and potential for health impact and sustainability. Raphael partnered with organizations to pilot and evaluate their intervention with $5000 seed-funding. The evaluation was guided by the conceptual framework of technological incubators. Outcomes and sustainability were ascertained through qualitative and quantitative analysis of records and interviews at 12 months and 3-5 years, and the Community Impact of Research Oriented Partnerships (CIROP) questionnaire was administered to community partners. RESULTS: Ninety proposals were submitted between 2013 and 2015 principally from non-governmental organizations (NGOs). Thirteen interventions were selected for 'incubation'. Twelve successfully 'hatched': three demonstrated sustainability with extension locally or nationally through acquiring external competitive funding; six continued to have influence within their organizations; three failed to continue beyond the pilot. Benefits to the organisations included acquisition of skills including advocacy, teaching and health promotion, evaluation skills and ability to utilize acquired knowledge for implementation. CIROP demonstrated that individuals' research skills were reported to improve (mean ± sd) 4.80 ± 2.49 along with confidence in being able to use knowledge acquired in everyday practice (5.50 ± 1.38) and new connections were facilitated (5.33 ± 2.25). CONCLUSIONS: Raphael, devised as a 'social incubator', succeeded in nurturing novel ideas engendered by community organizations that aimed to impact on health disparities. Judging by success rates of technological incubators its goals were realized to a considerable degree.

Learning social determinants of health through a home visiting course in the clinical years.

OBJECTIVE: The purpose of this study was to assess the impact of a new experience-based educational program aiming to teach social determinants of health (SDH) and health disparities, through a post-discharge home-visit conducted with patients recruited in hospital. METHODS: 105 clinical-year students visited 177 patients living in disadvantaged circumstances. Their home-visit reports were analyzed employing mixed methodology. Content analysis was conducted for classifying issues raised by students, and quantitative analysis to compare reports by level of elaboration, gender and class. RESULTS: Fifteen taxonomy items were identified. Social support and patients' medical conditions were most prevalent, followed by personal-related and community-related issues. Analysis demonstrated students' understanding of the relationship between SDH and patient health, and challenges patients face following discharge. Women and mixed couples provided more elaborate reports, which contained significantly greater critique of medical care. CONCLUSIONS: Meeting patients both in hospital and at home enhanced awareness of SDH. Students learned to view the patient comprehensively, and to understand the diverse factors affecting their health. Students, who had essentially sole responsibility for the home-visit, successfully integrated their skills to take action when needed. PRACTICE IMPLICATIONS: The ETGAR experience provided a means for effective learning about how social determinants impact on health.

Observational analysis of disparities in obesity in children in the UK: Has Leeds bucked the trend?

BACKGROUND: The prevalence of obesity in childhood is of high concern, especially in deprived populations. We explored trends in obesity following the introduction of a citywide strategy focused on preschool children. METHODS: Analysis of obesity prevalence using the National Child Measurement Programme 2009 to 2017 for primary-school children in Leeds using 5-year aggregated data for Leeds, comparable cities, and England as a whole. RESULTS: Prevalence of obesity in Leeds for school entry children fell significantly (9.4% to 8.8%), whilst comparable cities (CC) and England as a whole showed no change (comparison of trends: P < 0.001 and P < 0.001). The reduction in Leeds was primarily in the most deprived (11.5% to 10.5%; trend comparison CC: P < 0.001, Eng: P < 0.001), but also amongst the affluent (6.8% to 6.0%; trend comparison CC: P = 0.087, Eng: P = 0.012). Prevalence in older children in Leeds was unchanged whilst it increased for comparable cities and England (trend comparison CC: P < 0.001, Eng: P < 0.001). In the deprived, obesity increased: Leeds by 1.4%; CC 1.3%, England 1% (trend comparison Eng: P = 0.004). In the affluent, obesity prevalence reduced more in Leeds than elsewhere: 2% in Leeds, 0.8% in CC, and 0.7% in England (trend comparison CC: P < 0.001, Eng: P ≤ 0.001). CONCLUSIONS: There has been a notable decrease in the prevalence of obesity especially amongst the most disadvantaged children at entry to primary school in Leeds. How this was achieved merits in-depth consideration.

Mean and variance of greenness and pregnancy outcomes in Tel Aviv during 2000-14: longitudinal and cross-sectional approaches.

BACKGROUND: Natural environments may have beneficial impacts on pregnancy outcomes. However, longitudinal evidence is limited and the associations with variance in surrounding greenness is unknown. Our objective was to evaluate these associations among 73 221 live births in Tel Aviv, Israel. METHODS: Longitudinal exposure to mean of greenness during pregnancy and trimesters were calculated using satellite-based Moderate Resolution Imaging Spectroradiometer (MODIS) Normalised Difference Vegetation Index (NDVI) data. In addition, exposure to mean and variation of NDVI from high-resolution satellite and percentage of tree cover [Vegetation Continuous Fields (VCF)] at 300-m buffer were evaluated in a cross-sectional approach. Generalized linear models were used to estimate the crude and adjusted associations. We explore the possible mediating role of ambient exposures and distance to 'outdoor gyms' located in parks. RESULTS: Crude beneficial associations between exposure to higher mean NDVI during pregnancy and pregnancy outcomes were observed [for birthweight, 3rd/1st tertile exposure increased the mean by 25.5 g, 95% confidence intervals (CIs): 15.4, 35.5] and decreased the odds of low birthweight, small for gestational age, preterm deliveries (PTD) and very PTD. Adjustment for individual and neighbourhood-level markers of socio-economic status (SES) attenuated all the associations. Strongest associations were observed during the first and second trimesters. Cross-sectional associations for mean greenness were similar with narrower CIs, and associations with NDVI were stronger than with tree cover and stronger for mean compared with variance of greenness. Associations were consistent for term births, different buffer sizes and for further adjustment to maternal education. Stronger associations were observed for lowest SES. Distance to 'outdoor gyms' and variance of greenness had the largest estimates of mediation. CONCLUSION: This study adds to the limited information on when exposure to greenness is most beneficial, on the association with variance of greenness and the possible pathways. These observations require confirmation in other populations.

Risk and Protective Factors for Child Overweight/Obesity Among Low Socio-Economic Populations in Israel: A Cross Sectional Study.

Background and Aims: Scientific evidence regarding protective factors that contribute to healthy weight in childhood is limited and is particularly scarce in lower socio-economic populations in different ethnic groups. This study aimed to assess the prevalence of biological, behavioral and psychosocial factors for child overweight/obesity in Jewish and Arab population groups in Israel, and to compare their associations with child overweight/obesity in the two groups. Methods: Children aged 5-6 years were randomly selected from 20 Mother and Child Health clinics in towns and villages of lowest socio-economic ranking in Northern Israel. Children and mothers were invited for a special "One Stop Shop-Preparation for School" visit which included growth measurements. Questionnaires were distributed to mothers for self-report on biological, SES, psychological and lifestyle factors. Perinatal and early nutritional data were retrieved from clinic records. Multivariate analyses using logistic regression models predicting child overweight/obesity were conducted separately for Jewish (N = 371) and Arab (N = 575) children. Results: Overweight/obesity (BMI ≥85th centile) rates were higher in Jewish (25%) than Arab (19%) children. In both Jewish and Arab groups, respectively, maternal BMI (OR = 1.10 [95%CI = 1.04, 1.17]; OR = 1.08 [95%CI = 1.04, 1.13]), and child birthweight (OR = 1.33 [95%CI = 1.04, 1.71]; OR = 1.39 [95%CI = 1.11, 1.73]) were significant risk factors for overweight/obesity, and maternal self-efficacy regarding child's lifestyle was significantly protective (OR = 0.49 [95%CI = 0.28, 0.85]; OR = 0.54 [95%CI = 0.34, 0.85]). Additionally, four other maternal psychological and child behaviors were significantly associated with overweight/obesity in the Jewish group and two child lifestyle behavior factors in the Arab group. Moreover, significant interactions indicating moderation effects were found only in the Jewish group: maternal education and maternal age moderated the effect of maternal BMI on child overweight/obesity. No other moderation of risk factors was found. Discussion: In this study of children from low SES families, protective factors contributed to healthy child weight alongside risk factors for overweight/obesity. They differed between the population groups, and fewer variables explained overweight/obesity in Arab children. Although further expansion of these findings is required they point at the relevance of protective factors, maternal self-efficacy in particular, for understanding childhood obesity in specific ethnic contexts and for planning culturally adapted prevention programs in disadvantaged populations.

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.

Maternal and child health in Israel: building lives.

Israel is home to a child-oriented society that values strong family ties, universal child benefits, and free education for all children from 3 years of age to school grade 12. Alongside the universal health-care services that are guaranteed by the National Health Insurance Law and strong, community-based primary and preventive care services, these values have resulted in good maternal and child health. In 2015, infant and maternal mortality (3·1 deaths per 1000 livebirths and 2·0 deaths per 100 000 livebirths, respectively) were lower than the mean infant and maternal mortality of countries within the Organisation for Economic Co-operation and Development. Israel has already exceeded the developed regions' Sustainable Development Goal 2030 targets for maternal mortality, neonatal mortality, and mortality in children younger than 5 years in all population groups. Yet these accomplishments are marred by Israel's high prevalence of child poverty (more than 30%), particularly among Arabs (63%) and ultra-Orthodox Jews (67%). Although infant mortality has improved in all subpopulations since Israel was founded in 1948, infant mortality among Arabs is still more than twice as high as among Jews. To address these disparities in health, the Israeli Ministry of Health has created a special division and has funded an intervention programme to reduce the infant mortality among Bedouin Arabs. Other interventions include targeted and culturally appropriate health-care programmes and services for communities with a high number of at-risk children and young adults, dental health service for all children up to 15 years, and improved collaboration between health, education, and welfare services. The challenges faced by the Israeli health-care system include a growing trend towards medicalisation of prenatal care, ensuring staff are trained to treat developmental, behavioural, and psychosocial issues in children and their families, securing sustainable funding for health promotion and injury prevention programmes, expanding and improving the coordination of services for children with special needs or who are at risk, and programme assessment. Ensuring adequate funding for dedicated, preventive paediatric care and taking action on a nationwide scale to reduce child poverty are essential for maintaining health gains in children. In this Series paper, we describe the health indices, highlight disparities, and discuss the challenges in delivering and maintaining maternal and child health care in Israel.

How can medical schools contribute to bringing about health equity?

The role of medical schools is in a process of change. The World Health Organization has declared that they can no longer be ivory towers whose primary focus is the production of specialist physicians and cutting edge laboratory research. They must also be socially accountable and direct their activities towards meeting the priority health concerns of the areas they serve. The agenda must be set in partnership with stakeholders including governments, health care organisations and the public. The concept of social accountability has particular resonance for the Bar Ilan Faculty of Medicine in the Galilee, Israel's newest medical school, which was established with a purpose of reducing health inequities in the Region. As a way of exploring and understanding the issues, discussions were held with international experts in the field who visited the Galilee. A symposium involving representatives from other medical schools in Israel was also held to extend the discourse. Deliberations that took place are reported here. The meaning of social accountability was discussed, and how it could be achieved. Three forms of action were the principal foci - augmentation of the medical curriculum, direct action through community engagement and political advocacy. A platform was set for taking the social accountability agenda forward, with the hope that it will impact on health inequalities in Israel and contribute to discussions elsewhere.

Preventing child obesity: a long-term evaluation of the HENRY approach.

Childhood obesity has reached epidemic levels, yet many health professionals lack confidence in working with parents around lifestyle change. HENRY (Health Exercise Nutrition for the Really Young) aims to tackle this through training practitioners to work more effectively with parents of preschoolers around obesity and lifestyle issues.We evaluated the long-term impact of HENRY training on health professionals' knowledge, skills and confidence in tackling obesity prevention. All practitioners trained 2007-11 (n = 1601) were invited to complete an online survey. 237 emails (14.8%) were undeliverable; 354 (26.0%) of the remainder completed the survey. A majority (67%) reported using knowledge and skills gained on a regular basis in their professional lives. Sessions on the importance of empathy and key parenting skills were considered particularly useful, with 78% and 74% respectively reporting regular use of these skills. Effects on respondents' personal lives were also reported: 61% applied the knowledge and skills at home, identifying for example, more shared family mealtimes and reduced portion sizes. The impact endures, with 71% of those undergoing training > 12 months ago, stating that they continued to use concepts in their professional lives. The findings suggest that brief training can have a sustained impact on practitioners' professional and personal lives.

Assessment of childhood obesity in secondary care: OSCA consensus statement.

This expert opinion provides detailed guidance on assessing obesity in secondary paediatric practice. This guidance builds on existing recommendations from National Institute of Health and Clinical Excellence in the UK, and is evidence based where possible. Guidance is provided on which obese children and young people are appropriate to be seen in secondary care and relevant history and investigations, and guidance on when further investigation of causes and obesity-related comorbidity is appropriate.