Emulated Trial for Discharge Prescription of Guideline-Directed Medical Therapy and 15-Year Survival After Coronary Artery Bypass Graft Surgery.

OBJECTIVES: To explore admission and discharge prescription rates of guideline-directed medical therapy (GDMT), defined as aggregate antiplatelet agents, statins, and ß-blockers, after coronary artery bypass graft (CABG) surgery and to reveal its association with long-term survival. PATIENTS AND METHODS: This is a prospective cohort study-based emulated trial of patients undergoing elective or semi-elective isolated CABG surgery in 7 cardiothoracic units in Israel from January 1, 2004, to December 31, 2007, and followed up until December 31, 2020, for all-cause mortality. RESULTS: Only 59.2% of 968 patients (n=573) were discharged on GDMT after CABG surgery. Admission GDMT use conferred a 7 times greater likelihood of discharge GDMT prescription (odds ratio, 7.07; 95% CI, 5.04 to 9.91; P<.001), with no sex differences observed. After applying inverse probability of treatment weighting, baseline characteristics were well balanced between groups. During a median follow-up of 13.7 years, a Cox regression model with propensity score-adjusted inverse probability of treatment weighting revealed lower mortality in patients with discharge GDMT prescription who underwent CABG surgery than in their counterparts (hazard ratio, 0.75; 95% CI, 0.60 to 0.93; P=.008). CONCLUSION: The use of aggregate GDMT before surgery conferred a greater likelihood of GDMT prescription upon discharge, which, in turn, is associated with better long-term survival. Educational efforts of pertinent medical professionals are needed to minimize preventive treatment gaps. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00356863.

The association of medical, social, and normative factors with the implementation of end-of-life care practices.

BACKGROUND: End-of-life (EoL) care practices (EoLCP) are procedures carried out at the EoL and bear directly on this stage in the patient's life. Public support of these practices in Israel is far from uniform. Previous studies show that while ∼30% of participants support artificial respiration or feeding of terminally ill patients, 66% support analgesic treatment, even at the risk of shortening life. This study aimed to create a typology of six end-of-life care practices in Israel and assess the association of medical, social, and normative factors with the implementation of those practices. These practices included mechanical ventilation, artificial feeding, deep sedation, providing information to the patient and family caregivers, including family caregivers in EoL decision-making, and opting for death at home. METHODS: This cross-sectional study was performed as an online survey of 605 adults aged 50 or more in Israel, of which ~ 50% (n = 297) reported supporting a dying terminally ill relative in the last 3 years. Participants were requested to provide their account of the EoL process of their relative dying from a terminal illness in several aspects, as well as the EoL care practices utilized by them. RESULTS: The accounts of the 297 interviewees who supported a dying relative reveal a varied EoL typology. The utilization of end-of-life care practices was associated with the socio-normative beliefs of family caregivers but not with their socioeconomic status. Strong correlations were found between family caregiver support for three key practices (mechanical ventilation, artificial feeding, and family involvement in EoL) and the actual utilization of these practices in the care of dying patients. CONCLUSIONS: The findings portray an important image of equity in the utilization of EoLCP in Israel, as the use of these practices was not associated with socioeconomic status. At the same time, the study found substantial diversity in family caregivers' preferences regarding EoL care practices use not related to socioeconomic status. We believe that differences in preferences that do not lead to problems with equity or other important societal values should be respected. Accordingly, policymakers and health system leaders should resist calls for legislation that would impose uniform EoL practices for all Israelis. Instead, they should take concrete steps to preserve and enhance the widespread current practice of practitioners to adapt EoL care to the varied needs and preferences of Israeli families and cultural, social, and religious subgroups. These steps should include providing frameworks and tools for family caregivers to support their loved ones close to their deaths, such as educational programs, seminars, supportive care before and during the end of life of their loved ones, etc.

Development and Functionality of a Parsimonious Digital Food Frequency Questionnaire for a Clinical Intervention among an Indigenous Population.

Nutrition-related chronic diseases are a major problem among Indigenous populations. Appropriate dietary intake assessment tools are needed for nutritional surveillance and intervention; however, tools designed to measure the habitual dietary intake of Indigenous persons are largely lacking. We developed a digital food frequency questionnaire (FFQ) to measure habitual consumption among Australian Aboriginal adults and support personalized nutrition counseling. The primary contributors to energy, select nutrients, and inter-person variation (83 food groups) were identified from nationally representative 24 h recall (24HR) data, and they accounted for >80% of the total intake and inter-person variation of the nutrients of interest. Based on community input, a meal-based FFQ format was adopted, with a main food/beverage list of 81 items and the capacity to report on >300 additional items via the digital platform. The nutrient database was based on the Australian Food and Nutrient Database. Data for the first 60 study participants (70% female; median age: 48 years) were used to assess the FFQ's utility. The participants' median [IQR] reported energy intake (10,042 [6968-12,175] kJ/day) was similar to their median [IQR] estimated energy expenditure (10,197 [8636-11,551] kJ/day). Foods/beverages on the main FFQ list accounted for between 66% and 90% of the participants' reported energy and nutrient intakes; the remainder came from participant-selected extra items. The digital FFQ platform provides a potentially valuable resource for monitoring habitual dietary intake among Aboriginal adults and supporting chronic disease prevention and management interventions.

Polarization in public attitudes toward end-of-life decisions in Israel - A cross-sectional study.

OBJECTIVES: End-of-life (EoL) processes are a complex socio-normative and ethical phenomenon. This study aimed to generate a database of public opinion in Israel concerning EoL processes and decisions and to identify differences in attitudes across subgroups in the population, particularly based on experience as a family caregiver of a dying patient. METHODS: This cross-sectional study was performed in late March 2022. The study utilized an online sample of 605 adults over the age of 50 including those who accompanied a loved one to their death in the last 3 years. Participants were requested to provide their opinions and attitudes on several aspects of EoL decisions, including truth-telling, medically assisted dying, EoL procedures, pre-death actions, and family caregivers' engagement. RESULTS: While only 27% and ∼30% of participants support artificial respiration or feeding (respectively) of terminally ill patients, 66% support analgesic treatment, even at the risk of shortening life. The data show an association between religiosity and agreement with life-extending procedures. For example, while 83% of seculars support medically assisted dying, only 59% and 26% of traditional and religious respondents support it. However, no statistically significant differences were observed in support of family involvement in EoL process in any sociodemographic variable. SIGNIFICANCE OF RESULTS: The results of this study suggest that the Israeli public is relatively polarized on several issues about EoL processes, specifically patient autonomy and medically assisted dying. Yet, at the same time, there is a consensus among the Israeli public about certain EoL elements, particularly the importance of family caregivers in the EoL decision-making process.

Inequalities in end-stage renal disease: underprivileged and ethnic minority members are at higher risk.

BACKGROUND: Incidence of end-stage renal disease (ESRD) is higher in Israel than the European average. Socio-economic differences in ESRD have been reported globally, but many countries lack a national register. Using national data, we assessed which socio-demographic factors are associated with 5-year incidence of ESRD in Israel, where there is universal access to renal replacement therapy (RRT). METHODS: Data on all incident ESRD cases aged ≥20 years receiving chronic RRT between 1 January 2014 and 31 December 2018 (N = 7883) were collected from Israel's National Dialysis & Renal Transplant Register. Individual-level data on ESRD cases requiring RRT included residential area, age, gender, ethnicity (Jewish or Arab) and ESRD cause (diabetes, other, unknown/missing). Area-level data included age and sex distribution, socio-economic status (SES) and proportion of Arab population. The associations between individual-level socio-demographic characteristics and ESRD cause were tested in bivariate comparisons. The risk of developing ESRD during the study period (from all and specific causes) was estimated using multiple Poisson regression models with negative binomial distribution, using four parameters, namely sex, ethnicity, SES category and age strata, based on area-level distribution of these parameters, and with the whole population (aged ≥20 years) as the denominator. RESULTS: A socio-economic gradient was seen for ESRD from all causes, more marked for diabetic aetiology [rate ratio (RR)=0.45, 95% CI: 0.39-0.52 highest vs lowest SES categories] than from other (RR = 0.64, 95% CI: 0.55-0.75) or unknown cause (RR = 0.79, 95% CI: 0. 62-0.99). Based on population area-level data, predominantly Arab neighbourhoods showed higher risk for ESRD requiring RRT for all causes, with the strongest association for diabetes (RR = 1.69, 95% CI: 1.53-1.86) adjusted for SES, age and sex. CONCLUSIONS: A strong socio-economic gradient was demonstrated for ESRD requiring RRT. Arab ethnicity was associated with higher risk for ESRD, especially due to diabetes. Our findings suggest the need for allocation of health resources according to needs and culturally appropriate interventions for improving control of modifiable risk factors for chronic renal failure.

Agencies Displayed by Patients, Medical Teams, and Caregivers at the End of Life from the Perspectives of Family Members - A Qualitative Study.

Background: End-of-life (EoL) Care is challenging for terminally-ill patients and their caregivers. This research is aimed to examine the relational agencies of the patients, the caregivers, and the medical teams in the context of EoL care, with a particular emphasis on the caregivers. Methods: This study is based on the qualitative analysis of interviews with 12 individuals who were closely supported a loved one to their death from a terminal illness. Results: Information collected revealed several agency-related themes. Family caregivers are significant entities in managing the 'case' of a seriously ill individual. At the final or more advanced stages of the EoL process, caregivers gradually shift from a supportive role to being active agents, but not always backed by the necessary experience, knowledge, or the requisite emotional resilience. Conclusions: Based on recognizing their agentic proactivity, a clear and elaborate articulation of the family caregivers' roles is needed.

Correlates of protection against COVID-19 infection and intensity of symptomatic disease in vaccinated individuals exposed to SARS-CoV-2 in households in Israel (ICoFS): a prospective cohort study.

BACKGROUND: Identifying COVID-19 correlates of protection and immunity thresholds is important for policy makers and vaccine development. We aimed to identify correlates of protection of BNT162b2 (Pfizer-BioNTech) vaccination against COVID-19. METHODS: In this prospective cohort study, households within a radius of 40 km of the Sheba Medical Center in Israel in which a new SARS-CoV-2 infection (defined as the index case) was detected within the previous 24 h were approached between July 25 and Nov 15, 2021. We included adults (aged >18 years) who had received one or two vaccine doses, had an initial negative SARS-CoV-2 PCR and no previous infection reported, and had a valid IgG and neutralising antibody result. The exposure of interest was baseline immune status, including IgG antibody concentration, neutralising antibody titre, and T-cell activation. The outcomes of interest were PCR-positive SARS-CoV-2 infection between day 2 and day 21 of follow-up and intensity of disease symptoms (self-reported via a telephone questionnaire) among participants who had a confirmed infection. Multivariable logistic and ordered logit ordinal regressions were used for the adjusted analysis. To identify immunological thresholds for clinical protection, we estimated the conditional probability of infection and moderate or severe disease for individuals with pre-exposure IgG and neutralising antibody concentrations above each value observed in the study data. FINDINGS: From 16 675 detected index cases in the study region, 5718 household members agreed to participate, 1461 of whom were eligible to be included in our study. 333 (22·8%) of 1461 household members who were not infected with SARS-CoV-2 at baseline were infected within 21 days of follow-up. The baseline (pre-exposure) IgG and neutralising antibodies were higher in participants who remained uninfected than in those who became infected (geometric mean IgG antibody concentration 168·2 binding antibody units [BAU] per mL [95% CI 158·3-178·7] vs 130·5 BAU/mL [118·3-143·8] and geometric mean neutralising antibody titre 197·5 [181·9-214·4] vs 136 ·7 [120·3-155·4]). Increasing IgG and neutralising antibody concentrations were also significantly associated with a reduced probability of increasing disease severity. Odds of infection were significantly reduced each time baseline IgG antibody concentration increased by a factor of ten (odds ratio [OR] 0·43 [95% CI 0·26-0·70]) and each time baseline neutralising antibody titre increased by a factor of two (0·82 [0·74-0·92]). In our cohort, the probability of infection if IgG antibody concentrations were higher than 500 BAU/mL was 11% and the probability of moderate disease severity was 1%; the probability of infection if neutralising antibody titres were above or equal to 1024 was 8% and the probability of moderate disease severity was 2%. T-cell activation rates were not significantly associated with reduced probability of infection (OR 1·04, 95% CI 0·83-1·30). INTERPRETATION: Both IgG and neutralising antibodies are correlates of protection against SARS-CoV-2 infection. Our data suggest that IgG concentrations higher than 500 BAU/mL and neutralising antibody titres of 1024 or more are thresholds for immunological protection from SARS-CoV-2 delta variant infection. Potentially, updated protective thresholds against emerging variants of concern could be calculated, which could support decision makers on administration of new vaccination strategies and on the optimal period between vaccine doses. FUNDING: Israeli Ministry of Health.

Overcoming the effect of pandemic fatigue on vaccine hesitancy-Will belief in science triumph?

PURPOSE: The study aims to examine the factors that impact vaccination uptake and additional protective behavior during the fourth wave of the pandemic in Israel, whereas the "pandemic fatigue" phenomenon has been identified as a hurdle to adherence to protective health behaviors against coronavirus disease 2019 (COVID-19). DESIGN: A cross-sectional, structured questionnaire was utilized for this investigation in September 2021, during the fourth wave of the pandemic. METHODS: A sample of the adult (18+) Israeli population was employed for the study. Recruiting participants for the study was conducted through an online internet panel company that consists of over 100,000 members, representing all geographic and demographic sectors of the Israeli population. RESULTS: Our findings indicate that pandemic fatigue has begun to have cascading effects on vaccination efforts. In particular, this study found that at this stage of the COVID-19 pandemic, trust in authorities, and even threat perception components, such as concern and fear of contracting the disease, are incapable of predicting vaccination uptake. Instead, perception of the importance of the vaccine and its effectiveness are predictive of vaccination uptake. CONCLUSION: The findings indicate that at this stage of the pandemic, focusing on the robustness of the science behind the vaccine is more important than trying to regain public trust. The findings also suggest that risk communication employing fear tactics is losing its capacity to generate motivation for vaccination. CLINICAL RELEVANCE: The findings of this study reveal lessons learned from the COVID-19 global pandemic. Specifically, the study reveals how in times of prolonged crisis, we can currently and, in the future, prepare improved strategies for public communication in order to promote uptake of protective health behavior, such as vaccination.

Comparing Patient Perspectives on Diabetes Management to the Deficit-Based Literature in an Ethnic Minority Population: A Mixed-Methods Study.

Marginalized racial/ethnic minorities have disproportionately high rates of type 2 diabetes prevalence, complications and mortality. Researchers and policymakers have typically addressed these disparities using a deficit-based discourse focused on individual/cultural deficiencies or failure. A mixed-methods study was used to compare the deficit discourse to the perspectives of adults with diabetes in the Arab minority in Israel, using data from 10 focus groups (5 men's, 5 women's) and 296 quantitative in-person surveys. Both qualitative and quantitative data were triangulated. In addition, multivariable regression models tested associations between diabetes management perspectives and participant characteristics. Contrary to the deficit-based characterizations of patients as fatalistic and unknowledgeable, participants viewed diabetes as a chronic disease with serious complications. They expressed more support for patient responsibility in diabetes management than for passive fatalism, and were less fatalistic as educational level and adequacy of diabetes self-care training increased. The impact of social/environmental barriers and changing cultural norms on lifestyle behaviors was highlighted. Over 95% used prescription medications for diabetes management, although 35% reported economic barriers. The deficit discourse is not well-aligned with Arab patients' evolving perceptions and needs, and has deflected attention from the socioeconomic/structural determinants of health, and the healthcare system's responsibility to provide effective, culturally-relevant diabetes services.

Sex related differences in the characteristics and outcomes of heart failure: A sub analysis of heart failure disease management study.

Aims: This is a sub-analysis of a randomized controlled trial on heart failure (HF) disease management (DM) in which patients with HF (N = 1,360; 27.5% women) were assigned randomly to DM (N = 682) or usual care (UC) (N = 678). Study intervention did not significantly affect the rate of hospital admissions or mortality. This study evaluates sex-related differences in baseline characteristics, clinical manifestations, adherence to treatment and outcomes among the study cohort. Methods: Association between sex and hospital admissions and mortality was tested in multivariable models adjusted for the patients' baseline characteristics. The primary composite outcome of the study included time to first HF hospitalization or all-cause mortality. Secondary composite outcome included number of hospital admissions and days of hospitalization, for HF and all other causes. Results: Compared to males, females recruited in the study were on average 3 years older [median age 72 (62, 78) vs. 75 (65, 82), p = 0.001], with higher prevalence of preserved left ventricular function (LVEF ≥50%) and lower frequency of ischemic heart disease (IHD) (p ≤ 0.001). Females had shorter 6-min walking distance and worse quality of life and depression scores at baseline (p < 0.001). The proportion of patients receiving HF recommended medical treatment was similar among females and males. During a median follow-up of 2.7 years (range: 0-5), there were no significant differences between females and males with respect to the time elapsed until the study primary endpoint and its components in univariate analysis [557 (56.5%) males and 218 (58.3%) females were hospitalized for HF or died for any cause; p > 0.05]. Multivariable analysis showed that females were significantly less likely than males to experience the primary outcome [adjusted hazard ratio (HR) = 0.835, 95% CI: 0.699, 0.998] or to die from any cause [adjusted HR = 0.712; 95%CI: 0.560, 0.901]. The sex-related mortality differences were especially significant among patients with non-preserved EF, with IHD or with recent HF hospitalization. Females also had lower rates of all-cause hospital admissions [adjusted rate ratio = 0.798; 95%CI: 0.705, 0.904] and were more likely to adhere to HF medical therapy compared to males. Conclusion: Females with HF fare better than men. Sex related differences were not explained by baseline and morbidity-related characteristics or adherence to medical treatment.

Factors Affecting the Patient Journey in Scheduling a Specialist Appointment in a Public Healthcare System.

A questionnaire was developed to evaluate the journey experienced by patients from identifying a need to see a community specialist in Israel's public healthcare system, through scheduling an appointment and attending. A telephone survey was conducted with a nationally representative group of 3751 adults, in 2019 to 2020. Fifty-seven percent needed to see a specialist in the last 6 months; among those, 82%, visited a specialist. Among the 3% who did not make an appointment, in 41 of 52 (79%) cases this was due to long waiting time. Younger and more educated patients were more likely to try to get an earlier appointment. Timeliness (55%) and wanting a specific physician (43%) were major considerations in scheduling. Reported need was greater in females, Jewish versus Arab respondents, more educated and those with chronic illness. Those who did not make an appointment sought private care, emergency treatment, or went untreated. Although a large percentage of respondents did eventually get an appointment, vulnerable patients may have more difficulty navigating the system. Following the patient journey can provide insights to help design services better suited to patients' needs.

Is health-related quality of life 1-year after coronary artery bypass graft surgery associated with living in a greener environment?

INTRODUCTION: Greenery in the residential environment and in the hospital has been associated with improved surgical outcomes and recovery. We investigated the association between the level of residential greenness of patients with coronary disease and their heart disease-related Quality of Life (HRQoL) 1-year after a coronary artery bypass grafting (CABG) surgery. METHODS: Participants in a prospective cohort study who underwent CABG surgery at seven cardiothoracic units throughout Israel during the years 2004-2007 filled in the MacNew HRQoL one day before and one year after surgery. Successful recovery was defined as ≥0.5 increase in the MacNew score between baseline and follow-up. Exposure to residential greenness in 90 m and 300 m buffers around the patient's home was assessed with Linear Spectral Unmixing analysis of Landsat 30 m imagery. RESULTS: The cohort comprised of 861 patients (22% female) with a mean age of 65.5 years, and 59.2% classified as low-income. In the total cohort, higher residential greenness was associated with an improvement in emotional HRQoL (OR = 1.33 (95%CI: 0.99-1.79)), adjusting for demographic and socio-economic factors, living in the periphery/center, presence of diabetes, attending cardiac rehabilitation following surgery, BMI, and change in physical fitness and depression over the 1-year follow-up. Although no association was found between greenness and change in the physical or social subscales, a positive association was specifically observed among the low-income patients for the global HRQoL score, OR = 1.42 (95%CI: 0.97-2.10), as compared to the higher-income patients, p for interaction = 0.03. CONCLUSIONS: Residential greenness is associated with improvement in HRQoL 1-year after CABG surgery, but not the physical and social scales, only in low-income patients. Ensuring greenery in the living environment may act as a social intervention that supports human health and disease recovery.

Similarity of Protection Conferred by Previous SARS-CoV-2 Infection and by BNT162b2 Vaccine: A 3-Month Nationwide Experience From Israel.

The worldwide shortage of vaccination against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection while the pandemic still remains uncontrolled has led many countries to the dilemma of whether or not to vaccinate previously infected persons. Understanding the level of protection conferred by previous infection compared with that of vaccination is important for policy-making. We analyzed an updated individual-level database of the entire population of Israel to assess the protection provided by both prior infection and vaccination in preventing subsequent SARS-CoV-2 infection, hospitalization with coronavirus disease 2019 (COVID-19), severe disease, and death due to COVID-19. Outcome data were collected from December 20, 2020, to March 20, 2021. Vaccination was highly protective, with overall estimated effectiveness of 94.5% (95% confidence interval (CI): 94.3, 94.7) for documented infection, 95.8% (95% CI: 95.2, 96.2) for hospitalization, 96.3% (95% CI: 95.7, 96.9) for severe illness, and 96.0% (95% CI: 94.9, 96.9) for death. Similarly, the overall estimated level of protection provided by prior SARS-CoV-2 infection was 94.8% (95% CI: 94.4, 95.1) for documented infection, 94.1% (95% CI: 91.9, 95.7) for hospitalization, and 96.4% (95% CI: 92.5, 98.3) for severe illness. Our results should be considered by policy-makers when deciding whether or not to prioritize vaccination of previously infected adults.

Fighting a pandemic: sociodemographic disparities and coronavirus disease-2019 vaccination gaps-a population study.

BACKGROUND: Data suggest lower coronavirus disease-2019 (COVID-19) vaccination coverage among minority and disadvantaged groups. We aimed to identify interactions between sociodemographic factors associated with vaccination gaps. METHODS: This population study used Israeli National COVID-19 data (extracted: 10 May 2021). The analysis comprised 6 478 999 individuals age ≥15 years with aggregated area-level data on sex and age distribution and no COVID-19 history. We estimated vaccination hazard and cumulative incidence using the Fine and Gray competing risk model. RESULTS: Older age and higher socioeconomic status (SES) were associated, with stepwise higher cumulative vaccination rates (age 20-24: 67%, age ≥ 75: 96%; SES 1-3: 61%, 4-5: 74.2%, 6-7: 82%, 8-10: 87%). We found the lowest vaccination rates in Arab (65%) and Ultra-Orthodox Jewish (54%) areas. SES modified the association in Arab neighbourhoods, with higher coverage than in the non-Orthodox Jewish reference group in SES 1-3 [adjusted hazard ratio (HR) = 1.06; 95% confidence interval (CI): 1.02-1.11], and gradually lower coverage in higher SES classes (SES 6-7: HR = 0.83; 95% CI: 0.79-0.87). Vaccination rates were also higher among younger Arabs (≤45 years) compared with age counterparts in the reference population group (age 25-34: HR = 1.18; 95% CI: 1.12-1.28) and lower than the reference group among Arabs age ≥45 years. Among Ultra-Orthodox Jews, vaccination HRs remained below one across age and SES classes. CONCLUSIONS: Age and SES modified the association between population group and vaccination coverage. Identifying the interplay between sociodemographic characteristics and the underlying explanations may improve targeted efforts, aimed at closing vaccination coverage gaps and mitigating COVID-19.

Developing a National Set of Health Equity Indicators Using a Consensus Building Process.

BACKGROUND: Considerable health inequities documented in Israel between communities, populations and regions, undermine the rights of all citizens to optimal health. The first step towards health equity is agreement on a set of national indicators, reflecting equity in healthcare provision and health outcomes, and allowing monitoring of the impact of interventions on the reduction of disparities. We describe the process of reaching a consensus on a defined set of national equity indicators. METHODS: The study was conducted between January 2019 and June 2020, in a multistage design: (A) Identifying appropriate and available inequity measures via interviews with stakeholders. (B) Agreement on the screening criteria (public health importance; gap characteristics; potential for change; public interest) and relative weighting. (C) Constructing the consultation framework as an online, 3-round Delphi technique, with a range of experts recruited from the health, welfare and education sectors. RESULTS: Participants were of diverse age, gender, geographic location, religion and ethnicity, and came from academia, healthcare provision, government ministries and patient representative groups. Thirty measures of inequity, presented to participants, represented the following domains: Health promotion (11 indicators), acute and chronic morbidity (11), life expectancy and mortality (2), health infrastructures and affordability of care (4), education and employment (2). Of the 77 individuals contacted, 75 (97%) expressed willingness to participate, and 55 (73%) completed all three scoring rounds. The leading ten indicators were: Diabetes care, childhood obesity, adult obesity, distribution of healthcare personnel, fatal childhood injuries, cigarette smoking, infant mortality, ability to afford care, access to psychotherapy and distribution of hospital beds. Agreement among raters, measured as intra-class correlation coefficient (ICC), was 0.75. CONCLUSION: A diverse range of consultants reached a consensus on the most important national equity indicators, including both clinical and system indicators. Results should be used to guide governmental decision-making and inter-sectoral strategies, furthering the pursuit of a more equitable healthcare system.

Effect of ethnicity, country of origin and workplace on health behaviors and health perception among nurses: Cross-sectional study.

PURPOSE: The study aimed to (1) examine health behaviors and perceived health among nurses; (2) analyze the effect of nurses' personal and work characteristics on these variables; and (3) explore the relationship between health behaviors and nurses' health perception. DESIGN AND METHODS: A cross-sectional study was conducted among nurses working in health care organizations (HCOs) across Israel. An email with the online questionnaire was sent to nurses working in 19 HCOs across Israel during September-December 2018. FINDINGS: Of 18,120 nurses employed, 3542 completed the survey. Mean age was 44.8 years, 91% were female), 64.6% were hospital nurses and 52.8% were clinical staff nurses. Two-thirds of nurses did not achieve the physical activity (PA) target; the majority reported unfavorable eating habits; 66% slept less than 7 h at night and 15% smoke. Hospital nurses working night shifts reported the least favorable health behaviors. Non-Jewish nurses had less eating habits compared with Jewish nurses. Nurses born in the Former Soviet Union perceived their health as significantly worse than that of the other respondents. Binomial logistic regression demonstrated that, age, Israeli origin, achieving the PA target, having food breaks during work, consuming a Mediterranean diet, sleeping at least 7 h, undergoing screening tests as recommended, and not smoking predicted better health perception among nurses. CONCLUSIONS: Nurses, particularly hospital-based, non-Jewish and immigrants from the Soviet Union, demonstrated unfavorable health behaviors that may negatively affect their wellbeing and health perception. CLINICAL RELEVANCE: Interventions aimed at improving the health promoting mindset of nurses have the potential to improve their health and wellbeing and to enable them to become role models and health educators for patients and their families.

A strengths-based approach to exploring diabetes management in an Indigenous minority population: A mixed methods study.

Indigenous and other marginalized racial/ethnic minorities have poorer health status than majority populations, including higher rates of type 2 diabetes. These disparities have typically been addressed using a 'deficit-based' discourse that isolates disease management from the broader social, economic, political context and does not incorporate patient perspectives. We aimed to explore factors affecting glycemic control among Indigenous Arabs with diabetes in Israel using a strengths-based approach that centered participants' knowledge of their context, needs, resources and strengths. We conducted an exploratory sequential mixed methods study, which included 10 focus groups (5 men's, 5 women's) and 296 quantitative in-person surveys. Participants with diagnosed diabetes were randomly drawn from the patient list of the largest healthcare service organization (survey response rate: 93%). Prominent and interconnected themes emerged from focus group discussions, including: diet, physical activity, and social, economic, mental/psychological and political stress. The discussions raised the need for adapting diabetes management approaches to incorporate participants' communal, physical and psychological well-being, and socioeconomic/political realities. The connections between these factors and diabetes management were also reflected in multivariable analyses of the survey data. Women (OR: 2.03; 95% CI: 1.09-4.63), people with disabilities (OR: 2.43; 95% CI: 1.28-4.64), and unemployed people (OR: 2.64; 95% CI: 1.28-5.44) had higher odds of economic barriers to diabetes management. Furthermore, female sex (OR: 2.26; 95% CI: 1.25-4.09), unemployment (OR: 4.07; 95% CI: 1.64-10.10), and suboptimal glycemic control (OR: 1.20, 95% CI: 1.03-1.41 per 1-unit increase in HbA1c) were associated with moderate-to-severe depressive symptoms. A pro-active, team-based healthcare approach incorporating Indigenous/minority participants' knowledge, experience, and strengths has the potential to improve individuals' diabetes management. Healthcare services should be structured in ways that enable providers to listen to their patients, address their key concerns, and foster their strengths.

Waning Immune Humoral Response to BNT162b2 Covid-19 Vaccine over 6 Months.

BACKGROUND: Despite high vaccine coverage and effectiveness, the incidence of symptomatic infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been increasing in Israel. Whether the increasing incidence of infection is due to waning immunity after the receipt of two doses of the BNT162b2 vaccine is unclear. METHODS: We conducted a 6-month longitudinal prospective study involving vaccinated health care workers who were tested monthly for the presence of anti-spike IgG and neutralizing antibodies. Linear mixed models were used to assess the dynamics of antibody levels and to determine predictors of antibody levels at 6 months. RESULTS: The study included 4868 participants, with 3808 being included in the linear mixed-model analyses. The level of IgG antibodies decreased at a consistent rate, whereas the neutralizing antibody level decreased rapidly for the first 3 months with a relatively slow decrease thereafter. Although IgG antibody levels were highly correlated with neutralizing antibody titers (Spearman's rank correlation between 0.68 and 0.75), the regression relationship between the IgG and neutralizing antibody levels depended on the time since receipt of the second vaccine dose. Six months after receipt of the second dose, neutralizing antibody titers were substantially lower among men than among women (ratio of means, 0.64; 95% confidence interval [CI], 0.55 to 0.75), lower among persons 65 years of age or older than among those 18 to less than 45 years of age (ratio of means, 0.58; 95% CI, 0.48 to 0.70), and lower among participants with immunosuppression than among those without immunosuppression (ratio of means, 0.30; 95% CI, 0.20 to 0.46). CONCLUSIONS: Six months after receipt of the second dose of the BNT162b2 vaccine, humoral response was substantially decreased, especially among men, among persons 65 years of age or older, and among persons with immunosuppression.

Residential greenness and increased physical activity in patients after coronary artery bypass graft surgery.

AIMS: Physical activity is a fundamental component of rehabilitation following coronary artery bypass (CABG) surgery. Proximity to neighbourhood green spaces may encourage physical activity. We investigated the association between residential greenness and exercise-related physical activity post-CABG surgery. METHODS: Participants in a prospective cohort study of 846 patients (78% men) who underwent CABG surgery at seven cardiothoracic units during the time period 2004-2007 were interviewed regarding their physical activity habits one day before and one year after surgery. Exposure to residential neighbourhood greenness (within a 300 m buffer around their place of residence) was measured using the Normalized Difference Vegetative Index. Participation in exercise-related physical activity (yes/no), weekly duration of exercise-related physical activity and the change in exercise-related physical activity between baseline and follow-up were examined for associations with residential greenness, adjusting for socio-demographic factors, propensity score adjusted participation in cardiac rehabilitation and health-related covariates after multiple imputation for missing variables. RESULTS: Living in a higher quartile of residential greenness was associated with a 52% greater odds of being physically active (OR 1.52, 95% CI 1.22-1.90). This association persisted only (OR 1.75, 95% CI 1.35-2.27) among patients who did not participate in cardiac rehabilitation following surgery and was stronger in women (OR 2.38, 95% CI 1.40-4.07) than in men (OR 1.37, 95% CI 1.07-1.75). Participants who lived in greener areas were more likely to increase their post-surgical physical activity than those who lived in less green areas (OR 1.59, 95% CI 1.25-2.01). CONCLUSIONS: Residential greenness appears to be beneficial in increasing exercise-related physical activity in cardiac patients, especially those not particpating in cardiac rehabilitation after CABG surgery.