Improving care for minorities by health education in Israel.

1. Improving care for minorities by health education in Israel. Margalit Goldfracht*,**; Diane Levin*; Ofra Peled* Irit Poraz*; Dorit Weiss*; Nicky Liebermann *, * Clalit Health Services Headquarters,Community Div., Israel ** Family Medicine Department, Technion, Haifa, Israel EquiP Conference Brussels 2004

2. Mr. Raid Atrash Dr. Zuhadi Agbaria Dr. Muchamad Nagemi Dr. Yunes Abu Rabia Mrs. Siham Badarna Mrs. Nuhah Zeidan Dr. Napaz Nobani Dr. Huri Gharir Dr. Zoabi Ghalaal The members of the steering committees in the districts Main Contributors

5. "No one specific intervention, if used alone, led to major improvements in management of chronic diseases " Renders CM, Valk GD, Griffin SJ, Wagner EH, Eijk Van JT, Assendelft WJ. Interventions to improve the management of diabetes in primary care, outpatient, and community settings: a systematic review. [Diabetes Care. 2001;24:1821-33

6. Chronic Diseases Care Model Bodenheimer T, Wagner EH, Grumbach K. JAMA. 2002;288:1775-9

7. The elements of chronic care model: • Community resources and policies • Health care organization • Self management support • Delivery system design • Decision support • Clinical information systems

8. Patients become principal caregivers • Patients live with the disease many years • Proactive approach • Empowerment

9. Israeli largest HMO: insures 57% of Israeli population, 3,700,000 members Insures mainly the 6th socio-economical lower deciles of the population 1200 clinics nationwide 2,000 primary physicians 2,000 nurses in primary care 170,000 diabetes patients 27 ,000 (16%) Arabic diabetes patients Clalit Health Services - Background

10. Multifaceted quality improvement program Interventions: Clinical guidelines 1995, 2000 Structure Multi-professional steering team at the main management and districts Representative of the “Diabetes in the Community” at the executive and primary clinic level “Diabetes in the community” program 1996 -2003

11. Work methods Manual (1996) and computerized (2000) diabetes care map Diabetes registry in every clinic - manual (1996) and computerized (1998-2000) Clinical Pathway - “Policy statement of the Health Service Provider on the subject of diabetes (1998)” Interventions: B

12. Long term compulsory CME 1996,1997,1998,2000, 2001, 2002, 2003 (for all primary care providers) Patients’ empowerment: workshop for providers, health education kits, videos, workshops for patients Performance feedback: Interventions C

13. Quality Circle Goals, indicators Data comparison to the goals Data gathering Problem analysis Data gathering Intervention planning Implementation of the intervention

14. 1995-1999 Randomized sample of 2867 diabetes patients nation wide. Manual data gathering from medical records according to specific indicators 2001 and on Computerized data gathering of all the Diabetes population of the HMO according to well defined indicators Data Gathering

15. Diabetes patients’ follow up - Performance of HbA1c test at least once a year

16. Diabetes patients’ follow upDiabetes control according to HbA1c

17. Follow up and Diabetes Control 2001

18. Goal: to improve control of diabetes among Arabic population of diabetes patients Data gathering: The control of Arabic diabetics was worse: 20% well controlled versus 35% among non Arabs Quality Circle

19. Problem Analysis-Diabetes Control Medical team Beliefs Patient Culture Life Habits

20. Medical team • Quality of the team members According to the HMO policy • Language 90% Arabic speaking • Culture 90% Arabic culture • Accessibility Better than non Arabic population • Guidelines implementation Follow up better than non Arabic population 77% versus 70%

21. Life Habits -Physical ActivityAges 25-65 Survey Ministry of Health (MABA”T) 99-01

22. Life Habits – Obesity BMI>30 Ages 25-65 Survey Ministry of Health (MABA”T) 99-01

23. Diabetes Prevalence - Self ReportAges 25-65 % Survey Ministry of Health (MABA”T) 99-01

24. Culture • Fat is beautiful • Fat is successful • Only poor people walk • Women should not walk outside family compound unattended • Not eating as a guest is an offence to the host • Food is a center of festivities • Concept of chronic disease not clear

25. Beliefs • Fat is healthy • Woman with diabetes will not have children • Man with diabetes is impotent • People with diabetes are invalids Diabetes= stigma

26. Goal: to improve control of diabetes among Arabic population of diabetes patients Data gathering: The control of Arabic diabetics was worse: 20% well controlled versus 35% among non Arabs Problem analysis: the main problems are culture and beliefs of the Arabic population Quality Circle

27. Multidisciplinary team based on Arabic professionals Brainstorming – reasons for the difference in outcomes Brainstorming regarding the intervention Intervention: A health fair in the clinic -concentrating on healthy lifestyle Interventions

28. Quality Circle Goals, indicators Data comparison to the goals Data gathering Problem analysis Data gathering Intervention planning Implementation of the intervention

29. Health fair - stands for Healthy diet Smoking prevention Physical activity Foot care for diabetics Identification of metabolic syndrome (blood pressure testing, BMI, glucose tests) Intervention Planning

31. Lecture about diabetes by physician from the clinic A personal story of diabetes patient from the clinic The lecture was prepared by one of the Arabic professionals in Arabic and distributed to the clinics Intervention Planning

33. Attendance: the health happenings were attended by 6, 6674 people in 92 clinics. 30% identified themselves as diabetics. Methods: We have chosen a randomized cohort for evaluation of 300 people. All the participants were contacted by interviewer in Arabic and interviewed over the phone according to questionnaire HbA1c: We have identified this cohort in our computer data set. We have identified 157 diabetes patients who performed HbA1c test in 2001(before interventions) and 2002-2003(after interventions) Evaluation of the intervention

34. 6674 people attended the health fairs, 15% of all the diabetics. Demography: 37% males, 56% under age 50 30% identified themselves as diabetics, 20% arrived with a diabetes relative, 50% came due to general interest Results

35. Diabetes Control According to HbA1c Levels 2001-2002 N=157

36. Contents recollection

37. Change in life habits – self reported

38. Control of diabetes within Arabic population 2001-2003 according to HbA1c

39. There is a special need within Arabic population for knowledge concerning healthy life style specially among diabetes patients There is need for major campaign among Arabic population to change beliefs and culture to adopt healthier life style Health education employed within quality improvement is an effective method to change outcomes of management of chronic disease Conclusions