Transcript Improving care by health education for minorities in Israel.

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
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Main Contributors
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Mr. Raid Atrash
Dr. Zuhadi Agbaria
Dr. Muchamad Nagemi
Dr. Yunes Abu Rabia
Mrs. Siham Badarna
Mrs. Nuhah Zeidan
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Dr. Napaz Nobani
Dr. Huri Gharir
Dr. Zoabi Ghalaal
The members of the
steering committees in
the districts
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"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
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Chronic Diseases Care Model
Bodenheimer T, Wagner EH, Grumbach K. JAMA. 2002;288:1775-9
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The elements of chronic care model:
• Community resources and policies
• Health care organization
• Self management support
• Delivery system design
• Decision support
• Clinical information systems
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Patients become principal caregivers
• Patients live with the disease many years
• Proactive approach
• Empowerment
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Clalit Health Services - Background
• 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
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“Diabetes in the community”
program 1996 -2003
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
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Interventions: B
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)”
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Interventions C
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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:
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Quality Circle
Goals, indicators
Data comparison
to the goals
Data gathering
Implementation of
the intervention
Data gathering
Problem
analysis
Intervention planning
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Data Gathering
• 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
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Diabetes patients’ follow up - Performance
of HbA1c test at least once a year
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Diabetes patients’ follow up
Diabetes control according to HbA1c
HbA c>
HbA c<
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Follow up and Diabetes Control 2001
%
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follow up
HbA c<
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HBA c>
arabic p
non arabic
p
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Quality Circle
• 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
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Problem Analysis-Diabetes Control
Beliefs
Medical team
Patient
Culture
Life Habits
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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%
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Life Habits -Physical Activity
Ages 25-65
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%
. %
. %
Men
Women
Arabs
Non Arabs
Survey Ministry of Health (MABA”T) 99-01
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Life Habits – Obesity BMI>30
Ages 25-65
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Men
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Women
Survey Ministry of Health (MABA”T) 99-01
Arabs
Non Arabs
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Diabetes Prevalence - Self Report
Ages 25-65
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Men
Women
Arabs
Non Arabs
Survey Ministry of Health (MABA”T) 99-01
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Culture
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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
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Beliefs
• Fat is healthy
• Woman with diabetes will not have children
• Man with diabetes is impotent
• People with diabetes are invalids
Diabetes= stigma
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Quality Circle
• 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
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Interventions
• 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
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Quality Circle
Goals, indicators
Data comparison
to the goals
Data gathering
Implementation of
the intervention
Data gathering
Problem
analysis
Intervention
planning
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Intervention Planning
Health fair - stands for
• Healthy diet
• Smoking prevention
• Physical activity
• Foot care for diabetics
• Identification of metabolic syndrome (blood
pressure testing, BMI, glucose tests)
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Intervention Planning
• 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
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Evaluation of the intervention
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)
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Results
• 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
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Diabetes Control According to
HbA1c Levels 2001-2002
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HbA c<
<Hb C<
HbA C>
N=157
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Contents recollection
Issue
Diet
Percentage of
recollection
100%
Physical activity
99%
Treatment by medications
96%
Smoking prevention
96%
Foot care
98%
Follow up
96%
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Change in life habits
– self reported
Life habit
Diet
Change according
to instructions
40%
Physical activity
15%
Smoking
73%
Foot care
25%
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Control of diabetes within Arabic population
2001-2003 according to HbA1c
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HbA c<
HBA c>
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Conclusions
• 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
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