Diane Levin-Zamir

Media Health Literacy (MHL): development and measurement of the concept among adolescents

Increasing media use among adolescents and its significant influence on health behavior warrants in-depth understanding of their response to media content. This study developed the concept and tested a model of Media Health Literacy (MHL), examined its association with personal/socio-demographic determinants and reported sources of health information, while analyzing its role in promoting empowerment and health behavior (cigarette/water-pipe smoking, nutritional/dieting habits, physical/sedentary activity, safety/injury behaviors and sexual behavior). The school-based study included a representative sample of 1316 Israeli adolescents, grades 7, 9 and 11, using qualitative and quantitative instruments to develop the new measure. The results showed that the MHL measure is highly scalable (0.80) includes four sequenced categories: identification/recognition, critical evaluation of health content in media, perceived influence on adolescents and intended action/reaction. Multivariate analysis showed that MHL was significantly higher among girls (β = 1.25, P < 0.001), adolescents whose mothers had higher education (β = 0.16, P = 0.04), who report more adult/interpersonal sources of health information (β = 0.23, P < 0.01) and was positively associated with health empowerment (β = 0.36, P < 0.0005) and health behavior (β = 0.03, P = 0.05). The findings suggest that as a determinant of adolescent health behavior, MHL identifies groups at risk and may provide a basis for health promotion among youth.

Managing Childhood Overweight: Behavior, Family, Pharmacology, and Bariatric Surgery Interventions

IntroductIon A dramatic rise in overweight has been recently shown to occur among male and female adolescents in many countries, reaching epidemic proportions in Western industrialized countries (1). This increase in childhood obesity places a significant burden on physical, psychological, and social health and calls for an urgent implementation of diverse treatment strategies. It is currently accepted, and probably even required, for professionals to relate to childhood overweight, which signifies a physiological construct, rather than to childhood obesity, which bears considerable derogatory connotation (1). Accordingly, the US Centers for Disease Control and Prevention defines overweight among individuals 2–19 years old as the 95th percentile or greater of BMI-for-age (BMI = weight/height2), and risk for overweight as the 85th to 95th percentile of BMI-for-age (2). In this review we will use the term overweight, unless the use of obesity is required. Treating overweight children is of extreme importance, not only because it affects their physical and psychological well-being and development, but because a considerable proportion of overweight children are at risk to become obese adults (3). Thus, although the indications for medical interventions in overweight children are still not well defined, it is suggested, in accordance with this risk-related definition, that treatment is required in almost all overweight children, and in at risk for overweight children with related medical complications (1). All the authors of the present review article took part in an international multiprofessional consensus meeting dedicated to the issue of pediatric obesity held at the Dead Sea in Israel, in March 2004. The result of this meeting was a comprehensive consensus document where the evidence was summarized, and recommendations developed (1). The present review incorporates the findings of this consensus meeting with respect to currently available treatment options in pediatric obesity with an updated comprehensive systematic literature search of the Cochrane, PUBMED, PSYCHLIT, PSYCHINFO, and ERIC databases. Originally, we aimed to carry out a literature search for the decade before the consensus meeting (1994–2003), but subsequently added comprehensive updated information, including data published between 2004 and 2007. This time period has envisioned the most dramatic increase in the rates of pediatric obesity ever to occur (1). This suggests the presence of a very different treatment environment than before (3), calling for a critical appraisal of currently adequate treatments, promotion of new strategies, and enhancing the conditions for improving treatment outcome. The review is based on a total of 80 articles published between the years 1994 and 2007. The following interventions will be discussed: dieting and nondieting weight reduction programs (15 articles), change in lifestyle (18 articles), behavioral treatment (12 articles), family interventions (18 articles), pharmacotherapy (18 articles), surgical interventions (9 articles), and multidisciplinary in-patient interventions (7 articles) (quite a few articles relate to more than one treatment strategy). The study relates mostly to the findings of randomized control trials (RCTs), or controlled trials, unless otherwise specified.

The Association of Health Literacy with Health Behavior, Socioeconomic Indicators, and Self-Assessed Health From a National Adult Survey in Israel

There is a growing need to understand how health literacy influences health outcomes in diverse populations. The aim of this study was to examine the relationship between health literacy, health behavior, sociodemographic indicators, and self-assessed health in the adult population in Israel while identifying populations at risk for low health literacy. A cross-sectional national survey was conducted among 600 adults randomly selected from a national database. The Health Literacy Survey-Europe-Q16 (HLS-EU-Q16) research instrument, adapted for use in Israel, was the basis for home interviews in Hebrew, Russian, and Arabic. Three levels of health literacy were distinguished: More than 31% of the sample had inadequate or problematic health literacy, and 69% showed likely sufficient health literacy. Logistic regression analyses showed that after we controlled for other determinants, years of education (β = 1.8) and income (β = 2.2) were significantly associated with health literacy. Multinomial logistic regression analysis showed that health literacy, along with age, was the strongest independent variable associated with self-assessed health. Thus, health literacy, strongly influenced by income and years of education, may play a key role in determining self-assessed health, a proxy health outcome, beyond sociodemographic variables. The study results contribute to understanding the role of health literacy in health disparities and identifying action areas for health promotion.

A participatory process for developing quality assurance tools for health education programs

There is a constant need to find methods and tools for achieving high quality in health education and health promotion programs. The aim of this initiative was to develop standards and criteria for quality assessment of health education programs. Health educators participated in a process to develop these standards and criteria. A consensus was reached regarding the list of standards by participation of the health educators in two workshops. This list consisted of the three main stages of health education programs: planning, implementation and evaluation. Operational criteria for each standard were developed in order to be able to measure the standards. Four different subjects were chosen for the development of the criteria: menopause, smoking cessation, cardiac rehabilitation and prenatal care. A consensus regarding these criteria was reached by discussions in workshops. The tools developed were tested by interviewing health educators who were planning and running these programs. The tools built were found acceptable by the health educators as they provided information on the quality of the programs.

Refuah Shlema: a cross-cultural programme for promoting communication and health among Ethiopian immigrants in the primary health care setting in Israel Evidence and lessons learned from over a decade of implementation

The Refuah Shlema programme was established to reduce health disparities, promote health literacy and health indicators of the Ethiopian immigrant community in Israel, and included: (i) integrating Ethiopian immigrant liaisons in primary care as inter-cultural mediators; (ii) in-service training of clinical staff to increase cultural awareness and sensitivity; and (iii) health education community activities. Qualitative and quantitative evidence showed improvements in: (i) clinic staff—patient relations; (ii) availability and accessibility of health services, and health system navigation without increasing service expenditure; (iii) perception of general well-being; and (iv) self-care practice with regards to chronic conditions. Evidence significantly contributed to sustaining the programme for over 13 years.

Comparative analysis of diabetes self-management education programs in the European Union Member States

Diabetes self-management education (DSME) is generally considered as an integral part of diabetes care. The availability of different types of self-management in the European Union Member States (EUMS) remains uncertain. The aim of this study is to perform a comparative analysis of existing DSME programs (DSMEP) implemented in EUMS. Unpublished data regarding DSME in the EUMS was assessed with Diabetes Literacy Survey using wiki tool (WT) targeting patients and different stakeholders. An additional literature review (LR) was performed in PubMed to identify published studies regarding DSMEP in the EUMS from 2004 to 2014. A total of 102 DSMEP implemented in EUMS were reported in the WT and 154 programs were identified from the LR. Comparative analysis of the data indicated that a majority of programs are aimed at adults and only a minority at children and elderly. Only a small percentage of the programs utilize information technology for teaching and learning, and only one out of five programs pay attention to depression. The identified DSMEP aimed primarily to empower patients through increasing knowledge and changing attitudes and beliefs towards diabetes. This study provides an overview of the present state-of-the-art on diabetes self-management education programs in the 28 EUMS. To increase participation, existing DSMEP should be made more accessible to the patients as well as tailored to specific patient groups.

The impact of health literacy on diabetes self-management education:

Background: Diabetes self-management education (DSME) is generally considered to be a key determinant of the treatment outcomes and related costs of diabetes mellitus. While DSME programmes generally have positive outcomes, their effects may depend on certain factors, such as the type of programmes provided and patients’ level of health literacy (HL). Low HL has been associated with poorer self-management behaviours and poor medication adherence in diabetic patients, but its impact on the effects of DSME has not yet been systematically investigated. This study aimed to investigate the influence of HL on the self-reported effects of DSME programmes while taking the type of programme into consideration. Method: A total of 366 diabetic patients from nine countries completed a questionnaire measuring HL, self-management behaviours, problem perception, coping, perceived general health and well-being, before and after participating in a DSME programme. Results: DSME programmes were found to have positive effects on self-reported self-management behaviours and almost all psychological and health outcomes, regardless of HL level. Patients with high HL scored better on several diabetes outcomes than those with low HL, but all patients described benefiting from DSME. Individual and group-based programmes resulted in more positive effects on several diabetes outcomes than self-help groups, but no interaction with HL was found. Conclusion: Our findings confirm those of previous studies showing that DSME programmes have positive effects and that low HL is associated with lower diabetes outcomes but do not support the assumption that the effects of DSME programmes are influenced by the patient’s HL. However, due to the limitations of this study, further investigation is necessary to support these findings and improve our understanding about the impact of HL on DSME programmes’ effectiveness.

State of diabetes self-management education in the European Union Member States and non-EU countries. The Diabetes Literacy project.

Background Diabetes self-management education (DSME) is considered essential for improving the prevention and care of diabetes through empowering patients to increase agency in their own health and care processes. However, existing evidence regarding DSME in the EU Member States (EU MS) is insufficient to develop an EU-wide strategy. Objectives This study presents the state of DSME in the 28 EU MS and contrasts it with 3 non-EU countries with comparable Human Development Index score: Israel, Taiwan, and the USA (ITU). Because type 2 diabetes mellitus (T2DM) disproportionately affects minority and low-income groups, we paid particular attention to health literacy aspects of DSME for vulnerable populations. Methods Data from multiple stakeholders involved in diabetes care were collected from Feb 2014 to Jan 2015 using an online Diabetes Literacy Survey (DLS). Of the 379 respondents (249 from EU MS and 130 from ITU), most were people with diabetes (33% in the EU MS, 15% in ITU) and care providers (47% and 72%). These data were supplemented by an expert survey (ES) administered to 30 key informants. Results Access to DSME varies greatly in the EU MS: an average of 29% (range 21% to 50%) of respondents report DSME programs are tailored for people with limited literacy, educational attainment, and language skills versus 63% in ITU. More than half of adult T2DM patients and children/adolescents participate in DSME in EU MS; in ITU, participation of T1DM patients and older people is lower. Prioritization of DSME (6.1 ± 2.8 out of 10) and the level of satisfaction with the current state of DSME (5.0 ± 2.4 out of 10) in the EU MS were comparable with ITU. Conclusion Variation in availability and organization of DSME in the EU MS presents a clear rationale for developing an EU-wide diabetes strategy to improve treatment and care for people with diabetes.

Health Literacy, Diabetes Prevention, and Self-Management

In the last few decades, focus on how to achieve and support maintenance of optimal glycemic control has become a wellestablished research area. It is well known and accepted that the degree of blood glucose control, especially in diabetes mellitus type 2, is linkedwith the risk of developing complications such as heart disease, stroke, renal failure, and blindness [1, 2]. Patients’ knowledge about diabetes mellitus, their attitudes towards self-management, and self-management skills, together with lifestyle choices, are central to achieving and maintaining glycemic control, both in the short term and long term. The World Health Organization defines health literacy as “the personal characteristics and social resources needed for individuals and communities to access, understand, appraise and use information and services to make decisions about health” [3]. Health literacy is known to be associated with health outcomes, including chronic disease and diabetes [4]. Among people with type 2 diabetes, inadequate health literacy is independently associated with worse glycemic control, higher rates of retinopathy, and lower self-rated health [5, 6]. Inadequate health literacy may contribute to the disproportionate burden of diabetes-related problems among disadvantaged populations [6, 7]. A variety of measures have been developed to assess health literacy depending upon context, as reflected in the articles in this special issue. Needing to understand this association inmore depth and to explore potential interventions to improve diabetes health outcomes and quality of life was the basis for dedicating a special edition of this journal to such issues. The intention is to contribute to an evidence base that better informs diabetes treatment and prevention planning for patients, clinicians, and health policy decision-makers The main themes highlighted in this issue are health literacy and lifestyle in relation to diabetes, including studies exploring behavior change and motivation; mechanisms, moderators, and mediators of change; interventions to promote healthy lifestyles with respect to diabetes; self-care and self-management including health promotion aspects of diabetes care; health literacy; the role of family, peer support, and other care-givers, social networks, and distributed health literacy; and health systems navigation andmanagement.The 12 studies included reflect a global reach, with research from six countries across four continents.

Internal locus of control, health literacy and health, an Israeli cultural perspective

The association between health literacy (HL) and health outcomes, including self-perceived health (SPH) has been well documented. Yet the complexity of this association is not yet completely clear. Drawing on the Health Literacy Scale (HLS) study in Israel, we examined the association between HL, Internal Health Locus of Control (IHLOC) and SPH among Jews and Arabs. A face-to-face survey was conducted among 242 Arabs and 358 Jews. The questionnaire measured SPH, IHLOC and two measures of HL: a European HLScale (HLS-EU-16) and the Hebrew/Arabic Health Literacy Test (H/AHLT), based on the Short Test Of Functional Health Literacy in Adults. Analysis included multivariable logistic regressions and bootstrapping to identify mediation effects.  Among Jews, IHLOC seems to be a significant mediator between HL and SPH. IHLOC was strongly associated with SPH (OR = 6.13; CI = 3.2, 11.8), while HL was not significantly associated directly with SPH. Similar results were observed when using the H/AHLT as a measure of HL. Among Arabs a different pattern emerges; IHLOC was neither associated with SPH nor was it a mediator of the association between HL and SPH. The two measures of HL seem to have different associations with SPH among Arabs, as only H/AHLT was associated significantly with SPH, and not HLS-EU-16. Thus, those with higher levels of IHLOC assess their health as better than those with low IHLOC only among Jews, and not among Arabs. IHLOC seems to be a significant mediator between HL and SPH among some cultures. Among Arabs, only functional HL seems to be positively associated with SPH.