A Nursing Home in Arab-Israeli Society - Wiley Online Library

INTERNATIONAL HEALTH AFFAIRS

A Nursing Home in Arab-Israeli Society: Targeting Utilization in a Changing Social and Economic Environment Khalid Suleiman, MD w and Adrian Walter-Ginzburg, PhDz

This article is a case study of the first 10 years of operation (1992–2002) of the Dabouriya Home for the Aged, the first publicly funded culturally adapted nursing home for Israeli citizens of Arab descent. Although 44% of Arab Israelis and 26% of Jewish Israelis aged 65 and older are disabled, in 1999, 4.3% of the Jewish population but only 0.7% of the Arab-Israeli population aged 65 or older lived in long-term care institutions; disabled Arab-Israeli elderly were mainly cared for by families. As Arab-Israeli society modernizes and traditional caregiving is reduced, alternatives must be found for this growing, disabled population. Medical and administrative records of 404 people admitted consecutively to a 136-bed facility over 10 years were analyzed. Two distinct segments of the needy population were served: people with independent activity of daily living (ADL) function but little or no family to provide help with intermediate ADLs and those dependent in ADLs and with health problems, especially dementia. Economic, demographic, and social changes in Arab-Israeli society may mean that traditional caregivers will not be able to adequately care for this highly disabled population. Administrators of the public health system in Israel should be aware of the underutilization of publicly funded long-term care by disabled Arab Israelis and the lack of care alternatives for the population that does use nursing homes, because there may be severe consequences in terms of caregiver burden and social stress when disabled elderly people remain in unsuitable environments. J Am Geriatr Soc 53:152–157, 2005. Key words: Arab-Israeli; Israel; nursing home; utilization; modernization; status of women; status of elderly; institutionalization

W

hen formal long-term care services are offered to a traditional, conservative, modernizing society that cares for its elderly within the family, clan, and village,1 it is From the Dabouriya Home for the Aged, Dabouriya, Israel; wDepartment of Cardiology, HaEmek Hospital, Afula, Israel; and zHerczeg Institute on Aging, Tel Aviv University, Tel Aviv, Israel. Address correspondence to Adrian Walter-Ginzburg, PhD, Mavoh Ganigar 4, Tel Aviv, Israel 69359. E-mail: [email protected]

JAGS 53:152–157, 2005 r 2005 by the American Geriatrics Society

appropriate to examine the extent to which the services are adopted and to specify the niche that they fill.2 There are 1.2 million Arab Israelis, constituting about 20% of the total Israeli population; 76% are Muslim, 15% Christian, and 9% Druze.3 Despite economic and social differences between Jewish and Arab Israelis,4,5 life expectancy of Arab Israelis is high, continues to increase,3 and is higher in Arab Israelis than in similar populations in neighboring countries.6 Only 3.1% of Arab Israelis are aged 65 and older, compared with about 11% of Jewish Israelis, because of higher fertility and lower life expectancy,7 meaning that there are more potential sources of nonelderly social support among Arab Israelis than Jewish Israelis. Although 26% of Jewish Israelis and 44% of Arab Israelis aged 65 and older have difficulty with or are unable to perform some activities of daily living (ADLs),8,9 in 1999, 4.3% of the Jewish population (about 17% of the disabled Jewish elderly) and 0.7% of the Arab-Israeli population (2% of disabled Arab Israelis) aged 65 and older lived in an institutional setting.10 Provision of health care and longterm care to elderly Israelis is through universal health insurance (since 1995), which covers most acute and chronic health care and is responsible for regulating long-term care institutional care, with supervision and means-tested funding (analogous to Medicare) provided by the Ministry of Labour and Social Affairs or the Ministry of Health (depending on the eligibility of patients, based on their health and functional status).11,12 About 13% of Jewish and Arab elderly receive home care services under Community LongTerm Care Insurance, an entitlement home care program begun in 1987 that provides hours of services to the elderly from home care service providers or allowances to families without service providers.13 Because Arab-Israeli elderly are more disabled than Jewish-Israeli elderly, this represents 29% of the Arab and 52% of the Jewish disabled elderly.14 The overall picture is of a population with high needs and disproportionately low utilization of services from the public sector. This article presents a case study of the utilization of the first publicly funded, culturally adapted nursing home for Israeli citizens of Arab descent, the Dabouriya Home for the Aged (DHA), in the Arab village of Dabouriya. The goal is to understand the implementation of modern healthcare services in an underdeveloped sector of a relatively

0002-8614/05/$15.00

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JANUARY 2005–VOL. 53, NO. 1

developed country. The elderly Israeli-Arab population was offered, for the first time, modern, Western-style, institutional long-term care services culturally, architecturally, and socially adapted to their needs. Some characteristics of the first decade of this service are explored.

TRADITIONAL ARAB-ISRAELI SOCIETY Arab-Israeli society has, until recently, been rural and agricultural, with a social structure based on the extended family organized into locality-based hamulas that had prime responsibility for economically and physically caring for needy elderly family members.15,16 Islam requires children to honor, care for, and serve their parents in old age: ‘‘Your Lord has commanded that you be kind to your parents, for they did care for (you) when (you were) little’’ (Qur’an 17:23–4). In recent decades, traditional Arab-Israeli society underwent transformation to a modernizing, industrializing, and urbanizing society,16,17 congruent with changes worldwide in the organization of work and family life, the status of women, and the status of older people.1,18– 21 This forced the elderly Arab-Israeli population into a transition from familial to publicly provided services.15,22,23 As many women leave home for school and jobs, and younger people find their livelihood in cities rather than in rural areas, the need for alternative sources to care for the growing, disabled population of Arab-Israeli elderly is also growing. These demographic and economic trends became apparent in the 1980s, and Eshel (the Association for the Planning and Development of Services for the Aged in Israel, a nongovernmental organization established in 1969, www.jdc.org.il/eshel/eshelhom.html), the Ministry of Health, and the Ministry of Labour and Social Affairs worked together to finance and build a public nursing home, opened in 1992, in the Arab village of Dabouriya, located at the foot of Mt. Tabor in northern Israel near the Sea of Galilee. The nursing home administrators soon discerned reluctance on the part of the demonstrably disabled elderly to use the services. Not only did the nursing home fail to achieve full occupancy after 10 years of operation (in 2002 it was 87% occupied), but internal audits found that about one-fourth of residents who entered returned home within months of admission. The staff conducted a study to understand this phenomenon, and they found that the reasons the families themselves gave for leaving were not resident’s improved health or functional condition but rather social norms, feelings of shame, and social pressure on the families to bring their elderly relatives home,24 revealing a cultural stigma associated with placing elderly relatives in nursing homes. GOALS OF THE STUDY The goals of the current study were to understand the role of DHA in the modernizing Arab-Israeli society and to delineate whom the institutional services offered have served. The sociodemographic, health, functional, physical, and mental status of 404 residents admitted consecutively to DHA during the first 10 years of operation were examined to shed light on the role of the nursing home in light of norms of family care and documented social pressures against placing an elderly relative in the nursing home.

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Given the clash between tradition and medically and functionally driven needs, where does a nursing home fit in the spectrum of needs and services in Arab-Israeli society? The hypothesis was that the nursing home served those with little or no other source of care, such as the childless, and those with potential social support whose needs were too great for their families to meet.

METHODS DHA is a 136-bed facility designed to provide a socially, culturally, and religiously appropriate long-term care setting for elderly Arab Israelis. Residents’ health insurers provide health insurance, and means-tested subsidies by the Ministries of Health and of Labour and Social Welfare support the residential portion of their care. This analysis is based on administrative, medical, nursing, and social work records of DHA at admission and discharge or death as to sociodemographics, place of residence before admission, physical and mental function, morbidity, and health status. Using Microsoft Excel (Microsoft Corp., Redmond, WA), comparative statistics were calculated using chi-square with a level of clinical significance of Po.05. The following domains were assessed: ADLs: bathing/showering, dressing, eating, transferring in/out of bed/chair, and using the toilet25 Instrumental ADLs: care of personal possessions, using telphone, managing money, and securing personal items26 Cognitive status: Mini-Mental State Examination27 The Ministry of Health in Israel classifies the level of care needed by residents of long-term care institutions, and type of residence and services are determined by this classification: 1. Nursing patients: not independently mobile; bedridden or in a wheelchair; need full help with at least four of the above-listed ADLs. May also have cognitive disfunction but are classified according to mobility 2. Frail: independently mobile; independent in or need only partial help with basic ADLs, but need help with above listed instrumental ADLs; without significant cognitive disfunction 3. Mentally frail: independently mobile with significant cognitive impairment that affects daily independent functioning

RESULTS From December 1992 through December 2002, 404 residents from 71 villages and cities (69% from rural areas, 31% from urban areas) were admitted to the 136 beds in DHA. Seventy-six percent were Muslim, 22% Christian, and 2% Druze. Mean age standard deviation was 74.6 12.6 (Table 1). Fifty-eight percent were women (mean age 76.8), of whom 76% were nursing patients; 42% were men (mean age 72.9), of whom 55% were nursing patients. Twenty-three percent of the residents were younger than 65, 23% were aged 65 to 74, and 54% were aged 75 and

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Table 1. Demographic, Social, and Functional Characteristics of 404 Residents Admitted Consecutively to Dabouriya Home for the Aged, 1992 to 2002 Characteristic Age, mean SD Marital status, n (%) Married Widowed Divorced Never married Number of children, n (%) 0 1–3 4 Mean SD Lived alone before admission, n (%)

Nursing (n 5 259, 64%)

Frail (n 5 120, 30%)

Mentally Fail (n 5 25, 6%)

Total (N 5 404)

73.9 12.9

77.4 9.5

72.1 11.2

74.6 12.6

90 (35) 144 (56) 5 (2) 20 (11)

40 (33) 29 (24) 22 (10) 29 (24)

16 (64) 7 (28) 1 (4) 1 (4)

146 (36) 180 (45) 28 (7) 50 (12)

NS o.001 o.001 o.001

59 (23) 40 (15) 160 (62) 4.9 3.6 51 (20)

59 (49) 24 (20) 37 (31) 2.1 1.9 55 (46)

4 (16) 1 (4) 20 (80) 4.8 3.9 2 (8)

122 (30) 65 (16) 217 (54) 4.3 3.3 108 (27)

o.001 o.001 o.001 o.001 o.001

P-value

Nursing versus frail residents. Source: Medical and administrative records, Dabouriya Home for the Aged. SD 5 standard deviation

older. Eighty-six percent of the younger residents were nursing patients. Sixty-four percent of the mentally frail residents were married, compared with about one-third of nursing and frail residents. A higher proportion of nursing (56%) than of frail (24%) patients were widowed, and more of the frail (24%) than nursing (11%) patients had never been married. A high proportion (31%) had no children, and the frail were more likely to be childless (49%) than were nursing patients (23%) or the mentally frail (16%, Po.001). The mentally

Table 2. Disability and Health Characteristics of 404 Residents Consecutively Admitted to the Dabouriya Home for the Aged, 1992 to 2002 (N 5 404) 1992–1997 1998–2002 (n 5 203) (n 5 201) Characteristic Source of admission Community Hospitals Other nursing home Physical disability Disability in all basic activities of daily living Bed bound Cognitive deficit Mild to moderate Severe Specific diagnoses Stroke Dementia Hip fracture Hip fracture and stroke

Total

n (%) 148(73) 48 (24) 7 (3)

108 (54) 87 (43) 6 (3)

256 (63) 135 (34) 13 (3)

133 (66)

142 (71)

275 (68)

131 (65)

128 (64)

259 (64)

89 (44) 43 (21)

77 (38) 78 (39)

166 (41) 121 (30)

81 (40) 41 (20) 44 (22) 23 (11)

68 (34) 68 (34) 33 (16) 19 (9)

149 (37) 109 (27) 77 (19) 42 (10)

Po.05 (1992–1997 vs 1998–2002). Source: Medical and administrative records, Dabouriya Home for the Aged.

frail residents had large family structures; 64% were married and 80% had four or more children. Of the three categories of residents, the frail were most likely to have lived alone before entering the nursing home (46%), compared with 20% of the nursing patients and 8% of the mentally frail (Po.001). Disability and health characteristics of the residents during two periods of time, 1992 to 1997 and 1998 to 2002, were examined to help understand whether health and physical characteristics of the residents shifted as the nursing home became an established institution. A ward for the mentally frail was opened in 1998, providing a care option for that portion of the population. In addition, staff made efforts to fill unoccupied beds with handicapped and disabled younger people, causing the proportion of people younger than 65 to rise from 14% in the 1992 to 1997 period to 31% in the 1998 to 2002 period. Sixty-three percent of those admitted had been living in the community, with more coming straight from the community in the earlier period (73%) than in the later period (54%) (Table 2). Thirty-four percent overall were admitted directly from hospitals, a proportion that increased from 24% to 43% over time. Only 3% were admitted from other nursing homes in both periods. Sixty-eight percent of those admitted to the nursing home were disabled in all the basic ADLs, and 64% were bed bound, with little change between earlier and later years in either characteristic. Although only a minority of those admitted to the nursing home were mentally frail, more than 65% of residents admitted in the earlier period and 77% of those admitted in the later period had cognitive deficits, associated with the opening of the ward for the mentally frail in 1998. The most frequent disease diagnoses were stroke, which decreased over time; dementia, which increased almost 50% over time; and hip fracture and both hip fracture and stroke, both of which declined. The reasons at admission of why the resident moved to DHA include inability of the family to cope at home (69% and 63%, respectively, for admissions from hospital and

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community), repeated hospitalizations (57% and 45%), medical conditions that families could not treat (49% and 41%), and housing inadequate to needs (41% and 32%) (Table 3). Social problems and refusal to treat at home were stated to be lesser issues.

DISCUSSION Two challenges face providers of long-term care services to disabled populations: ensuring that adequate services are available and that those in need of the services use them. In economic terms, there are issues of supply and issues of demand, and the job of the health services system is to try to bring those forces into balance. As in economics, there can be a lag between increase (or change) in demand and provision of supply, especially when the supply involves building infrastructure, such as a nursing home, or designing and funding care programs. There also may be a lag between the increase in supply and increase or adaptation of demand to the new supply. For Arab-Israeli disabled elderly, a highly disabled group living in a society in transition from tradition to modernity, there is decreasing supply of traditional family caregivers, but there seem to be more obstacles to developing appropriate demand for an increasing supply of publicly provided services than for disabled Jewish citizens of Israel. The characteristics of those who used DHA confirmed that utilization was the result of the competing claims of

Table 3. Reasons for Admission to Dabouriya Home for the Aged, 1992 to 2002 From Hospital (n 5 135) Cause Family unable to cope with the ill elder at home Repeated hospitalizations Complications due to inadequate treatment at home (dehydration, pressure ulcers, repeated infectious diseases and others) Inadequate housing Social problems Family refused to treat the elder at home

From Community (n 5 256) n (%)

93 (69)

161 (63)

77 (57)

116 (45)

66 (49)

105 (41)

55 (41)

82 (32)

28 (21) 34 (25)

97 (38) 46 (18)

Note: Respondents could give more than one answer, so responses sum to more than 100%. Source: Medical and administrative records, Dabouriya Home for the Aged.

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norms and needs. Those who have large families follow social norms that encourage care of the disabled at home, but when the elderly need extensive nursing or develop cognitive deficits, the norm is violated and the family turns to the formal sector for care. Likewise, despite the norm of family care, some of those less dependent physically, the frail residents, could live in the community if there were adequate social networks, but it was found that the frail had the fewest children and were most likely to be living alone, indicating smaller social networks. They violated the norm of large families, so their need for care could not be met in the community, and they turned to a nursing home. All this confirms the hypothesis that the nursing home serves those with little or no other source of care and those whose families cannot meet their needs. Cultural norms of Arab Israelis cannot be discounted as an influence on the low rate of utilization of formal sector services. A study conducted inside DHA found that fully one-fourth of residents admitted during the first 10 years of operation left the institution after an average of 5.4 months, most because of social norms, feelings of shame, and social pressure, not because of rehabilitation or improvement in health.24 That the low proportion of Arab-Israeli elderly living in institutions remained stable at 0.7% of the population, despite the development of an additional seven nursing homes in the Arab sector during the 1990s, indicates the difficulties of matching the demand for nursing homes of very disabled people by simply increasing supply.10 These findings show that DHA serves two distinct segments of the needy population: frail residents with little or no family to provide care and nursing and mentally frail residents whose families cannot provide the level of service necessary.28,29 The nursing residents had many children, but their need for full support with ADLs made it difficult for their families to care for them at home. Half of those classified as frail had no living children and entered the nursing home despite independence in ADLs because of lack of family,30 pointing to a population for whom DHA provides a social and a medical solution to care in old age. The many residents younger than 65, most victims of traffic accidents or birth defects, lived in an institution built for the elderly because of a lack of other appropriate living arrangements and because the administrative staff of the nursing home wished to fill empty beds. Some possible explanations of why DHA was not fully occupied after 10 years have been explored, and the two niches that it fills were described. Arab Israelis have been found to use other health services at lower rates than comparable Jewish Israelis.31–33 Nursing home utilization by Arab Israelis might be inhibited because families lose subsidies for home care paid to them when other caregivers are not available; a preference for remaining in the community and within the extended family; a negative attitude, verging on stigma, against placement of an elderly family member in an institution away from home;24 lack of knowledge of services; and unwillingness or inability of rural families to travel to Dabouriya for visits.34 Although Dabouriya is located in the northern part of Israel, where 43% of all Arab Israelis aged 65 and older live,35 this rural area has relatively poor intervillage public transportation, and families from nearby communities may face transportation difficulties visiting a relative in Dabouriya. U.S. studies show that

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minorities use institutional solutions less than whites,36 and cognitive, health, and functional problems, as well as smaller social networks, are associated more with institutional use,37,38 consistent with the findings that health problems, caregiver burden,39 and inadequate housing were important self-reported reasons for entering the nursing home. A Canadian study found lower socioeconomic status associated with higher risk of nursing home admission in a population with universal health insurance,40 a finding that shows that a mature, universal caregiving system can care for all eligible needy persons. This study had limitations. The study of one nursing home cannot cover all aspects of institutional long-term care by Arab Israelis, a population of more than one million people, but because DHA was the first publicly funded nursing home in the Arab-Israeli population sector, it is worthy of examination as a case study. Second, because care for the elderly is a new item on the agenda in Arab and Eastern Mediterranean countries,41 examining the experience in Dabouriya can help bring supply and demand for long-term care into balance in similar cultural environments. During the period of the study, an entitlement home care program, Community Long-Term Care Insurance, was fully implemented in Israel,13 and it might be claimed that home care was substituted for institutional care, but a brief analysis shows that only 33% of disabled Arab elderly receive services from nursing homes, home care, and day care, compared with 72% of disabled Jewish elderly,14 showing underutilization of that program as well. Given the economic, demographic, and social changes in Arab-Israeli society described here, in the near future, traditional caregiving arrangements may not provide adequate assistance to a highly disabled population. Understanding the characteristics of utilization of a modern nursing home can help plan future services as part of a spectrum of options for long-term care offered to and used by Arab Israelis as this sector modernizes. The long-term trend is troubling. The proportion of the Jewish-Israeli population aged 65 and older in nursing homes was 4.4% in 1990; by 1999 it was 4.9%, whereas the proportion of Arab Israelis in nursing homes remained 0.7%.42 Despite a trend in the Western world to encourage home care and discourage institutional care for the elderly, this study demonstrated that institutional care provides a solution for those with less-available social support and for those whose needs are greater than can be met in the community. It is important that the administrators of the public health system in Israel become aware of the underutilization by disabled Arab Israelis of publicly funded long-term care, which may indicate severe consequences in terms of caregiver burden and social stress when disabled elderly remain in unsuitable environments.38,43,44 As has been said of other ethnic groups in another country, ‘‘the resiliency of these caregiving arrangements cannot be taken for granted,’’45 and the day may come when Arab-Israeli families can no longer shoulder the burden of their ill and disabled older members.

ACKNOWLEDGMENTS The authors would like to acknowledge the ongoing funding of the DHA by the Association for the Planning and


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Development of Services for the Aged in Israel (Eshel) and the Ministries of Health and of Labour and Social Affairs. The staff of DHA and the members of the Association for the Elderly, Dabouriya, Israel, are owed a special debt of gratitude for their hard work. All of the analysis is entirely our own, and we are responsible for any errors or misinterpretations.

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