Southern et al. International Journal for Equity in Health (2015) 14:63 DOI 10.1186/s12939-015-0193-8
RESEARCH ARTICLE
Open Access
Varied utilisation of health provision by Arab and Jewish residents in Israel Jo Southern1, Hector Roizin2, Muhannad Daana2, Carmit Rubin3, Samantha Hasleton2, Adi Cohen2, Aviva Goral3, Galia Rahav4, Meir Raz2, Gili Regev-Yochay3,4* and for the PICR group
Abstract Introduction: Provision of healthcare is considered a basic human right. Delivery and uptake is affected by many complex factors. Routine vaccinations are provided free of charge in Israel to all residents. The Palestinian Israeli Collaborative Research (PICR) group conducted research on vaccine impact at eight primary care facilities in east Jerusalem (EJ) and central Israel (IL) which allowed assessment and comparison of interactions of these Arab and Jewish populations, respectively, with healthcare services. Methods: Families attending clinic with a child under five years old were invited to participate. Utilisation of healthcare was assessed using data from standardise questionnaires completed after enrolment, using proxies of vaccination status, antibiotic use, primary care physician and hospital visits as well as demographics such as household size. Differences between EJ and IL were assessed using chi squared tests; univariate analyses identified potential confounders which were tested in a multiple logistic regression model for any independent associations between region and outcome. Results: Children in EJ were significantly more likely to live in larger households, with tobacco smokers, to have been breastfed, hospitalised and used antibiotics recently than those in IL, who were significantly more likely to have recently seen a primary care physician (all p < 0.01). Receipt of routine vaccinations, given at well baby clinics, was similar between the regions at above 95 % (p = 0.11), except for influenza which was delivered separately at primary physician clinics to 5 % (EJ) and 12 % (IL). Receipt of pneumococcal vaccine when paid for separately was significantly higher in IL than EJ (3 % vs 31 %). Multivariate analysis identified the most important independent predictors of these differences as region, age and household size. Conclusions: Healthcare in Israel is of a very high standard, but it is not uniformly utilised within the community in all geographical areas, though in some key areas, such as uptake of most routine childhood vaccination, equality seems to be achieved. To ensure excellent healthcare is achieved across the population, inequalities must be addressed, for instance in health promotion and other activities, which could improve and normalise health outcomes.
Introduction Healthcare is considered a basic human right [1, 2], with access to medical care essential in establishing and maintaining efficiently functioning communities. Access to and utilisation of health care provisions at both the individual and population level is complex. * Correspondence:
[email protected] 3 Infectious Disease Epidemiology Section, The Gertner Institute, Tel Hashomer 52621, Israel 4 Infectious Disease Unit, Chaim Sheba Medical Center, Ramat Gan 52621, Israel Full list of author information is available at the end of the article
Many factors are involved in how populations access health care including financial, organisational, social and cultural variability, meaning affordability, physical access, and acceptability of the service, not only its supply. The availability of services and barriers to access have to be considered in the context of differing perspectives, health needs and material and cultural settings of diverse groups in society [3]. The opportunity to assess the utilisation of healthcare facilities in discrete communities served under the same health policy was provided through a study conducted in primary care facilities by the Palestinian
© 2015 Southern et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http:// creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Southern et al. International Journal for Equity in Health (2015) 14:63
Israeli Collaborative Research group (PICR) [4, 5]. While the major aim of the PICR study was to assess the impact of pneumococcal vaccination, data were also recorded on how these communities accessed medical care. In this analysis, utilisation of healthcare provision was assessed using the proxies of visits to the primary pediatrician, prescription of antibiotics, receipt of vaccines (primary, influenza as well as pneumococcal conjugate vaccine (PCV7)) and hospitalisations. As with many countries, provision of vaccines in Israel is under national policy guidance from the Health Ministry, which delivers a vaccination programme across all age groups free of charge, known as the National Immunisation Policy (NIP) [6]. The programme is delivered in primary care under the “Uniform Benefits Package”, which is managed by four non-profit Health Maintenance Organisations (HMOs), that are supported by employer contributions and the National Insurance Institute, to which registration with one is compulsory for all citizens and residents by law [7]. It is of note that primary immunisations in the NIP are delivered in Israel at specialised “well baby” clinics, where babies are also taken for routine check-ups and weighing etc., but that influenza vaccines are delivered through the primary care physician service. PCV7 was approved for use in 2007 in Israel, and introduced into the Israeli NIP in July 2009, under a 2, 4, 12 month schedule, with a two dose catch-up for those under two years of age, free of charge.
Method Institutional review board (IRB) and patient consent
IRB approvals were given by local committees of the Sheba Medical Centre and Macabbi Healthcare Services (MHS). Written informed consent was given by a parent for each participating child before enrolment. Districts, clinics and study populations
Eight clinics in two districts participated: 1) East Jerusalem (EJ) District - four large MHS clinics located in different neighbourhoods in East Jerusalem, serving the exclusively Palestinian population living there, who have been considered Israeli residents since 1967 and thus treated according to Israeli Health law and policy. 2) Central Israel (IL) District - four similarly large MHS clinics, located in three cities in Hashfela District, Bat-Yam, Rishon Lezion, and Holon, serving the population living there (>99 % Jewish population). Any child under five years of age, who visited any of the participating clinics for any reason in the two districts (EJ and IL) during May-July of two consecutive years (2009–2010), was recruited if a parent agreed and gave written informed consent. All participants were managed according to the Israeli Health policy, insured
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by the same HMO; MHS, one of the major HMOs in Israel, treating approximately one third of the Israeli population. Screening
Information from medical files recorded as part of the study documentation included the diagnosis, if any, at the screening visit as well as medical and vaccination histories since birth. In addition, trained study coordinators interviewed parents using standardised questionnaires to collect demographic data and information on antibiotic use that may have not been recorded in the medical files. Where any data differed between these two sources, for instance for vaccines administered, the information recorded in the primary care pediatrician notes was considered correct. Data recorded included information relating to health outcomes as indicators of engagement with health services, including: physician visits, antibiotic prescriptions and hospitalisations both current and in the previous three months; receipt of influenza, PCV7 vaccines. Data relating to confounders that were included in the current analyses were: age; gender; family size and specifically number of siblings; parent(s) smoking tobacco in the household; diagnosed comorbidities. Statistical analyses
Descriptive statistics are given as frequency distributions for each of the outcomes and confounders within region (EJ and IL). The chi-square test was used to assess differences between regions. Data on potential confounders were also available from the study questionnaires and were included in the analyses here. Variables that were shown to be significant in the univariate analysis (p < 0.05) were all included in multiple logistic regression analyses, to assess whether there was an independent association between region and outcome after controlling for all other factors, as well as to determine the independent predictors for vaccination compliance. All statistical analyses were performed using SAS 9.4.
Results Lifestyle factors (Table 1)
Analyses demonstrated the inclusion of a similar proportion of index children in terms of age and sex (p = 0.19, and p = 0.84 respectively). However, it was apparent that these children lived in significantly different size of households with the majority in both locations living in households of 4–6 people but a higher proportion in EJ in households of seven or more people (18.2 % vs. 5.3 %, p < 0.01). Significantly more children in EJ lived in a house where tobacco was smoked (49.5 % vs. 26.2 %, p < 0.01) and where that smoker was more commonly male than female (45.4 % vs 8.7 %, p < 0.01)) than in IL (28.9 % vs 21.6 %, p = 0.06). Breastfeeding was
Southern et al. International Journal for Equity in Health (2015) 14:63
Table 1 Demographics of the two populations under Israeli health policy included in the study, East Jerusalem (EJ) and Israel (IL) Variable
EJ
IL
P-value
N Age of child (years), mean, sd
659
1099
N/a
2.04, 1.42
1.95, 1.35
0.27
Percentage males
57.8
57.3
0.84
Mean number of people in household
4.9
4.4
