Diane Levin-Zamir, MPH, CHES Director, Department of Health Education and Promotion Clalit Health Services

1. "Refuah Shlema" – Cultural Liasons in Primary Care Lessons Learned from 10 Years of Implementation Diane Levin-Zamir, MPH, CHES Director, Department of Health Education and Promotion Clalit Health Services

2. “Refuah Shlemah” A Cross-Cultural Program for Promoting Health Among Ethiopian Immigrants in the Primary Care Setting • Since 1984, nearly 80,000 Ethiopians have immigrated to Israel – new immigrants arrive each week • Significant adjustment problems due to cultural disparities exist particularly regarding health and health care; navigation of the primary health care system.

3. Population in Israel by Culture Druze Christian 1 . 64 % Other Arabs 2 . 34 % 1 . 77 % Moslem Arabs 14 . 80 % Jews living in Israel more Jews than 10 years New Immigrants . % 43 63 16 . 01 %

4. Clalit Health Services 3.6 million members, 30,000 workers 1,350 primary and specialized care clinics 14 hospitals 416 pharmacies 40 diagnostic imaging centers 67 laboratory centers 83 physiotherapy units 30 occupational therapy units 87 diet & nutrition consultation units 22 mental health clinics 20 alternative medicine clinics 70 dental clinics

5. Private Sector NGOs Community Organizations Hospital Primary Care Services Public

6. Scope Over 40 community clinics serve neighborhoods with high concentration of Ethiopian residents

7. Needs • Significant adjustment problems due to cultural disparities exist particularly regarding health and health care; navigation of the primary health care system • Problems with diagnosis and treatment – distress among the community and the providers

8. Objectives - 1997 • Significant improvement of services that are given in the primary care setting - culturally appropriate • Improved participation of the Ethiopian member with regard to self-care and follow-up • Prevent detrimental changes in lifestyle, through health education and promotion – according health literacy

9. Health Health Literacy Empowerment

10. Western Medicine Cause (Specific or Non-specific) Symptom Diagnosis Treatment/Cure Time

11. Traditional Medicine Cause Diagnosis Socio-Cultural Identity Symptom Treatment/Cure

12. “Refuah Shlemah” 1. employing Ethiopian immigrant facilitators on a full time basis, who have been trained to work as health liasons and inter-cultural mediators between patients and physicians 2. training clinical staff with the aim of changing their attitudes and thus bridging inter-cultural gaps, by increasing awareness and sensitivity regarding Ethiopian perception of health and dis-ease causation 3. cooperatively implementing health education activities for new immigrants

13. Partners • The program was initiated by Clalit Health Services and the Joint Distribution Committee. • Detroit and Palm Beach Federations. • National Insurance Institute • Ministry of Absorption • Maccabi and Leumit Health Services • Ministry of Health.

14. Partners • Clalit Health Services • Ministry of Health

15. The Program • Clinics were chosen for the program based on the size of the Ethiopian community they serve, and the average age of the group • Cultural mediators/liasons were recruited. • A training program was immediately established, and has continued for 10 yrs.

16. The Program • Training of the primary care staff to learn how to work with the cultural liason/mediator was the fist challenge • Maintaining the objective of bridging the cultural gap and not just translating was and is a challenge • After several months, the cultural liasons became an integral part of the team

17. Evaluation • Was conducted by in two phases the Brookdale Institute • Examined the effect of the intervention on Ethiopian immigrants • The first phase looked at the general population that visited primary care clinics

18. The Major Findings The program was effective in: Improving physician-patient relations, Improving availability and accessibility of medical services and Improving the ability to navigate the health system No significantly increase in expenditure on services was incurred. Brookdale Institute, 2002

19. Selected Health Education Programs • Care of children with fever • Healthy lifestyle for diabetics • Use of prescription medication • Prevention examinations • Care of child with asthma • Home accident prevention

20. Second Phase of Evaluation The results include: • improved perception of general health status among the experimental clinics, • no perceived difference in perceived well being among the diabetics and asthmatics. • some aspects of self care were more positive as a result of the program, for example physical activity, etc. Brookdale Institute, 2002

21. Conclusion A health mediator in primary care clinics can significantly bridge the communication gap in a multi-cultural setting supporting and empowering an immigrant population. Specific improvements for asthmatics and diabetes in the present ecclectic model showed initial improvement. A model is needed in which the health mediators concentrate specifically on these groups with special health needs.

22. Conclusions The cultural liasons/mediators are vital in order to facilitate communication with, and treatment of, Ethiopian residents. The integration of a cultural liason/mediator should not be temporary, rather must be sustained as an integral part of the service and a vital contribution to the community.

23. Conclusions “Secret of success” – collaborative inter-disciplinary and inter-organizational efforts, including pooling financial and professional resources

24. Thank you for your attention! dianele@clalit.org.il