Can subjective and objective socioeconomic status explain minority health disparities in Israel?

Disparities in health exist between the three main population groups in Israel, non-immigrant Jews, immigrants from the former Soviet Union (arriving in Israel since 1990) and Arabs. This study examines the relationship between health and socioeconomic status in this multicultural population and assesses to what extent subjective and objective socioeconomic measures may explain the disparities in health. A random cross sectional telephone survey of 1004 Israelis aged 35–65 was performed. The questionnaire measured physical and mental health-related quality of life using the Short Form 12. Information regarding subjective socioeconomic status (SSS) and objective socioeconomic status (SES) was collected.Arabs and immigrant women from the former Soviet Union had worse physical health compared to non-immigrant Jews. Immigrant and Arab men and women had worse mental health compared to non-immigrant Jews. Multivariable log-linear regression analysis adjusting for age, SSS or SES explained the disparities in physical health between Arab and non-immigrant Jewish men. However, SSS and SES did not explain the disparities in physical health between the three groups of women. The disparities in mental health between immigrants and non-immigrant Jews can be explained by SSS for both men and women, whereas the disparities between Arabs and Jews can be explained by objective SES only among women. Employed men reported better physical and mental health. Part of the disparities in mental health in Israel can be attributed to differences in SSS and SES in the different groups. However, there is a need to identify additional factors that may add to the disparities in both physical and mental health. The disparities due to socioeconomic status vary by health measure and population group.     

Self-reported health as a cultural health determinant in Arab and Jewish Israelis MABAT--National Health and Nutrition Survey 1999-2001

Subjective health (SH) status serves as a measure of health in many studies of health-related issues as it is a good predictor of mortality, morbidity, and use of health services. The measure is used in many population groups. However, the degree to which it measures the same condition in different ethnic groups is not clear. Within Israel's first National Health and Nutrition Survey (MABAT) conducted during 1999-2001, face-to-face interviews were held with 3222 Israeli interviewees, 2379 Jews and 843 Arabs, aged between 25-64 years. Respondents reported their SH, co-morbidity, and other socioeconomic characteristics. Arabs reported higher levels of SH than Jews. In logistic regression analysis, co-morbidity was a much stronger correlate of poorer SH in the Arab than in the Jewish population. The association between socioeconomic variables depended on ethnic group and sex. The findings indicate that SH in Jews and Arabs does not necessarily have the same meaning in relation to objective measures of health, and caution should be exercised in the use of this measure in different population groups with different cultures. Arabs tend to evaluate health better than Jews even though life expectancy is lower and morbidity and mortality are higher in the former population group. Yet diagnosis of a disease increases the frequency of reporting lower SH, more in Arabs than in Jews.     

Social trust and self-rated health in US communities: a multilevel analysis

This study assessed the contextual and individual effects of social trust on health. Methods consisted of a multilevel regression analysis of self-rated poor health among 21,456 individuals nested within 40 US communities included in the 2000 Social Capital Community Benchmark Survey. Controlling for demographic covariates, a strong income and education gradient was observed for self-rated health. Higher levels of cominunity social trust were associated with a lover probability of reporting poor health. Individual demographic and socioeconomic preditors did not explain the association of community social trust with self-rated health. Controlling for individual trust perception, however, rendered the main effect of community social trust statistically insignificant, but a complex interaction effect was observed, such that the health-promoting effect of community social trust was significantly greater for high-trust individuals. For low-trust individuals, the effect of community social trust on self-rated health was the opposite. Using the latest data available on community social trust, we conclude that the role of community social trust in explaining average population health achievements and health inequalities is complex and is contingent on individual perceptions of social trust. Future multilevel investigations of social capital and population health should routinely consider the cross-level nature of community or neighborbood effects.     

Inequalities in Use of Health Services among Jews and Arabs in Israel

Objectives. To compare the levels of utilization of health services in Jews and Arabs taking into account differences in levels of socioeconomic status (SES) in a country with a National Health Insurance Law (NHIL).
Data Source/Study Setting. A cross-sectional National Health Interview Survey was carried out in Israel based on a random sample of telephone numbers as part of the EUROHIS project (WHO European Health Interview Survey 2003–2004).
Study Design. A random telephone survey included 9,352 interviews. Questions included use of health care services, health status, and socioeconomic variables.
Principal Findings. After adjusting for sex, age, income, education, marital status, and self-reported chronic diseases, Arabs more often reported visiting a family physician (odds ratio [OR]=1.56, 95 percent confidence interval [CI]=1.35–1.81) and less often reported visiting a specialist (OR=0.73, 95 percent CI=0.60–0.89) compared with Jews. In addition, the odds ratio for hospitalization was similar among Arabs and Jews (OR=1.16, 95 percent CI=0.97–1.38). SES was associated with utilization of health care services only in the Jewish population.
Conclusions. A different pattern of utilization of health care services was observed in Arabs and Jews. This was not explained by differences in socioeconomic levels. More research is needed regarding the distribution of services between Jews and Arabs.     

Social capital and inequality in health between single and couple parents in Sweden

AIMS: To study whether social capital is associated with health among parents and if so, whether existing inequalities in health between single and couple parents could be better understood by introducing social capital as a possible mechanism for how health is distributed. MATERIAL AND METHODS: At total of 2,500 parents with children in the age range of 4-16 years were randomized from existing national registers and asked to participate in a nationally distributed postal questionnaire; 1,589 parents participated (277 single and 1,312 couple), giving a response rate of 64%. The questionnaire contained questions regarding sociodemographic and socioeconomic characteristics, self-rated health, emotional and instrumental social support, civic and social participation, and trust. Social capital was measured by different levels of civic and social participation and trust. A multivariate analysis was used in order to find possible associations between social capital and health, when adjusted for social support, sociodemographic and socioeconomic characteristics. RESULTS: A low level of social capital (both social participation and trust), when adjusted for social support, socioeconomic and sociodemographic variables, was clearly and positively associated with less than good self-rated health. Social capital was unevenly distributed between single and couple mothers. CONCLUSIONS: Social capital is positively associated with self-rated health, at an individual level. The uneven distribution of social capital between single and couple mothers may be of some importance when trying to further understand and possibly alter the inequality in health that exists between single and couple parents.     

Lung cancer in Israel, 1962–1982 I. Jews and Arabs

The magnitude and dynamics of lung cancer incidence in Jews and Arabs in Israel between the years 1962 and 1982 were studied. In general, age-standardized incidence rates increased consistently between the years 1962 and 1976 among Jewish (24% increase) and Arab (39%) males, and to a lesser degree among Jewish females (15%). Arab females had the highest (77%) increase. From 1977 to 1982 a general decrease in incidence rates, which was largest among Arab males (19%) and females (15%), was noted. Rates among Jewish males are currently 26% higher than among Arab males, and are 162% higher among Jewish females than in Arab females. Lung cancer rates in both males and females in Istrael (Jews and Arabs) are lower than in most developed countries in the world. Among the possible reasons are differences in the population risk factors profile, availability of health care and the level of diagnosis and ascertainment of cases.     

Inequality in medical care in Israel: Arabs and Jews in the Jerusalem district of the General Sick Fund

Background: Differences in health and health services use amongdifferent ethnic groups within populations have been alwaysa major concern in democratic societies. Past research has documentedthe gaps both in health and in services utilization betweenthe Israell Arab and Jewish populations. Methods: This paperstudies the 1993 utilization of health services by a sampleof 70,000 Arabs and Jews insured by the General Sick Fund (Clalit),the biggest sick fund in Israel, in the Jerusalem district.The Arab population consists of Palestinian residents of greaterEast Jerusalem and Israell Arabs, offering a unique opportunityto study the health care use of the three population groups.Results: The results show that, while the mean annual cost ofcare per user is the same for Jews and Arabs, Arabs insureesare dramatically less likely to use medical services, controllingfor age, gender, income, chronic conditions and settlement size.This was found true for both ambulatory and in-patient careand, in particular, for elderly persons. The Israell Arabs arethe most intensive users of care compared to the Jews and thePalestinians. Conclusion: The gaps in utilization can be attributedto differences in accessibility, traditionalism and social andcultural assets. Early findings following the implementationof the National Health Insurance Law in 1995 indicate that somedifferences in accessibility to and use of medical servicesbetween Arabs and Jews have been reduced. The founding of thePalestinian Authority Council will hopefully further enhancethe use of medical care and the health state of the Palestinianpopulation.     

Does area-based social capital matter for the health of Australians? A multilevel analysis of self-rated health in Tasmania

BACKGROUND: Material circumstances and collective psychosocial processes have been invoked as potential explanations for socioeconomic inequalities in health; and, linking social capital has been proposed as a way of reconciling these apparently opposing explanations. METHODS: We conducted multilevel logistic regression of self-rated health (fair or poor vs excellent, very good, or good) on 14 495 individuals living within 41 statistical local areas who were respondents to the 1998 Tasmanian Healthy Communities Study. We modelled the effects of area-level socioeconomic disadvantage and social capital (neighbourhood integration, neighbourhood alienation, neighbourhood safety, social trust, trust in public/private institutions, and political participation), and adjusted for the effects of individual characteristics. RESULTS: Area-level socioeconomic disadvantage was associated with poor self-rated health (beta = 0.0937, P < 0.001) an effect that was attenuated, but remained significant, after adjusting for individual characteristics (beta = 0.0419, P < 0.001). Social trust was associated with a reduction in poor self-rated health (beta = -0.0501, p = 0.008) and remained significant when individual characteristics (beta = -0.0398, P = 0.005) were included. Political participation was non-significant in the unadjusted model but became significant when adjusted for individual characteristics (beta = -0.2557, P = 0.045). The effects of social trust and political participation were attenuated and became non-significant when area-level socioeconomic disadvantage was included. CONCLUSION: Area-based socioeconomic disadvantage is a determinant of self-rated health in Tasmania, but we did not find an independent effect of area-level social capital. These findings suggest that in Tasmania investments in improving the material circumstances in which people live are likely to lead to greater improvements in population health than attempts to increase area-level social capital.     

Ethnic Differences in Reported Smoking Behaviors in Face-to-Face and Telephone Interviews

Different modes of gathering data on self-reported health measures and self-reported risk factors are used frequently in research. However, data on the influence of the mode of collection of data on self-reporting are limited. The aim of the study was to identify associations between the mode of data collection and self-reported smoking in two distinct ethnic groups, Jews and Arabs in Israel. During the last 2 years, data were collected in two national surveys regarding the smoking behaviors of Jews and Arabs in Israel. In the telephone surveys 4713 Israeli residents were interviewed and in the face-to-face interviewees 3239 people were interviewed. The interviewees were between the ages 25 and 64. There was no significant difference in smoking rates between face-to-face interviews and telephone interviews among Jewish men or women after adjusting for other variables associated with smoking. However, there was a difference between the two methods of data collection in the Arab population also after the adjustment. In this group, respondents tended to report more often being a smoker in the face-to-face interviews. This was especially apparent in Arab women. There was no significant difference in the reported number of cigarettes smoked in the two modes of data collection. In Arabs compared to Jews there is a significant difference between reporting smoking during a telephone interview and a face-to-face interview. The mode of data collection can affect comparisons between different groups.     

Social capital and self-rated health: a contextual analysis.

OBJECTIVES: Social capital consists of features of social organization--such as trust between citizens, norms of reciprocity, and group membership--that facilitate collective action. This article reports a contextual analysis of social capital and individual self-rated health, with adjustment for individual household income, health behaviors, and other covariates. METHODS: Self-rated health ("Is your overall health excellent, very good, good, fair, or poor?") was assessed among 167,259 individuals residing in 39 US states, sampled by the Behavioral Risk Factor Surveillance System. Social capital indicators, aggregated to the state level, were obtained from the General Social Surveys. RESULTS: Individual-level factors (e.g., low income, low education, smoking) were strongly associated with self-rated poor health. However, even after adjustment for these proximal variables, a contextual effect of low social capital on risk of self-rated poor health was found. For example, the odds ratio for fair or poor health associated with living in areas with the lowest levels of social trust was 1.41 (95% confidence interval = 1.33, 1.50) compared with living in high-trust states. CONCLUSIONS: These results extend previous findings on the health advantages stemming from social capital.     

Injury inequalities: morbidity and mortality of 0-17 year olds in Israel

BACKGROUND: To determine whether there are inequalities in the incidence of fatal and non-fatal unintentional injuries among Jewish and Arab children in Israel. METHODS: A nationwide random sample of injured children aged 0-17 attending emergency rooms (ER) during one year was selected (n = 11 058). The number of cases was weighted to 365 days and rates and odds ratios (OR) were calculated. Logistic regression was performed to study the OR of hospitalization in the total population and among Jews and Arabs controlling for independent variables. RESULTS: The incidence of ER admissions among the Jews was 752.6/10 000 (95% CI: 738.1-767.1), 1.5 times higher than among the Arabs (492.8/10 000, 95% CI: 472.8-512.8). However, the rate of hospitalization was 1.1 times higher among Arabs than among Jews and the mortality rate was 3.2 times higher among Arabs than among Jews. CONCLUSIONS: The differences in injury rates for fatal and non-fatal injuries may be due to differences in the severity of injuries or in the use of services by the two populations. A study is underway to elucidate this point.     

The Relationship between Type 2 Diabetes,Differentiation of Self,and Emotional Distress: Jews and Arabs in Israel

Type 2 diabetes mellitus (T2DM) is considered a global epidemic, and is constantly on the rise. In Israel, the percentage of diabetics in the Arab population is twice that found in the Jewish population (12% and 6.2%, respectively). Findings suggest that low differentiation of self (DoS: emotional reactivity+ fusion with others, I-position, emotional cutoff) may raise vulnerability to certain physiological pathologies by increasing susceptibility to psychological distress. The major goal of this study was to test differences in DoS and emotional distress (anxiety and depressive symptoms) between diabetic and healthy participants. The second aim was to examine cultural differences within these metrics. Another purpose was to examine the relationship between DoS and emotional distress among healthy and diabetic participants. The sample included 261 participants, of whom 154 were healthy and 107 were diabetic. Diabetics reported more severe depressive symptoms, higher levels of anxiety and emotional cutoff and lower levels of I-position than healthy individuals. The groups did not differ in their levels of emotional reactivity + fusion with others. Arabs demonstrated higher levels of emotional cutoff, anxiety and depressive symptoms and lower levels of I-position than Jews. However, Arabs and Jews did not differ in their levels of emotional reactivity + fusion with others. Emotional reactivity + fusion with others contributed the most to diabetes among Arabs, while depressive symptoms contributed the most among Jews. Finally, among Jewish participants, age was positively correlated with emotional cutoff and depressive symptoms. Emotional cutoff was positively correlated with anxiety and depressive symptoms. Emotional reactivity + fusion with others was positively correlated with anxiety. Among Arab participants, age was positively correlated with emotional cutoff, anxiety and depressive symptoms. I-position was negatively correlated with all study variables. Emotional cutoff was positively correlated, anxiety and depressive symptoms. Emotional reactivity + fusion with others was positively correlated with anxiety and depressive symptoms.     

Social participation, trust and self-rated health: a study among ageing people in urban, semi-urban and rural settings

This study examined associations between self-rated health and combinations of social participation and trust among ageing people in three living areas of Finland (N=2815, 66% response rate). Social participation and trust combinations were: low social capital (low participation/low trust), traditionalism (low/high), "the miniaturisation of community" (high/low) and high social capital (high/high). The highest rate of good self-rated health was found among the high social capital group, but after adjusting for background variables, statistical significance remained only in the urban area. High social capital measured at an individual level may thus promote health among ageing people.     

Social capital and self-rated health: results from the US 2006 social capital survey of one community

Using data from the 2006 Social Capital Community Survey in Duluth, Minnesota, and Superior, Wisconsin, USA, we investigate associations between individual social capital measures (attitudes on trust, formal group involvement, informal socializing, organized group interaction, social support and volunteer activity) and self-rated health after controlling for individual and economic characteristics. In particular, we address issues of social capital as an endogenous determinant of self-reported health using instrumental variables probit estimation. After accounting for the endogeneity of these various measures of individual social capital, we find that individual social capital is a significant predictor of self-rated health.     

A multilevel analysis of social capital and self-rated health: Evidence from the British Household Panel Survey

Social capital is often described as a collective benefit engendered by generalised trust, civic participation, and mutual reciprocity. This feature of communities has been shown to associate with an assortment of health outcomes at several levels of analysis. The current study assesses the evidence for an association between area-level social capital and individual-level subjective health. Respondents participating in waves 8 (1998) and 9 (1999) of the British Household Panel Survey were identified and followed-up 5 years later in wave 13 (2003). Area social capital was measured by two aggregated survey items: social trust and civic participation. Multilevel logistic regression models were fitted to examine the association between area social capital indicators and individual poor self-rated health. Evidence for a protective association with current self-rated health was found for area social trust after controlling for individual characteristics, baseline self-rated health and individual social trust. There was no evidence for an association between area civic participation and self-rated health after adjustment. The findings of this study expand the literature on social capital and health through the use of longitudinal data and multilevel modelling techniques.     

Disorganization Theory,Neighborhood Social Capital,and Ethnic Inequalities in Intimate Partner Violence between Arab and Jewish Women Citizens of Israel

We draw on social disorganization (SD) theory and social capital to examine the impact of neighborhood environment on the ethnic gap in intimate partner violence (IPV) between Arab and Jewish women in Israel. We linked census data on neighborhood socioeconomic status (SES) to national data we gathered in 2014–2015 on 1401 women (436 Arab, 965 Jewish) age 16–48. Women were interviewed while visiting 65 maternal and child health clinics throughout Israel. We used General Estimated Equation (GEE) multivariate logistic regression models to adjust for clinic cluster effects and estimated the contribution of neighborhood collective efficacy, problems, relative socioeconomic status (SES), bridging and linking social capital, and social support to explaining ethnic inequalities in IPV, while adjusting for women’s socioeconomic and socio-demographic characteristics. We found that any IPV is higher among Arab compared to Jewish women (odds ratio (OR) and 95% confidence intervals (CI) = 4.19 (2.72,6.42)). Collective efficacy and social group membership (bridging social capital) had no effect on the ethnic inequality in any IPV and types of IPV. Women’s active participation in social groups (linking social capital), higher social support, and living in neighborhoods with relative SES similar to the ethnic group average) had a protective effect from any IPV and physical IPV. Neighborhood problems were associated with increased any IPV and physical IPV. In the final model, the ethnic gap in IPV was reduced but not eliminated (OR (95%CI) = 3.28 (2.01, 5.35). Collective efficacy did not explain the ethnic gap in IPV, while women’s active participation (linking social capital) had a protective effect from IPV. Given the protective nature of women’s activism in this population, future research should investigate how this might be incorporated into solutions to IPV. In addition, reducing neighborhood problems, improving neighborhood SES, and increasing social support might help reduce IPV among Arab women, thus decreasing the ethnic gap in IPV.     

The contextual effects of social capital on health: A cross-national instrumental variable analysis

Past research on the associations between area-level/contextual social capital and health has produced conflicting evidence. However, interpreting this rapidly growing literature is difficult because estimates using conventional regression are prone to major sources of bias including residual confounding and reverse causation. Instrumental variable (IV) analysis can reduce such bias. Using data on up to 167 344 adults in 64 nations in the European and World Values Surveys and applying IV and ordinary least squares (OLS) regression, we estimated the contextual effects of country-level social trust on individual self-rated health. We further explored whether these associations varied by gender and individual levels of trust. Using OLS regression, we found higher average country-level trust to be associated with better self-rated health in both women and men. Instrumental variable analysis yielded qualitatively similar results, although the estimates were more than double in size in both sexes when country population density and corruption were used as instruments. The estimated health effects of raising the percentage of a country’s population that trusts others by 10 percentage points were at least as large as the estimated health effects of an individual developing trust in others. These findings were robust to alternative model specifications and instruments. Conventional regression and to a lesser extent IV analysis suggested that these associations are more salient in women and in women reporting social trust. In a large cross-national study, our findings, including those using instrumental variables, support the presence of beneficial effects of higher country-level trust on self-rated health. Previous findings for contextual social capital using traditional regression may have underestimated the true associations. Given the close linkages between self-rated health and all-cause mortality, the public health gains from raising social capital within and across countries may be large.     

The contextual effects of social capital on health: a cross-national instrumental variable analysis

Past research on the associations between area-level/contextual social capital and health has produced conflicting evidence. However, interpreting this rapidly growing literature is difficult because estimates using conventional regression are prone to major sources of bias including residual confounding and reverse causation. Instrumental variable (IV) analysis can reduce such bias. Using data on up to 167,344 adults in 64 nations in the European and World Values Surveys and applying IV and ordinary least squares (OLS) regression, we estimated the contextual effects of country-level social trust on individual self-rated health. We further explored whether these associations varied by gender and individual levels of trust. Using OLS regression, we found higher average country-level trust to be associated with better self-rated health in both women and men. Instrumental variable analysis yielded qualitatively similar results, although the estimates were more than double in size in both sexes when country population density and corruption were used as instruments. The estimated health effects of raising the percentage of a country's population that trusts others by 10 percentage points were at least as large as the estimated health effects of an individual developing trust in others. These findings were robust to alternative model specifications and instruments. Conventional regression and to a lesser extent IV analysis suggested that these associations are more salient in women and in women reporting social trust. In a large cross-national study, our findings, including those using instrumental variables, support the presence of beneficial effects of higher country-level trust on self-rated health. Previous findings for contextual social capital using traditional regression may have underestimated the true associations. Given the close linkages between self-rated health and all-cause mortality, the public health gains from raising social capital within and across countries may be large.     

Self-Reported Type 2 Diabetes and Diabetes-Related Eye Disease in Jews and Arabs in Israel

Prevalence rates of diabetes and its complications may be higher in minorities. We assessed these rates in Jews and Arabs living in Israel. Data were pooled from the first and second Israeli national health interview surveys. 9625 Jews and 2401 Arabs participated in the analysis. The age adjusted rate of self-reported diabetes was 10.7 % among Arabs and 5.7 % among Jews [odds ratio (OR) 2.14, 95 % confidence interval 1.77–2.60]. After adjustment for risk factors the OR decreased to 1.28 (95 % CI 1.04–1.59). The rate of self-reported diabetes-related eye disease was 37.6 % among Arabs with diabetes and 18.3 % among Jews (OR 2.69, 95 % CI 1.84–3.93). After adjustment the odds among Arabs were still double that of Jews (OR 2.26, 95 % CI 1.44–3.56). Self-reported type 2 diabetes and diabetes-related eye disease were higher among Arabs. Multi-disciplinary and cultural sensitive approach is required in order to improve diabetes care among the Arab population.     

Colorectal cancer screening, intentions, and predictors in Jewish and Arab Israelis: a population-based study.

Random samples of 358 Jews and 162 Arabs in Israel aged 50 to 75 were compared by telephone survey for colorectal cancer (CRC) screening performance and intentions. Participants completed questionnaires on CRC screening, health beliefs, health locus of control, and CRC worries; rate of CRC screening and intention to be screened proved lower among Arabs. They received fewer recommendations from physicians, perceived lower severity of CRC and lower benefits of early detection of CRC, and had lower cancer worries, lower internal health locus of control, and higher external health locus of control. Jewish/Arab ethnicity predicted ever undergoing screening and screening intention before cognitive perceptions and worries were entered. After that, perceiving higher susceptibility and more benefits to screening, and having lower external health locus of control predicted CRC screening and screening intention, which was associated with higher cancer worries. Programs should be tailored to address ethnic groups' different health beliefs.