Diane LevinZamir, MPH, CHES

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"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
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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.

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Population in Israel by Culture
Druze
Christian

Other
1
.
64

Arabs
2
.
34

1
.
77

Moslem
Arabs
14
.
80

Jews
living in
Israel more
Jews
than
10
years
New
Immigrants
.

43
63
16
.
01

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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
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Hospital
Primary Care Services
Public
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Scope

• Over 40 community clinics serve
• neighborhoods with high
• concentration of Ethiopian residents

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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

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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

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Western Medicine
Cause (Specific or Non-specific)
Symptom
Diagnosis
Treatment/Cure
Time
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Traditional Medicine
Cause
Diagnosis
Socio-Cultural Identity
Symptom
Treatment/Cure
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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
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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.

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Partners

• Clalit Health Services
• Ministry of Health

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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.

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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

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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

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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
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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

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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
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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.

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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.

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Conclusions

• Secret of success collaborative
  inter-disciplinary and inter-organizational
  efforts, including pooling financial and
  professional resources

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Thank you for your attention! dianele_at_clalit.org.i
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