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Background Concern about the cost and affordability of cancer drugs is widespread and well known. Even in countries with universal healthcare systems or health insurance for all, additional patient out-of-pocket (OOP) expenses are prevalent. Studies showed that honest communication between oncologists and patients is an important component in alleviating financial burden of cancer care. The study explores patient-caregiver-oncologist communication regarding the affordability of OOP medication and the extent to which this communication is related to families’ financial burden after their loved ones’ death. Methods A cross-sectional survey is conducted in Israel among 491 primary caregivers of deceased cancer patients, Jewish and Arab, in three oncology centers. Results About 43% caregivers said that they and/or the patients had paid OOP for medications during the last half-year of the patient's life. Most (73%) oncologists who suggested an OOP medication hardly asked or did not ask about financial ability and took little or no interest in ability to afford it, 43% hardly explained or did not explain the advantages of an OOP medication, and 52% hardly explained or did not explain any treatment alternatives. A linear regression analysis reveals that older age and female gender are related to less communication about an OOP medication and that better education, greater affluence, and having private health insurance are related to more communication. About 56% of caregivers say that OOP payment for medications inflicted a very heavy or heavy financial burden on patients and their households. A regression analysis revealed that physicians’ interest in their financial ability and in the explanation they gave decreased their burden. Conclusions Discussing and explaining the meaning of OOP payment alleviates the financial burden that families experience. It is crucial to develop and invest in improving oncologists’ education and skills to communicate costs more openly. Key messages

Background Youth whose parents are unemployed have poorer health and well-being, including more injuries that result in hospitalization. The current study examined the possibility of an association of parents’ employment status with youth injury and the interaction of this status with other socio-economic factors and ethnicity. Methods We distributed to adolescents aged 11–15 years, in class, the Israel Health Behavior in School-Aged Children Survey. We distinguished between any injury and severe injury, defining the latter as one necessitating the use of a cast, stitches and crutches or overnight hospitalization. Results Of 13 705 respondents, 6224 (45%) had an injury in the past year that required medical treatment and 1827 pupils (13.5%) reported severe injuries. The odds of any injury were 1.86 for boys as against girls (95% confidence interval [CI] 1.73–1.99), 0.80 for school grade (95% CI 0.78–0.82), 1.56 for Arabs vs. Jews (95% CI 1.43–1.70) and 1.10 for high Family Affluence Scale (FAS) vs. medium FAS (95% CI 1.01–1.21). Only in the low FAS group, when two parents were unemployed, the odds for severe injury was 1.36 (95% CI 1.03–1.78); when one or two parents were employed, the odds of severe child injury were the same (OR 1.13 and 95% CI 0.92–1.40). Conclusion Factors that were found to increase the risk of injury among youth were parental unemployment, low socio-economic status and Arab ethnicity. The home environment was the most common place for injury.

Background The increasing prevalence of cognitive decline (CD) in old age has become a global challenge. Our study aims to enhance understanding of this phenomenon by evaluating longitudinal effects of personal and national determinants on memory decline (MD) among European retirees. Methods We used data from two interviews collected in 12 European (EU) countries and in Israel by SHARE - a multidisciplinary, cross-national bank of survey data. Our sample included 11,930 retirees aged 50+ who were interviewed at baseline (T1) and again four years later (T2). MD was evaluated by the change in the recalled number of words at T2 compared to those remembered at T1. Ten words were presented at each interview and participants were asked to repeat them, first immediately and again after a few minutes (maximum 20 words). The scale for evaluation of change over time ranged from -20 to + 20. Results Except for gender, all of our explanatory variables had a significant effect on MD including age, education, health/function status, depressive symptoms, early retirement, active lifestyle and EU-countries divided into four geographical regions. Decline over time in physical and mental health variables had an additional significant negative effect on memory. Conclusions These findings lead us to suggest focusing on what we know and are able to change in order to postpone MD. In addition to promotion of national policies to prolong years of education and participation in the workforce, we recommend introducing programs that encourage people to postpone retirement, and adjusting workplace conditions in order to enable older persons to continue contributing to the workforce. We also suggest promoting an active lifestyle among older adults, especially in Mediterranean and eastern European nations by implementing health and active leisure education programs. Key messages Declines in health and functioning negatively affect memory, while education and active lifestyle have a protective effect. Moreover, early retirement has a similar negative effect on memory change in each of the studied EU-regions even when controlling for all of the personal and behavioral factors.

Background For young women, mammography has limited effectiveness and entails exposure to radiation, discomfort and additional costs. As in other countries, the Israel Ministry of Health does not officially recommend mammograms for women under age 50 who do not belong to risk groups. The study identifies factors associated with the willingness to undergo mammography, contrary to the official guidelines. Methods Using the Health Belief Model (HBM), we surveyed Israeli women aged 40-51 who are not at high risk for developing breast cancer and who had or had never undergone mammography. Results The results show that socio-demographic characteristics, private insurance coverage, out-of-pocket payments to physicians, and two HBM categories-lower levels of perceived barriers to mammography (OR = 0.70, 95% CI = 0.53-0.92) and higher levels of health motivation (OR = 1.65, 95% CI = 1.19-2.29) - are associated with the decision to undergo mammogram. In addition, higher levels of perceived susceptibility to illness (OR = 1.32, 95% CI = 1.00-1.73) and previous experience with mammography (OR = 8.26, 95% CI = 3.71-18.41) are significant predictors of women's intentions to undergo early mammography. Conclusions Understanding the factors associated with women's tendency to have mammograms contrary to recommendations can help nurses and healthcare policymakers in creating health-promotive programs targeting this group of women. Taking policy steps to increase women's confidence in Ministry of Health guidelines will reduce the potential damage of cumulative radiation over the lifetime of young women and lower the number of false positives. Preventing unnecessary mammograms might reduce costs to households and HMOs, lessen ineffective use of medical facilities and help relieve the burden on the health system. Key messages Taking policy steps to increase women's confidence in Ministry of Health guidelines will reduce the potential damage of cumulative radiation over lifetime and lower the number of false positives. Preventing unnecessary mammograms will reduce costs to households and HMOs, lessen ineffective use of medical facilities and help relieve the burden on the health system.

Background Cancer imposes a substantial economic burden on society, health and social care systems, patients and their families. This study aims to examine the out-of-pocket spending of cancer patients in their last year of life, in six countries with health insurance systems that have a defined benefits package. Methods Data from SHARE and SHARE End-of-Life surveys, conducted between 2006 and 2015 among people aged 50+ were analyzed. Family members of deceased persons were interviewed in order to learn about the circumstances of their relative's death. Results This study found that out-of-pocket spending of cancer patients during their last year of life, in six developed countries with universal health insurance systems, is 4.5% on average of the total household income at that time. The results also show differences among the countries in out-of-pocket expenditures of the total household income: 2.2% in the Netherlands, 4.3% in Israel, 5% in Germany, 5.1% in Austria, 5.1% in Belgium and 8.2% in Switzerland. Whereas the out-of-pocket spending on nursing home care was 7.8% of the total household income in Switzerland, in the Netherlands and in Israel it was negligible. In contrast, the out-of-pocket spending for home care due to disability surged to 5.6% in Israel and 3.7% in Austria, whereas in other countries it was very low. Conclusions This is probably due to the split between the health and the social systems in Israel. The social security administration in Israel is responsible for financing personal care, and the patients have to apply for it themselves. Since the deterioration in functional ability of cancer patients might be quite rapid, many of them pay for professional assistance themselves, until they are approved as eligible for public funds, a process that may last a few weeks. This information is important to health and social policy makers, in order to better adapt the benefits package to the patients' needs. Key messages Cancer imposes a substantial economic burden during the last year of life. The economic burden varies across European countries with health insurance systems. Even countries with a universal benefits package take different approaches to prioritizing services and drugs for cancer care and leave some components of care to individual out-of- pocket payment.

Background The latest statistics on household size in the EU show that in 2017 around one third of households in the EU comprised single adults without children. The study documents a direct relationship between individuals’ health and patterns of healthcare expenditure by isolating single-person households and creating a new reference group in which household healthcare expenditure is based on one person’s expenditure patterns in accordance with his or her own state of health. Methods The study matched two surveys using Propensity Score Matching based on single-person household, age, and gender. Structural Equation Modeling (SEM) explores paths of relation between the population’s income and socioeconomic level and its health self-assessment and expenditure. Results Single-person households’ health expenditure increases with age and the differences in most expenditure categories are significant. The current study looks into the direct and indirect effects of income, gender, and SES on health insurance and other out-of-pocket health expenses among single-person households. A direct link exists between income, gender, and socioeconomic status (SES) and several aspects of health expenditure, depending on the specific age group. The indirect effects are attested via health status assessment, in which a negative correlation is found between self-assessed health status and various health-expenditure categories. Conclusions The last-mentioned result may support the general perception that single-person households who feel that they are doing better than their near-equals enjoy better health. This line of inquiry yields a better examination of how a single-person household’s state of health affects expenditure patterns without assuming ab initio that expenditure patterns attest to state of health. Key messages Healthcare system and policymakers have to be mindful of the profile of single-person households and should ensure to examine these households’ patterns of healthcare expenditure as a function of age. Policymakers should seek alternative sources of funding for the single-person households’ health-insurance outlays and should examine alternative ways of restraining their expenditure on dental care.

Background In July 2013, Israel was swept with fear of a polio outbreak. In response to the importation of wild polio virus, the Ministry decided to take preventive action by administering oral poliovirus vaccine (OPV) to all children born after 1 January 2004 who had received at least one dose of inactivated poliovirus vaccine (IPV) in the past. This study analyzes the vaccination uptake rates resulting from the mass polio vaccination campaign on the basis of health inequality parameters of socioeconomic status (SES), principles of solidarity, and the Gini inequality index. The research explores understanding the value of the Gini inequality index within the context of SES and solidarity. Methods The study is based on data gathered from the Israeli Ministry of Health’s administrative records from mother-and-child clinics across Israel. The research population is comprised of resident infants and children whom the Ministry of Health defined as eligible for the OPV between August and December 2013. Results The higher the SES level of the area where the mother-and-child clinic is located, the lower the OPV vaccination uptake is. The greater the income inequality is in the municipality where the mother-and-child clinic is situated, the lower the vaccination uptake. As time passed in the vaccination campaign, vaccination uptake increased regardless of the location of the mother-and-child clinics. The highest vaccination uptake rate was found among populations of low SES and low Gini inequality index. The lowest vaccination uptake rate was found among populations of high SES/high Gini inequality index. Conclusions Public health professionals promoting vaccine programs need to make specially-designed efforts both in localities with high average income and in localities with a high level of income diversity/inequality. Such practice will better utilize funds, resources, and manpower dedicated to increasing vaccination uptake across varying populations and communities. Key messages The higher the SES in municipalities with mother-and-child clinics, the less likely children were to be vaccinated. The lower the Gini inequality index, there is a higher polio vaccination uptake among of children.

Background It is a common custom to visit patients in hospital. Visitors often bring along outside food products, including some that may not be recommended for the patient. Even so, neither the Ministry of Health nor the hospitals have explicit guidelines in place as to what people can and cannot bring their inpatient friends or kin. The study deals with three main questions: What are the patterns of spending on outside food products for inpatients? What are the types of food products brought for inpatients? How medical professionals view the matter? Methods This quantitative study uses three closed-structured-questionnaire surveys-among visitors, inpatients, and medical staff. Thematic analysis of the findings yields patterns of spending on outside food products for inpatients, the types of food products brought, awareness of the health implications of consuming these products, patterns of consumption among inpatients, and how medical professionals view the matter. Results There are five major findings: (a) Most expenditure on outside food for inpatients occurs in the first few days of hospitalization. (b) Most food brought to inpatients is not defined as healthy. (c) There is a gap between visitors’ awareness of the health implications of bringing food to inpatients and their actual conduct. (d) Most patients realize that the food brought to them is bad for their health but tend to eat it anyway. (e) Medical staff disapproves of bringing food to inpatients. Conclusions Information on the extent of bringing food to inpatients, and the types and nature of what is brought, sheds light on the question of food security among inpatients, with emphasis on the motive behind the (in)correct nutrition. Information about the attitudes of patients, visitors, and medical staff toward the need to continue bringing food sheds light on questions of equality and social justice in inpatient care. Key messages Healthcare services should be more aware of assuring inpatients’ right to correct nutrition in the senses of reducing inpatients’ exposure to externalities that may impede their convalescence. Healthcare services should be more mindful of the advantages of using the egalitarian nutrition system that hospitals operate for all patients.

Background Economic determinants such as socioeconomic inequalities and parents’ employment have a profound impact on the health of adolescents in terms of unhealthy weight-control behaviours (UWCB). In addition, various family factors may play a role in adolescents’ weight-control behaviours (WCB). This study examines the association among socioeconomic status, perceived family wealth, and number of employed parents and Israeli adolescents’ WCB and asks whether family variables (parental communication, monitoring, support, and family meals) mediate WCB. Methods Data from the cross-sectional questionnaire of the 2014 Israeli Health Behaviour in School-Aged Children study are analysed using structural equation modelling. The research population includes approximately 7,000 Israeli schoolchildren in grades 6, 8, and 10. The association among socioeconomic status (SES) factors (SES measures, parental employment), sociodemographic factors, and weight-control behaviours among adolescents is calculated. Results High family affluence and high perceived family wealth are negatively associated with unhealthy weight-control behaviour. Having two employed parents leads to lower levels of UWCB. Family-related variables like family communication and support and parental monitoring are found to mitigate unhealthy weight-control behaviours. Family meals have a significantly positive effect on healthy weight-control behaviour and a significantly negative impact on unhealthy weight-control activities. Conclusions The findings suggest that economic factors such as SES and number of employed parents are necessary strategies for long-term weight-control practice. The combination of WCB and family meals is the most effective method for adolescents’ healthy weight-control behaviour. Key messages The study highlights the importance of considering the quality of family communication and support as a health asset that may contribute to WCB among young people. Family affluence and perceived family wealth, which were two separate measurements, were perceived differently by adolescents.