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Abstract: A major debate in prehistory revolves around the time and place of the earliest habitual use of fire and the hominin species responsible for it. Here we present a newly discovered hearth at Qesem Cave (Israel) that was repeatedly used and was the focus of hearth-centered human activities, as early as three-hundred-thousand years ago. The hearth, identified based on mineralogical and microscopic criteria, contains two superimposed use cycles, each composed of shorter episodes – possibly the earliest superimposed hearth securely identified to date. The hearth covers ca. 4 m2 in area making it a uniquely large hearth in comparison to any contemporaneous hearth identified thus far, possibly indicating it has been used by a relatively large group of people. In addition, the hearth is located in the center of the cave and is associated with butchered animal remains and a dense flint assemblage. The flint assemblage indicates spatially differentiated meat cutting and hide working activity areas. The central location of the hearth within the cave and the activities associated with it may reflect an embedded perception of space organization of the Qesem Cave inhabitants. Since fire was habitually used throughout the 420–200 ky sequence of Qesem Cave, where preservation conditions are alike throughout, we suggest that this unique hearth may reflect a development in nature and most probably in the intensity of fire use in Qesem Cave, from ca. 300 ka ago onwards. [Copyright &y& Elsevier]

Abstract: We present here the results of a U–Th dating project at Qesem Cave, a Middle Pleistocene, late Lower Paleolithic site in Israel. It provides 54 new MC-ICP-MS U–Th ages for speleothems from the cave. The results indicate that human occupation started sometime between ∼420 and 320 ka and ended between 220 and 194 ka. A survey of dates from culturally similar sites in the Levant indicates that the general range of ca. 400–ca. 200 ka is an appropriate estimate for the life span of the Acheulo-Yabrudian Cultural Complex (AYCC). [ABSTRACT FROM AUTHOR]

Context: Surveys carried out among users of medical services can be a useful tool for health care organizations in designing proper services. Specifically, patients' views of direct access to specialists can be useful to health organizations considering the gatekeeper model.Objective: To assess patients' opinions about direct access to specialists and referral to specialists through their primary care physician.Design: An intercept survey, in which patients were interviewed at the randomly selected service provision sites, was carried out in 3 districts in Israel during 1995. A total of 1445 and 1289 patients were interviewed in primary care and specialty clinics, respectively.Setting: Primary care and specialty clinics in 3 regions in Israel serving 750000 members of Kupat Holim Clalit, Israel's largest sick fund.Participants: Hebrew-speaking members of Kupat Holim Clalit who visited the primary care or specialty clinics in the 3 regions during the study period.Main Outcome Measures: Rate of preferences for direct access to specialists and preferences for referral through primary care physician.Results: Fifty-two percent of the respondents preferred direct access to specialists, while 48% preferred a referral from their primary care physician. Multivariate logistic regression analysis indicated that the preference for direct access was significantly lower among patients older than 45 years (odds ratio [OR], 0.75; 95% confidence interval [CI], 0.62-0.91); patients whose primary care physician was a specialist in family medicine (OR, 0.80; 95% CI, 0.67-0.97); and patients who were satisfied with their primary care physician (OR, 0.34; 95% CI, 0.27-0.44). Preference for direct access was significantly higher among more highly educated patients (OR, 1.38; 95% CI, 1.16-1.65) and patients residing in Jerusalem (OR, 2.46; 95% CI, 2.05-2.95) and those younger than 45 years who were dissatisfied with their family physician or a primary care physician who was not board certified. If direct access was not available, 33% of respondents would leave the sick fund and 48% would remain; 19% did not know.Conclusions: Informing sick fund members, particularly the younger and more educated among them, about the advantages of consulting with the primary care physician, as well as providing specialty training in family medicine to primary care physicians, may reduce patients' preference for direct access to specialists. [ABSTRACT FROM AUTHOR]

Abstract: Preliminary results of the investigation of the microfauna at the Acheulo-Yabrudian Middle Pleistocene site of Qesem Cave, Israel, are presented. Thus far the assemblage includes ca. 10,000 bone and tooth fragments, of which 50% could be identified to the generic and some hundreds to the species level. Based on the current material, the fauna includes the following squamate reptiles: Laudakia sp., Chamaeleo sp., Gekkonidae indet., Lacertidae indet., Scincidae indet., Pseudopus sp., Varanus sp., Colubroidea indet. (at least three species) and micromammals: Suncus etruscus, Crocidura cf. leucodon, Crocidurinae indet. (large form), Chiroptera indet., Sciurus cf. anomalus, Cricetulus cf. migratorius, Microtus guentheri, Nannospalax ehrenbergi, Dipodillus cf. dasyurus, Meriones cf. tristrami, Gerbillidae indet., Mus cf. musculus, Apodemus cf. flavicollis. These results suggest that the fauna includes only taxa that occur recently in the territory of Israel. The ecological preferences of the nearest living relatives of the recorded taxa allow us to infer a paleoenvironment with a mosaic of open and woodland habitats. However, comparing the lower with the upper levels of the microfauna-bearing profile, a slight shift towards more wooded conditions might be detectable. Biostratigraphical inferences from the recorded micromammal taxa cover a rather wide age range, whereas the radiometric (U-series and preliminary TL) dating enable a provisionally estimated date for the microfauna-bearing levels at 360-300 ka. Detailed morphometric comparisons with material from other sites in the region are necessary and may yet provide further insights. [Copyright &y& Elsevier]

Background: COVID-19 is an ongoing global crisis, with a multitude of factors that affect mental health worldwide. We explored potential predictors for the emergence and maintenance of depression, anxiety, and posttraumatic stress symptoms (PTSS) in the general population in Israel., Methods: Across the span of 16 months, 2478 people completed a repeated self-report survey which inquired psychiatric symptoms and pandemic related stress factors (PRSF). We applied mixed-effects models to assess how each stressor contributes to depression, anxiety and PTSS at each time point, and longitudinally assessed participants who completed at least two consecutive surveys (n = 400). We weighted our sample to increase representativeness of the population., Results: Fatigue was the strongest predictor for depression, anxiety and PTSS at all time points, and predicted deterioration overtime. Financial concerns associated with depression and anxiety at all time points, and with their deterioration overtime. Health related concerns were uniquely associated with anxiety and PTSS at all time points and their deterioration, but not with depression. Improvement in sense of protection overtime associated with decrease in depression and anxiety. Hesitancy towards vaccination was associated to higher financial concerns and lower sense of protection by the authorities., Conclusions: Our findings accentuate the multitude of risk factors for psychiatric morbidity during COVID-19, and the centrality of fatigue in determining mental health outcomes., Competing Interests: Declaration of Competing Interest The authors declare no conflicts of interest., (Copyright © 2023. Published by Elsevier B.V.)

Introduction: Patients with advanced Parkinson's disease (PD) may require device-aided therapies (DAT) for adequate symptom control. However, long-term, real-world efficacy and safety data are limited. This study aims to describe real-world, long-term treatment persistence for patients with PD treated with levodopa-carbidopa intestinal gel (LCIG). The study also aims to describe patient profiles, treatment discontinuation rates, co-medication patterns, monotherapy rates, and rates of healthcare visits and their associated costs for patients receiving all forms of DAT (deep brain stimulation [DBS], continuous subcutaneous apomorphine infusion [CSAI], or LCIG)., Methods: In this retrospective analysis of the Israeli Maccabi Healthcare Services database, adult patients with PD were analyzed in three cohorts, based on DAT (DBS, CSAI, or LCIG). The primary endpoint was LCIG treatment persistence 12 months after initiation., Results: This analysis included 161 DAT-treated patients (LCIG, n = 62; DBS, n = 76; CSAI, n = 23). Among those who discontinued, the mean time to discontinuation was 86.4 months for LCIG and 42.4 months for CSAI (p = 0.046). Twelve months after initiation, 14.3% LCIG, 10.7% DBS, and 5.9% CSAI patients were not receiving any additional anti-parkinsonian therapy. At the last recorded visit, 28.6% LCIG, 13.3% DBS, and 5.9% CSAI patients received DAT as monotherapy. During the first 12 months after initiation, 45.2% LCIG, 65.2% CSAI, and 1.3% DBS patients had no reported hospitalization days. Annual healthcare visit costs decreased following LCIG initiation (US$9491 vs. $8146) and increased following DBS ($4113 vs. $7677) and CSAI ($6378 vs. $8277)., Conclusion: DAT are well maintained in patients with advanced PD. These retrospective data suggest that patients receiving LCIG may have higher long-term persistence rates compared with patients receiving CSAI. A subgroup of patients was treated with DAT as monotherapy without additional oral anti-parkinsonian therapy, with LCIG showing the highest rates., (© 2022. The Author(s).)

Background: COVID-19 pandemic has major ramifications for global health and economy, with growing concerns about economic recession and implications for mental health. Here we investigated the associations between pandemic-related income loss with financial strain and mental health trajectories over a 1-month course, in two independent cohorts., Methods: Two independent studies were conducted in the U.S and in Israel at the beginning of the outbreak (March-April 2020, T1; study I: N = 2904, study II: N = 1267) and at a 1-month follow-up (T2; study I: N = 1318, study II: N = 241). Mixed-effects models were applied to assess associations among COVID-19-related income loss, financial strain, and pandemic-related worries about health, with anxiety and depression, controlling for multiple covariates including pre-COVID-19 income., Results: In both studies, income loss and financial strain were associated with greater depressive symptoms at T1, above and beyond T1 anxiety, worries about health, and pre-COVID-19 income. Worsening of income loss was associated with exacerbation of depression at T2 in both studies. Worsening of subjective financial strain was associated with exacerbation of depression at T2 in one study (US)., Conclusions: Income loss and financial strain were uniquely associated with depressive symptoms and their exacerbation over time, above and beyond pandemic-related anxiety. In times when a myriad of stressors are affecting mental health worldwide, our findings reveal specific links between the economic impact of COVID-19 and psychiatric outcomes., (Copyright © 2021. Published by Elsevier B.V.)

Objectives: Little is known about the mental health outcomes of hospitalized COVID-19 patients. The aims of the study were: (1) to examine the trajectories of anxiety, depression, and pandemic-related stress factors (PRSF) of COVID-19 hospitalized patients one-month following hospitalization; (2) to assess the presence of post-traumatic stress symptoms (PTSS) a month after hospitalization; (3) to identify baseline risk and protective factors that would predict PTSS one month after hospitalization., Methods: We contacted hospitalized COVID-19 patients (n = 64) by phone, at three time-points: during the first days after admission to the hospital (T1); after ~two weeks from the beginning of hospitalization (T2), and one month after hospitalization (T3). At all time-points we assessed the levels of anxiety and depression symptoms, as well as PRSF. At T3, PTSS were assessed., Results: The levels of depressive and anxiety symptoms decreased one-month following hospitalization. Moreover, higher levels of anxiety (standardized β = 1.15, 95% CI = 0.81-1.49, p < 0.001) and depression (β = 0.97, 95% CI = 0.63-1.31 p < 0.001) symptoms during the first week of hospitalization, feeling socially disconnected (β = 0.59, 95% CI = 0.37-0.81 p < 0.001) and experiencing a longer hospitalization period (β = 0.25, 95% CI = 0.03-0.47 p = 0.026) predicted higher PTSS scores a month post-hospitalization., Conclusions: We identified early hospitalization risk factors for the development of PTSS one month after hospitalization that should be targeted to reduce the risk for PTSS., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Healthcare workers (HCW) treating coronavirus disease 2019 (COVID-19) patients face high levels of psychological stress. We aimed to compare mental health outcomes, risk and protective factors for posttraumatic stress symptoms (PTSS), probable depression, and anxiety between HCW working in COVID-19 and non-COVID-19 wards., Methods: A self-report survey, administered in a large tertiary hospital in Israel during the peak of the COVID-19 outbreak was completed by 828 HCW (42.2% physicians, 57.8% nurses. Patient-Reported Outcomes Measurement Information System; the Patient Health Questionnaire-9; the Primary Care-Post Traumatic Stress Disorder Screen for DSM-5 (PC-PTSD-5) were used for assessing anxiety, depression, and PTSS, respectively. Pandemic-related stress factors, negative experiences, and potential protective factors were also assessed., Results: Median PC-PTSD scores differed significantly between study teams (χ 2 [5] = 17.24; p = .004). Prevalence of probable depression and anxiety were similar in both groups. Risk factors for mental health outcomes included mental exhaustion, anxiety about being infected and infecting family. Overall, higher proportion of the COVID-19 team witnessed patient deaths as compared to the non-COVID-19 team (50.2% vs. 24.7%). Witnessing patient death at the COVID-19 wards was associated with a four-fold increased likelihood of PTSS (odds ratio [OR] = 3.97; 95% confidence interval [CI], 1.58-9.99; p = .0007), compared with the non-COVID-19 wards (OR 0.91; 95% CI, 0.51-1.61; p = .43)., Conclusions: Witnessing patient death appears to be a risk factor for PTSS unique to HCW directly engaged in treating patients with COVID-19. Our findings suggest that helping HCW cope with COVID-19 related deaths might reduce their risk of posttraumatic stress., (© 2021 Wiley Periodicals LLC.)

Sustainable resource management is of central importance among agrarian societies in marginal drylands. In the Negev Desert, Israel, research on agropastoral resource management during Late Antiquity emphasizes intramural settlement contexts and landscape features. The importance of hinterland trash deposits as diachronic archives of resource use and disposal has been overlooked until recently. Without these data, assessments of community-scale responses to societal, economic, and environmental disruption and reconfiguration remain incomplete. In this study, micro-geoarchaeological investigations were conducted on trash mound features at the Byzantine-Early Islamic sites of Shivta, Elusa, and Nesanna to track spatiotemporal trends in the use and disposal of critical agropastoral resources. Refuse derived sediment deposits were characterized using stratigraphy, micro-remains (i.e., livestock dung spherulites, wood ash pseudomorphs, and plant phytoliths), and mineralogy by Fourier transform infrared spectroscopy. Our investigations detected a turning point in the management of herbivore livestock dung, a vital resource in the Negev. We propose that the scarcity of raw dung proxies in the studied deposits relates to the use of this resource as fuel and agricultural fertilizer. Refuse deposits contained dung ash, indicating the widespread use of dung as a sustainable fuel. Sharply contrasting this, raw dung was dumped and incinerated outside the village of Nessana. We discuss how this local shift in dung management corresponds with a growing emphasis on sedentised herding spurred by newly pressed taxation and declining market-oriented agriculture. Our work is among the first to deal with the role of waste management and its significance to economic strategies and urban development during the late Roman Imperial Period and Late Antiquity. The findings contribute to highlighting top-down societal and economic pressures, rather than environmental degradation, as key factors involved in the ruralisation of the Negev agricultural heartland toward the close of Late Antiquity., Competing Interests: The authors have declared that no competing interests exist.

For years there has been much speculation surrounding the abandonment of the Middle Bronze Age IIB palace of Tel Kabri, ca. 1700 BCE. There are no weapons, hoards of money and jewelry, or visible evidence for fire, which rules out hostile attack or conquest. There are also no indications of drought or environmental degradation that might have forced the inhabitants to vacate the site, nor mass graveyards to indicate a pandemic. The current study uses micro-geoarchaeological methods to show that the demise of the palace was rapid, with walls and ceilings collapsing at once prior to abandonment. Macroscopic data (stratigraphic and structural) from five excavation seasons were reexamined, showing that at least nine Potential Earthquake Archaeological Effects (PEAEs) are found and associated with the last occupation phase of the site's palace. All lines of evidence point to the possibility that an earthquake damaged the palace, possibly to a point where it was no longer economically viable to repair. This conclusion is compounded by the discovery of a 1-3 m wide trench that cuts through the palace for 30 m, which may be the result of ground shaking or liquefaction caused by an earthquake. This study shows the importance of combining macro- and micro-archaeological methods for the identification of ancient earthquakes, together with the need to evaluate alternative scenarios of climatic, environmental, and economic collapse, as well as human-induced destruction before a seismic event scenario can be proposed., Competing Interests: The authors have declared that no competing interests exist.

Objective: To examine the effect of a novel antistigma intervention curriculum (ASIC) in reducing stigma toward psychiatry among medical students., Methods: Medical students from 8 hospitals in central Israel were divided into intervention (n = 57) and control (n = 163) arms. The students completed the 30-item Attitudes Toward Psychiatry (ATP-30) and the Attitudes Toward Mental Illness (AMI) scales at psychiatry rotation onset and conclusion. The ASIC was designed to target prejudices and stigma through direct informal encounters with people with serious mental illness (SMI) during periods of remission and recovery. Supervised small-group discussions followed those encounters to facilitate processing of thoughts and emotions that ensued and to discuss salient topics in psychiatry. The study was conducted between November 2017 and July 2018., Results: Significant between-group differences were found at endpoint for attitudes toward psychiatry and psychiatric patients (P < .001). Although changing attitudes toward psychiatry as a career choice was not part of the ASIC, a significant between-group difference emerged by endpoint (P < .001)., Conclusions: Implementation of an ASIC that includes contact with individuals with lived SMI experience followed by supervised small-group discussions is effective in reducing stigma in medical students' perceptions of people with mental illness and psychiatry. Further evaluation is warranted with regard to the long-term destigmatizing effects of an ASIC., Trial Registration: ClinicalTrials.gov identifier: NCT03907696., (© Copyright 2020 Physicians Postgraduate Press, Inc.)

Introduction: In 2012, 183,896 work migrants and 47,704 asylum-seekers and work-migrants arrived in Israel. These populations are at high-risk for depression, anxiety and posttraumatic stress disorder (PTSD). The Open Clinic of Physicians for Human Rights (PHR) delivers free medical and mental health services to these individuals., Aims: To evaluate exposure to traumatic events, and compare the prevalence and risk for PTSD, depression and anxiety symptoms between work-migrants and asylum-seekers., Methods: An analytical cross-sectional study of adults visiting the Open Clinic was conducted. Participants completed self-report questionnaires including information on demographics and exposure to traumas, depression, anxiety and PTSD. Statistical models were constructed to predict outcome variables of PTSD, depression and anxiety as dichotomist variables using a logistic regression, and association odds ratio (OR) and confidence interval (CI) on 95% level., Results: There were 241 participants; 165 asylum-seekers, 76 work-migrants. Work-migrants were exposed to more traumatic events. A total of 17-31% met PTSD criteria. Significantly more asylum-seekers met PTSD criteria. A total of 43%-50% met criteria for depression and/or anxiety, with no between-group differences. Significant association was found between immigration status and PTSD risk. Exposure to traumatic events was significantly associated with the prediction of PTSD, depression and anxiety., Discussion: Exposure to traumatic events was high among the Open Clinic service users, specifically work-migrants. Prevalence and risk for post-traumatic symptoms were significantly higher among asylum-seekers. It is important to conduct further research, in order to characterize risk and resilience factors in this excluded population, and to plan language and culture-competent mental health services.

Over the last two decades, much of the recent efforts dedicated to the Levantine Middle Paleolithic has concentrated on the role of open-air sites in the settlement system in the region. Here focus on the site of 'Ein Qashish as a cases study. Located in present-day northern Israel, the area of this site is estimated to have been >1300 m2, of which ca. 670 were excavated. The site is located at the confluence of the Qishon stream with a small tributary running off the eastern flanks of the Mt. Carmel. At the area of this confluence, water channels and alluvial deposits created a dynamic depositional environment. Four Archaeological Units were identified in a 4.5-m thick stratigraphic sequence were dated by Optically Stimulated Luminescence (OSL) to between-71 and 54 ka, and probably shorter time span-~70-~60 ka. Here we present the diverse material culture remains from the site (lithics, including refitted sequences; modified limestone pieces; molluscs; faunal remains) against their changing paleogeographic backdrop. Skeletal evidence suggests that these remains were associated with Neanderthals. The large-scale repeated accumulation of late Middle Paleolithic remains in the same place on the landscape provides a unique opportunity to address questions of occupation duration and intensity in open-air sites. We find that each occupation was of ephemeral nature, yet presents a range of activities, suggesting that the locale has been used as a generalized residential site rather than specialized task-specific ones. This role of 'Ein Qashish did not change through time, suggesting that during the late Middle Paleolithic settlement system in this part of the southern Levant were stable., Competing Interests: The authors received funding from Derekh Eretz Inc. This does not alter our adherence to all the PLOS ONE policies on sharing data and materials.

The late Middle Palaeolithic (MP) settlement patterns in the Levant included the repeated use of caves and open landscape sites. The fossil record shows that two types of hominins occupied the region during this period-Neandertals and Homo sapiens. Until recently, diagnostic fossil remains were found only at cave sites. Because the two populations in this region left similar material cultural remains, it was impossible to attribute any open-air site to either species. In this study, we present newly discovered fossil remains from intact archaeological layers of the open-air site 'Ein Qashish, in northern Israel. The hominin remains represent three individuals: EQH1, a nondiagnostic skull fragment; EQH2, an upper right third molar (RM 3 ); and EQH3, lower limb bones of a young Neandertal male. EQH2 and EQH3 constitute the first diagnostic anatomical remains of Neandertals at an open-air site in the Levant. The optically stimulated luminescence ages suggest that Neandertals repeatedly visited 'Ein Qashish between 70 and 60 ka. The discovery of Neandertals at open-air sites during the late MP reinforces the view that Neandertals were a resilient population in the Levant shortly before Upper Palaeolithic Homo sapiens populated the region.

Background: Measuring the progress of mental health treatment aids in assessment and monitoring of psychotherapeutic outcomes. The OQ-45 is a widely accepted measure of such outcomes. The aim of this study was to validate the Hebrew and Arabic versions of the OQ-45., Method: Data were collected from three samples: non patient university students (n=189), university mental health clinic patients (n=37), and outpatient mental health clinic patients (n=135). Subjects completed the OQ-45 as well as the BSI and PHQ-9 questionnaires., Results: Test-retest and internal reliability, and concurrent and discriminative validity of both OQ-45 versions were satisfactory. Sensitivity of the Hebrew and Arabic versions was 0.70 and 0.80, respectively, and the specificity was 0.69and 0.93, respectively. Sensitivity-to-change was noted only for the Symptom Distress (SD) subscale., Limitations: Sensitivity-to-change was not demonstrated for the total OQ-45, possibly due to a too-short follow-up period., Conclusions: Adequate psychometric properties of the Hebrew and Arabic OQ-45 suggest that they can serve as useful measures of mental health treatment in Israel.Further research is necessary to confirm norms, cut-off scores and sensitivity-to-change using a larger representative population and diverse types of treatment over a longer period of time.

This study evaluated patients' and physicians' characteristics associated with the purchase of benzodiazepines by older primary care patients in Israel. The analytic sample consists of those 6,421 patients age 65 and older. We used multi-level analysis with whether or not benzodiazepines were purchased at least once between June 2005 and 2007 as an outcome. We also evaluated patients' and physicians' characteristics associated with the purchase of benzodiazepines for 6 months or longer. Almost half the sample (41.5%) purchased benzodiazepines at least once during the study period and more than half (54.5%) of those purchasing benzodiazepines had a continued purchase for 6 months or longer. Physicians' characteristics explained only a small portion of the variance associated with purchasing, whereas patients' demographic and clinical characteristics were associated with purchasing. Any intervention to improve the use of benzodiazepines should be directed at both patients and physicians.

In this article, we present the results of a study that was conducted among 15 family physicians who had incorporated complementary and alternative medicine (CAM) into their clinical work in Israel. We aimed to explore the types of boundaries those physicians encountered, how these boundaries were contoured, and under what circumstances they were crossed. We conducted in-depth interviews with the physicians in 2008, and found that epistemological and cognitive boundaries did not pose a problem for them. However, with regard to the organizational boundary, the participants indicated that it was necessary to use a variety of strategies before they could utilize their CAM skills. Many of the participants indicated that the epistemological differences between the biomedical and CAM paradigms, such as the absence of evidence-based medicine in CAM practices, are not important. The ease with which boundaries were crossed in the complex social context described here is characteristic of postmodern societies. On the whole, the integrative physicians interviewed can be viewed as "postmodern" professionals who reject the impermeability of many long-established boundaries and hierarchies.

The association between childhood and adolescent abuse and suicidal behavior, and the possible contribution of abuse to sex differences in non lethal suicidal behavior, was investigated. Data were extracted from the Israel-based component of the WHO World Mental Health Survey (Kessler & Utsun, 2008a). Increased risk for ideation, plan, and suicidal attempt were associated with childhood abuse, and increased risk for attempt was associated also with abuse at adolescence. No associations with sex or sex by abuse interactions were observed. The higher frequency of childhood abuse among women could account in part for their higher rates of suicidal attempts as compared to men., (© 2012 The American Association of Suicidology.)

Reports indicate sharp increase in prevalence of autism spectrum disorders (ASD). We aimed to assess the time trend in prevalence of ASD in Israel and describe demographic characteristics of the registered cases. We reviewed the autism registry of the Israeli Ministry of Social Affairs which includes 4,709 cases and identified 4,138 cases born between the years 1986 and 2005. Registered cases were mainly males (84.4%) and Jewish (96.6%). Prevalence data indicated an increase from 1.2 per 1,000 in those born in 1986 to 3.6 per 1,000 in 2003. Greater increase was seen in males, reaching a peak of 5.7 per 1,000, compared to 1.2 per 1,000 in females. Increased ASD prevalence was observed among Israeli children born in 1986-2005.

Purpose: Countries with Muslim populations report relatively lower rates of suicide. However, authors have noted methodological flaws in the data. This study examined reliable rates of completed suicide, suicide ideation, planning and attempts among Muslims as compared to Jews in Israel., Methods: For completed suicide, information was extracted from death certificates (2003-2007); the National Emergency Room Admissions Database (NERAD) provided data on suicide attempts (2003-2007); and the Israel National Health Survey (INHS) (2003-2004) was used for self reports on lifetime suicide ideation, planning and attempts., Results: Completed suicide rates among Muslim-Israelis (3.0 per 100,000) were lower compared to Jewish-Israelis (8.2 per 100,000). Based on NERAD, attempted suicide rates among men were lower for Muslims compared to Jews, while among women aged 15-44 no differences were found. In the INHS, the rate of self-reported lifetime suicide attempts was significantly higher among Muslims (2.8%) compared to Jews (1.2%), while lifetime prevalence rates of suicide ideation (6.6%) and planning (2.1%) in Muslims did not differ from Jews (5.2 and 1.9%, respectively)., Conclusions: Conceivably, the lower rate of completed suicide among Muslim-Israelis might be explained by the strenuous proscription of suicide by the Koran. However, its extension to suicide attempts is equivocal: attempts were higher among Muslims than among Jews according to self-reports but lower in the NERAD records. Social pressures exerted on the reporting agents may bias the diagnosis of self-harm in both the latter data source and in the death certificates.

Objective: The objective was to assess the association between asthma and depressive symptoms (DS) and to evaluate the relationship between DS and risk factors [smoking, physical inactivity, body mass index (BMI) and sleep duration] in asthmatic individuals., Methods: We analyzed data from the Israeli National Health Interview Survey, conducted among 9509 participants aged ≥21 years in 2003-2004. Data on sociodemographic factors, chronic respiratory disorders, DS and risk factors were obtained through telephone interviews. DS were measured using Short Form 36 mental health items. Analyses were performed using multivariate logistic regression models., Results: A total of 393 participants (4.2%) reported chronic asthma in the 12 months previous to the interview. Of those, 37.4% had DS, compared with 21.8% of nonasthmatic participants [odds ratio (OR), 1.84; 95% confidence interval (CI), 1.47-2.30; P<.001]. DS in asthmatic individuals were significantly associated with physical inactivity [adjusted OR (AOR), 2.01; 95% CI, 1.12-3.61; P=.02], with smoking (AOR 1.80; 95% CI, 1.04-3.12; P=.04) and with less sleep (AOR, 1.81; 95% CI, 1.03-3.19; P=.04). DS in asthmatic participants were not associated with BMI., Conclusions: DS are common in asthmatic individuals and are significantly associated with physical inactivity, with smoking and with less hours of sleep. Such health-related risk factors may impact on the course of asthma and on overall health., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objective: To evaluate patient and physician characteristics associated with the type of psychotropic medications (anti-anxiety, antidepressant, or both) purchased., Methods: The Clalit Health Care Services is the largest managed care health fund in Israel, a country that employs a universal healthcare system. We randomly sampled 30,000 primary care patients over the age of 22 as of January, 2006., Results: Overall, 2,217 purchased either antidepressant or antianxiety medications at least once during the year 2006 and had no prior purchases during the last quarter of 2005. The majority (1,518; 68.4%) purchased only anti-anxiety medications and as many as 264 (12%) purchased both anti-anxiety and antidepressant medications. The remaining 435 (19.6%) patients purchased only antidepressant medications. Physician level characteristics explained only a small portion of the variance and, thus, were not included in further analysis. Several patient level characteristics, including age, somatic, and psychiatric diagnosis were associated with the purchase of different types of medications., Conclusions: Contrary to clinical guidelines, the purchase of anti-anxiety medications is more prevalent than the purchase of antidepressant medications. In a managed care setting, patient characteristics have a greater role in determining purchasing patterns than provider characteristics; potentially, because of the managed care characteristics that actively guide the care provided to patients.

Background: A crucial element in controlling blood pressure is non-pharmaceutical treatment. However, only a few studies specifically address the question of hypertensive patients' compliance with physicians' recommendations for a healthy lifestyle., Objectives: To explore factors associated with hypertensive patients' compliance with lifestyle recommendations regarding physical activity, smoking cessation and proper diet., Methods: We performed a secondary data analysis of a representative sample of 1125 hypertensive patients in Israel's two largest health funds. Data were collected in 2002-2003 by telephone interviews using structured questionnaires. The response rate was 77%. Bivariate and multivariate analysis was conducted., Results: About half of the hypertensive patients reported doing regular exercise and adhering to a special diet; 13% were smokers. About half reported receiving counseling on smoking cessation and diet and a third on physical exercise. A quarter reported receiving explanations regarding self-measurement of blood pressure and signs of deterioration. Multivariate analysis revealed that patients' beliefs about hypertension management, their knowledge on hypertension and its management, and physician counseling on a healthy lifestyle and self-care, have an independent effect on compliance with recommended lifestyle behaviors., Conclusions: The low counseling rates suggest that there may be a need to improve physicians' counseling skills so that they will be more confident and effective in delivering this service to their patients. A model based on educating both physicians and patients may contribute to improving the care of hypertensive patients.

Objective: To analyze the temporal trends of obesity over time among male adolescents of different ethnic origins., Methods: Population-based national data of subjects presenting at recruitment centers for medical examinations as part of screening for military draft. Subjects were 17-year-old Jewish males (n=1 140 937) born in the years 1950-1986. Data on body mass index (BMI) were measured (without clothing and shoes) by physicians. We calculated the prevalence of obesity (BMI 29.4 or higher) for each year by ethnic origin group. A Multinomial logistic regression model was used to estimate the effects of ethnic origin and other risk factors on the likelihood of obesity., Results: Over time, obesity rates have risen among all ethnic groups of adolescents. Multinomial regression analysis showed a lower likelihood of obesity among those of Asia-Africa origin as compared with other groups. However, obesity rates have increased more significantly over time among this ethnic group compared with the other groups., Conclusion: A significant finding of this study is the disparities in temporal trends in the likelihood of obesity over time. Among adolescents of Asia-Africa origin the likelihood of obesity increased more steeply over time compared with other groups of adolescents. Health services in Israel should thus consider Asia-African origin as a distinct risk factor and target interventions to prevent future obesity among these adolescents.

Background: Previous research suggests that depression is common in individuals with asthma. Research on the association between depressive symptoms and health-related risk behaviors in persons with respiratory disorders is scarce., Objective: To assess the association between asthma and depressive symptoms; and to evaluate the relationship between depressive symptoms and risk behaviors (smoking, physical inactivity and obesity) in individuals with asthma., Methods: We analyzed data from the Israeli National Health Interview Survey [INHIS-1), conducted on a large sample (N = 9,509) of the adult Israeli population (age > or = 21 years) in 2003-4. Data on socio-demographic factors, chronic respiratory conditions, depressive symptoms and risk behaviors were obtained through telephone interviews. Analyses were performed using adjusted Logistic regression models., Results: A total of 381 participants (4.0%) reported chronic asthma in the year previous to the interview. Of those, 15.5% had moderate depressive symptoms compared with 7.2% of participants with no respiratory conditions (odds ratio, 1.95; 95% CI, 1.40-2.72; P < .0001). Depressive symptoms in individuals with asthma were significantly associated with smoking (adjusted odds ratio (AOR) 3.31; 95% CI, 1.58-6.91; P = .001 for moderate depressive symptoms; AOR 1.91; 95% CI, 1.05-3.45; P = .03 for mild depressive symptoms); moderate but not mild depressive symptoms were significantly associated with physical inactivity (AOR, 3.05; 95% CI, 1.52-6.12; P = .002). These associations were stronger in females. Depressive symptoms were not associated with obesity., Conclusions: Among Israelis with chronic asthma, depressive symptoms are associated with important differences in health behaviors (higher rates of smoking and lack of physical activity) which may impact on the course of respiratory illness and on overall health.

In 1998, Israel's national health insurance system introduced a modest co-payment for visits to specialist physicians. This study takes advantage of a natural experiment in which 15% of the population--the poor and disabled--was exempted from these co-payments. It used the micro-level panel data of three large health plans on the physician visits of 50,000 members per plan in 1997-2001. The data indicate that, following introduction of the co-payment, specialist visits increased among non-exempt members, relative to exempt members, of two health plans that together account for two-thirds of the population. This paper illustrates how, unlike the Health Insurance Experiment and other US studies of cost sharing, the structure of the co-payment in Israel may have inadvertently limited the incentive to decrease consumer demand and may have created an incentive for the health plans to increase visit rates, especially among the non-exempt members. Other countries that have implemented co-payment systems with exemptions may benefit from the Israeli experience in designing and evaluating their systems., (Copyright © 2010 John Wiley & Sons, Ltd.)

Childhood and adolescence abuse is a risk factor for later psychopathology. We examined the association between the age when sexual (SA) and physical (PA) abuse first occurred and mood and anxiety disorders and their respective age of onset, emotional distress, and sleep disturbances. Data were gathered from the Israel-based component of the World Mental Health Survey (N = 4859). Abuse was elicited by direct questions. Psychiatric disorders were diagnosed with the Composite International Diagnostic Interview, emotional distress with the 12-item General Health Questionnaire, and sleep disturbances by self-report. Multivariate analyses indicated an increased risk for psychopathology among subjects who reported childhood SA and PA. SA was associated with lifetime mood (odds ratio [OR] = 1.7) and anxiety (OR = 2.3) disorders; PA with lifetime anxiety disorder (OR = 2.8); and any abuse with increased risk for lifetime mood (OR = 1.7) and 12-month anxiety disorders (OR = 1.8). Earlier onset of SA or PA was associated with increased risk for later psychopathology.

In this paper we present new data pertaining to the paleo-landscape characteristics at the Acheulian site of Revadim, on the southern coastal plain of Israel. Sedimentological, isotopic, granulometric and micromorphological studies showed that the archaeological remains accumulated in an active fluvial environment where channel action, overbank flooding and episodic inundation occurred. Measurements of total organic matter and its carbon isotopic composition indicate that the hominin activity at the site started at a period of relatively drier conditions, which coincided with erosion of the preceding soil sequence. This process led to the formation of a gently-undulating topography, as reconstructed by a GIS model. Later deposition documents relatively wetter conditions, as indicated by carbon isotopic composition. Formation processes identified at the site include fluvial processes, inundation episodes that resulted in anaerobic conditions and formation of oxide nodules, as well as small-scale bioturbation and later infiltration of carbonate-rich solutions that resulted in the formation of calcite nodules and crusts. The combination of micro-habitats created favorable conditions that repeatedly drew hominins to the area, as seen by a series of super-imposed archaeological horizons. This study shows that site-specific paleo-landscape reconstructions should play an important role in understanding regional variation among hominin occupations and in extrapolating long-term behavioral patterns during the Middle Pleistocene., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Objective: To examine patterns of visits by residents of northern Israel displaced during the Israel-Lebanon War of 2006 to an urgent care system in central Israel and to compare these patterns with those of local patients., Design: Retrospective analysis of electronic medical records., Setting: Urgent care clinic system in and around Jerusalem, Israel., Participants: Patients residing in northern Israel who presented from July 12 to August 21, 2006. Local patients who presented during the same time period were used for comparison., Interventions: None., Main Outcome Measures: Chief complaints, discharge diagnoses, demographics, and visit characteristics., Results: There were a total of 1,175 visits for 938 northern patients, reflecting 6.7 percent of total visits to this system. Overall age distribution of northerners was generally similar. As a proportion of visits, adult northerners were less likely to visit for chief complaints of injury or laceration and more likely to visit for complaint of back pain. They were more likely to have a discharge diagnosis of chest pain, anxiety, or hypertension. Northern children and adolescents were less likely to visit due to injury or fall or to have a discharge diagnosis of fracture. They were more likely to have a discharge diagnosis of gastroenteritis or tonsillitis., Conclusions: Patterns of common discharge diagnoses were generally similar between northern and local residents, with the exception of fewer injury-related visits and more anxiety-related visits. Urgent care appears to have served an important function for displaced individuals during this war, mostly for routine medical needs.

Objectives: Limited data exist on the link between psychological distress and regular physical activity in the general population. We examined the association of psychological distress with physical inactivity, independently of sociodemographic and behavioral factors in a large community sample. We also examined whether psychological distress is related to limitations in day-to-day activities due to emotional problems., Methods: Information on physical activity, sociodemographic, and behavioral factors was obtained through telephone interviews of 5708 subjects aged > or = 21 years from a cross-sectional study-the first Israeli National Health Interview Survey (2003-2004). Psychological distress and limitations due to emotional problems were measured using the five-item Mental Health scale (MHI-5) and role emotional scales derived from the SF-36 questionnaire., Results: In multivariate analyses, high psychological distress level was associated with increased odds of physical inactivity among both men (adjusted OR=1.30, 95% CI=1.09-1.55) and women (adjusted OR=1.31, 95% CI=1.11-1.53). Psychological distress was strongly associated with limitations in day-to-day activities due to emotional problems., Conclusions: In this cross-sectional study of adult men and women, psychological distress was independently associated with physical inactivity. Psychological distress may limit day-to-day activities in general and reduce the success of health promotion activities. These findings could help in identifying subjects facing difficulties in initiation and adherence to these activities., (2009 The Institute For Cancer Prevention. Published by Elsevier Inc. All rights reserved.)

Obesity increased monotonically from 1.2% to 3.8% of males age 17 (1967-2003). Low socioeconomic status had an independent positive effect on obesity. The likelihood of obesity had risen more steeply over time among the low socioeconomic status group than among other adolescents. Rise in obesity, standard of living, and income inequality (as measured by the Gini index) increased concomitantly.

Since the implementation of the legislation in Israel concerning rehabilitation of people with psychiatric disabilities in the community in 2001, an increasing number of individuals, currently estimated at nearly 15,000, have been receiving the psychiatric rehabilitation "basket of services." A systematic investigation of the extent to which these services have had a positive impact on the intended outcome is required, to evaluate the effectiveness of the newly developed psychiatric rehabilitation basket of services. This evaluation has become a priority item on the mental health agenda in Israel. This opinion paper, based on a conceptual analysis and selective review of the relevant literature, discusses concepts and principles that seem important for the development of strategies to constructively assess the outcome of psychiatric rehabilitation services (PRS) in Israel. More specifically, several fundamental issues related to outcome monitoring are reviewed, such as what outcome domains should be assessed, who should conduct the assessments and from whom should data be collected and with whom and how should it be shared. The complexity of these issues are reviewed and possible strategies to deal with them are discussed.

Purpose: This article aims to analyze existing and preferred labor divisions between physicians and nurses treating patients with hypertension and diabetes in managed care organizations., Design/methodology/approach: A mail survey was conducted in 2002/2003 among a representative sample of 743 physicians employed by Israel's largest managed care health plans (78 percent response rate). A telephone survey among a representative sample of 1,369 hypertensive or diabetic patients (77 percent response rate) was also used., Findings: Findings reveal a conspicuous gap between actual labor division and what physicians perceive to be ideal. Possible reasons for this gap are discussed and strategies for facilitating collaboration, which would improve service quality as well as work life quality for both physicians and nurses., Originality/value: This study provides empirical data on the extent of nurse involvement in managed care organization chronic patient care, as well as comparing them to physicians' preferences regarding nurse involvement.

Objective: Research on status inconsistency (SI) and its impact on mental health has been dormant for many years. This study tested the association between SI and emotional distress, anxiety and mood disorders., Methods: Data were gathered from the Israel-based component of the World Mental Health Survey (n = 4,859). SI was defined by the combination of high education (13+ years) with low income (1st decile). Mood and anxiety disorders were diagnosed with the composite international diagnostic instrument (CIDI), and emotional distress was measured with the 12-item general health questionnaire (GHQ-12)., Results: Multivariate analysis showed increased risk for mood or anxiety disorders among SI subjects (n = 231), odds ratio (OR) = 1.75, 95% confidence interval (95% CI) 1.13-2.63. The estimate was slightly attenuated when marital status was added to the model (OR = 1.55, 95% CI 1.0-2.39). SI subjects showed higher GHQ-12 scores., Conclusion: SI, which can disrupt an individual's sense of coherence, is associated, although not causally, with increased 12 month prevalence rates for mood or anxiety disorders and with higher psychological distress.

Background: At present, Israel's mental health system functions separately from its physical health system in terms of financing, planning, organization and practice setting. The government is responsible for the provision of mental health care, while the country's four, competing, non-profit health plans are responsible for physical health care. A reform effort is underway to transfer legal responsibility for the provision of mental health care from the government to the health plans., Aims: The main objectives of this paper are to summarize the key components of the reform, its objectives, and the concerns that it has raised. The paper also seeks to foster interactions between experts from Israel and other countries about the Israeli reform., Methods: The analysis is based on official government documents, the scholarly literature about the Israeli reform and the relevant international literature about mental health care in other countries, participation in key public meetings related to the reform, discussions with leaders of the reform effort, and discussions with leading mental health experts in other countries., Results: Two elements of the reform--the application of managed care principles to mental health and the integration of mental and physical care--are shown to be central both to the reform's objectives and to the concerns that have been raised about the reform., Discussion: These same two elements are relevant to many countries implementing or considering reforms in their mental health systems., Conclusions: The architects of the Israeli reform could learn a great deal from the experience with mental health care and related reforms in other countries. At the same time, the Israeli reform could offer important insights and lessons for other countries., Implications for Policy: The Government of Israel should work with the international mental health care professional community to create frameworks that would facilitate cross-national learning., Implications for Further Research: It will be important to monitor the implementation of the reform and evaluate its impact, in order to assess the extent to which the objectives are met and the extent to which the concerns materialize. Cross-national research collaborations could be very helpful.

Background: Previous studies have reported that as a group, individuals affected by psychotic and nonpsychotic disorders perform below norms on cognitive tests. Other studies have indicated that unaffected siblings of individuals affected by psychotic disorders also perform below norms on the same tests. We investigated cognitive performance on a large, population-based sample of individuals, affected at the time of testing by nonpsychotic disorders, and their unaffected siblings., Methods: Subjects were taken from a population-based cohort of 523,375, 16- to 17-year-old male adolescents who had been assessed by the Israeli Draft Board. Cognitive test scores were examined in sib-pairs discordant for nonpsychotic (n = 19,489) and psychotic (n = 888) disorders and compared with 224,082 individuals from sibships with no evidence of mental illness., Results: There appears to be a gradient in cognitive performance (worst to best) from individuals currently affected by psychotic illnesses (Cohen's d = -.82), followed by individuals currently affected by nonpsychotic illness (Cohen's d = -.58), unaffected siblings of individuals affected by psychotic illness (Cohen's d = -.37), unaffected siblings of individuals affected by nonpsychotic illness (Cohen's d = -.27), and members of sibships with no evidence of mental illness. Unaffected siblings of both psychotic and nonpsychotic individuals from multiple affected sibships (more then one affected sibling) had worse cognitive test scores compared with unaffected siblings from simplex sibships (only one affected sibling)., Conclusions: The results support, but do not prove, the notion that cognitive impairment in psychiatric disorders is familial and cuts across diagnostic entities.

Purpose: The purpose of this paper is to identify the factors that contribute to the success or failure of quality assurance programs implemented by Israeli managed care health plans., Design/methodology/approach: An in-depth study of seven quality assurance programs was conducted, comparing successful with unsuccessful ones using the comparative "case study" method. Employing a semi-structured questionnaire, 42 program directors and professionals in the field were interviewed., Findings: A number of factors associated with the programs' success emerged. Those external to the program included: ongoing management support, resource allocation, information system support and perceived financial benefit for the organization. Internal factors included: leadership, perceived problem's importance, laying the groundwork in the field, involving field staff in planning and implementation and staff motivation., Originality/value: The study provides insights into ways to encourage the implementation of successful quality assurance programs in the special organizational context of managed care health plans. As the implementation relies heavily on data, one important precondition is the development of computerized information systems to facilitate ongoing data collection. It is also necessary from the planning stage to take into account organizational factors that affect success.

Purpose: This paper aims to analyze the development of "pay-for-performance" (P4P) programs implemented by Israel's two largest sick funds, insuring 78 percent of the population., Design/methodology/approach: Analysis of the main features and their evolution over time, the observed outcomes and concerns related to implementing these programs., Findings: Our analysis revealed that although implementation has been successful, both managers and physicians have voiced concerns regarding the effect of measuring clinical performance such as focusing attention on the measured areas while neglecting other areas, and motivating a statistical approach to patient care instead of providing patient-centered care., Originality/value: The Israeli case provides an interesting example of nation-wide, long-term implementation of the pay-for-performance program. Therefore, it provides other countries with the opportunity to assess features that may facilitate successful implementation, as well as highlighting issues related to the outcomes of P4P programs.

Depression is a leading cause of morbidity, disability and health care utilization. It is commonly encountered in primary care settings yet is often missed or suboptimally managed. We summarize studies conducted in Israel on the prevalence of depression in primary care settings, its correlates, and predictors of treatment and outcome, and discuss their implications for clinical practice and public health policy. An electronic search was conducted using the MEDLINE and PsychINFO databases. The inclusion criteria were original studies that assessed aspects of depression in a population aged 18 or older, were conducted in primary care settings in Israel, and had sufficient detailed description of depression-related measures, study sample and outcome measures. Twelve articles reporting results from seven studies met these criteria. The prevalence of current depression in primary care varied considerably across studies: 1.6-5.9% for major depression, 1.1-5.4% for minor depression, 14.3-24% for depressive symptoms. Depression was consistently related to female gender and fewer years of education, and was associated with disability, decreased quality of life, and increased health-related expenditure. Many cases of depression were undiagnosed and most patients had persistent depression or achieved only partial remission. Depression represents a serious challenge for the primary health care system in Israel. Greater efforts should be focused on screening and treating depression in primary care. However, the studies reviewed here used different methodologies and assessed different aspects of depression and, therefore, should be generalized cautiously. Systematic research on the prevalence, correlates and management of depression in primary care, with emphasis on collaborative care models, is strongly needed to inform research, clinicians and health care policy makers.

The Amudian (late Lower Paleolithic) site of Qesem Cave in Israel represents one of the earliest examples of habitual use of fire by middle Pleistocene hominids. The Paleolithic layers in this cave were studied using a suite of mineralogical and chemical techniques and a contextual sedimentological analysis (i.e., micromorphology). We show that the lower ca. 3m of the stratigraphic sequence are dominated by clastic sediments deposited within a closed karstic environment. The deposits were formed by small-scale, concentrated mud slurries (infiltrated terra rosa soil) and debris flows. A few intervening lenses of mostly in situ burnt remains were also identified. The main part of the upper ca. 4.5 m consists of anthropogenic sediment with only moderate amounts of clastic geogenic inputs. The deposits are strongly cemented with calcite that precipitated from dripping water. The anthropogenic component is characterized by completely combusted, mostly reworked wood ash with only rare remnants of charred material. Micromorphological and isotopic evidence indicates recrystallization of the wood ash. Large quantities of burnt bone, defined by a combination of microscopic and macroscopic criteria, and moderately heated soil lumps are closely associated with the wood-ash remains. The frequent presence of microscopic calcified rootlets indicates that the upper sequence formed in the vicinity of the former cave entrance. Burnt remains in the sediments are associated with systematic blade production and faunas that are dominated by the remains of fallow deer. Use-wear damage on blades and blade tools in conjunction with numerous cut marks on bones indicate an emphasis on butchering and prey-defleshing activities in the vicinity of fireplaces.

Despite continuous efforts, healthcare organizations still find it difficult to influence physicians to follow clinical guidelines. Previous studies have not taken into account the organizational context of the physicians' practice. We conducted a survey of a representative sample of 743 primary care physicians employed in Israel's 2 largest managed care health plans. The findings indicated that "commitment to the health plan" and "perceived monitoring by the health plan" had an independent positive effect on familiarity with guidelines for treating diabetes. We propose that managers of healthcare organizations consider enhancing physicians' commitment to the organization as a means for increasing their adherence with clinical guidelines, thereby improving the quality of care provided to diabetic patients.

This paper examines primary care physicians' perceptions of a National Health Insurance Law that introduced managed competition into Israel's health care system, and the factors affecting their perceptions. Between April and July 1997, we conducted a mail survey of primary care physicians employed by Israel's four health plans (which are managed care organizations). Eight hundred questionnaires were returned, representing a response rate of 86%. The findings indicate that, overall most physicians support the components of the National Health Insurance Law with statistically significant differences among physicians by health plan. Multivariate analysis revealed that, contrary to theoretical expectations, a perceived decrease in professional autonomy and in the status of the profession following reform did not significantly affect attitudes toward national health insurance. These findings highlight the need for additional empirical studies to further examine theoretical contentions about the implications of infringing on the professional autonomy and the dominant status of physicians. The principal and most interesting finding of this study was the independent effect of health plan affiliation on physicians' attitudes toward each of the five components of the National Health Insurance Law, after controlling for background characteristics, for the reform's perceived effect on the physicians' autonomy and status in the health plan, and for the reform's perceived effect on the level of health plan services and the health plan's financial situation. We found that physicians' perceptions tended to conform to the formal position of their health plan, suggesting the need to analyze the attitudes of physicians in their organizational context, rather than treating them as members of a uniform professional community.

Background: Women appear to be more vulnerable than men to emotional distress (ED) However, ED often goes unrecognized by family physicians., Purpose: To (1) assess the rate of inquiry about ED by family physicians and (2) explore the association between physician's inquiry about ED and women's satisfaction with care., Methods: Telephone interviews were conducted in 2003 using a structured questionnaire in a representative sample of 991 Israeli women aged 22 years or older, with a response rate of 84%., Results: 33% of women reported ED during the past year but only 15% of women reported having discussed ED with their family physician in the last year. Higher rates of discussion of ED with the physician were found among women who had experienced ED (22.5%), those who had a chronic illness (20.1%) had low income (22.7%), and were Arabic (29.5%) or Russian speakers (26.3%). Multivariate analysis indicated that women who had discussed ED with their physician expressed higher satisfaction with the physicians professional level (OR = 6.85), attitude (OR = 2.45), spending enough time (OR = 2.90), and listening to the patient (OR = 3.19), compared with women who had not discussed ED with their physician., Conclusions: Given the current low rates of inquiry about ED, it appears that developing sensitivity to women's emotional concerns and encouraging physicians to inquire about ED should be given higher priority in medical education at all levels. Furthermore, since inquiry about ED not only improves the appropriateness of care but is also associated with higher satisfaction with the physician, organizations in a competitive health care environment may have a particular interest in promoting this practice.

Diabetes is aggravated by a sedentary lifestyle, obesity and smoking. Based on a theoretical model relating attitudes and behavior, this study examined the association between physicians' self efficacy in counseling diabetic patients on life style behaviors and their counseling practices. Data were gathered from a representative sample of 743 primary care physicians in Israel's two largest health plans. The main findings were that only a small percentage of physicians felt capable of influencing their patients' life-style behaviors. Self-efficacy had an independent effect on the likelihood of counseling diabetic patients on life style behaviors, controlling for other background variables. We conclude that there is a need for enhancing physicians' life-style counseling skills, and that social workers could expand their role by training physicians to counsel effectively. This could both improve the care of diabetic patients, and strengthen the status of the social work profession in the healthcare system.

Objectives: To assess: a) the prevalence and determinants of self-reported emotional distress in the Israeli population; b) the rate of self-reported discussion of emotional distress with family physicians; and c) the association between such discussions and patient satisfaction with care., Design: Retrospective, cross-sectional survey that was conducted through structured telephone interviews in Hebrew, Arabic, and Russian. This study was part of a larger study assessing patients' perceptions of the quality of health services., Participants: A representative sample of 1,849 Israeli citizens aged 22 to 93 (response rate: 84%)., Independent Variables: Gender, age, ethnicity (spoken language), education, income, self-reported chronic disease, self-reported episode(s) of emotional distress during the last year, and having discussed emotional distress with the family physician., Outcome Measure: satisfaction with care., Results: 28.4% reported emotional distress and 12.5% reported discussion of emotional distress with a primary care physician in the past year. Logistic regression identified female gender, Arab ethnicity, low income, and chronic illness as independent correlates of emotional distress. These as well as Russian speakers and having experienced emotional distress during the past year were identified as independent correlates of discussion of emotional distress with the family physician. Patients who reported discussion of emotional distress with their family physician were significantly more satisfied with care., Conclusions: Encouraging physicians to detect and discuss emotional distress with their patients may increase patient satisfaction with care, and possibly also improve patients' well-being and reduce health care costs.

Context: Maternal and paternal ages are associated with neurodevelopmental disorders., Objective: To examine the relationship between advancing paternal age at birth of offspring and their risk of autism spectrum disorder (ASD)., Design: Historical population-based cohort study., Setting: Identification of ASD cases from the Israeli draft board medical registry., Participants: We conducted a study of Jewish persons born in Israel during 6 consecutive years. Virtually all men and about three quarters of women in this cohort underwent draft board assessment at age 17 years. Paternal age at birth was obtained for most of the cohort; maternal age was obtained for a smaller subset. We used the smaller subset (n = 132 271) with data on both paternal and maternal age for the primary analysis and the larger subset (n = 318 506) with data on paternal but not maternal age for sensitivity analyses., Main Outcome Measures: Information on persons coded as having International Classification of Diseases, 10th Revision ASD was obtained from the registry. The registry identified 110 cases of ASD (incidence, 8.3 cases per 10 000 persons), mainly autism, in the smaller subset with complete parental age data., Results: There was a significant monotonic association between advancing paternal age and risk of ASD. Offspring of men 40 years or older were 5.75 times (95% confidence interval, 2.65-12.46; P<.001) more likely to have ASD compared with offspring of men younger than 30 years, after controlling for year of birth, socioeconomic status, and maternal age. Advancing maternal age showed no association with ASD after adjusting for paternal age. Sensitivity analyses indicated that these findings were not the result of bias due to missing data on maternal age., Conclusions: Advanced paternal age was associated with increased risk of ASD. Possible biological mechanisms include de novo mutations associated with advancing age or alterations in genetic imprinting.