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Introduction A low response to COVID-19 vaccination was observed among the Arab population in Israel. Efforts to improve this achieved moderate results. Objectives The aim of this study was to examine the extent to which demographic and cultural factors, the media, trust, perceptions, and government policies influence the willingness of Arabs to be vaccinated against COVID-19. Methods A cross-sectional survey was conducted among Israeli Arabs (558 respondents). The questionnaire was distributed through social networks between January 16 and 26, 2021. The t-tests, Chi-square tests, Z tests, which were used to evaluate the significance of variables, and Pearson correlations calculated for the study variables were used for statistical analysis. Hierarchical logistic regression was calculated to assess the extent of background influence on the odds for vaccination, and mediation was examined using the Process procedure. Results Moderate means were found for attitudes towards vaccination, vulnerability, vaccine effectiveness, and pandemic fatigue. A lower score was found for accessibility to medical services, social norms, and emotional barriers. Trust was highest in health-related authorities, whereas trust in government and the media was the lowest. Higher pandemic fatigue was associated with lower trust and lower odds for vaccination. Discussion Lack of awareness of the specific needs of the Arab minority in Israel, lack of vaccination campaigns in Arabic language, long neglect of Arabs in the Israeli health system, mistrust of governmental authorities by the Arabs, and low socioeconomic background of Israeli Arabs might have led to lower trust levels and incompliance with governmental policies among Arabs. Addressing these issues may benefit the entire population. The authors believe that “A chain (in population health) is only as strong as its weakest link.”

During the first lockdown in Israel, citizens were instructed to visit community clinics only for urgent cases. However, they were not informed that emergency departments (EDs) were safe. Reports from the National Ambulance Services showed a 22% increase in at-home deaths during the lockdown. Perhaps, the reason is because some critically ill patients postponed referrals and came “at the last minute”. After the first lockdown, the Ministry of Health (MOH) declared that hospital EDs were safe. The objective of the study was to examine the rates of admission from EDs to hospital wards, and non-COVID-19 in-hospital deaths during the first lockdown in Israel, compared with the second and third lockdowns. From the business intelligence software of the Rambam Medical Center in Israel, we collected data about the rates of admission to the ED, the non-COVID-19 in-hospital deaths during the three lockdowns, during the same periods in the previous three years, and the main five causes of non-COVID-19 deaths. Data comparison was done using multiple chi-square tests. ED admission numbers were significantly higher during the first lockdown than during the second (χ2 (1, n = 36,245) = 24.774, p = 0.00001) and third lockdowns (χ2 (1, n = 36,547) = 8.7808, p = 0.0030). We found a significantly higher number of non-COVID-19 in-hospital deaths vs. discharges during the first lockdown than in the second and third lockdowns (χ2 (2, n = 26,268) = 7.794, p = 0.0203) The number of deaths due to respiratory diseases was significantly higher during the first lockdown than in the second lockdown (χ2 (1, n = 572) = 8.8185, p = 0.0029) and in the third lockdown (χ2 (1, n = 624) = 9.0381, p = 0.0026), and deaths from infectious diseases were higher during the first lockdown than during both the second and third lockdowns (χ2 (1, n = 566) = 5.9479, p = 0.0147, and χ2 (1, n = 624) = 9.5978, p = 0.0019), respectively. The onset of CVA and CVD are abrupt, while respiratory and infectious diseases may have an insidious pattern; this may have led patients to postpone referrals to hospitals to the “last minute” during the first lockdown, perhaps due to fears of contracting COVID-19, and as a result of vague instructions. Citizens and policymakers must be made aware of this point during future pandemics.

The Israeli cachibol league, Mamanet, is a grass roots non-professional community sports club for mothers. Our aim was to assess if participants in the Mamanet League have higher levels of social capital and if social capital and wellbeing improve with time. Two groups were interviewed: a control group not participating in the league and a group of Mamanet participants. The women were interviewed within 3 months of joining (T1) and 13–15 months later (T2). The questionnaire included questions on sociodemographic characteristics, social capital (social support, social involvement, trust) and wellbeing (self-reported health (SRH), psychosomatic symptoms, depressive symptoms). At T1 the participants had higher social capital and SRH scores than the control group and lower psychosomatic and depressive symptoms compared with the control group. Participation in the Mamanet League seems to improve two of the three social capital measures: social support and social involvement, showing an increase among the Mamanet group over time and no change in the control group. Participation in the league had no significant effect on wellbeing during this period. Women that participate in sports clubs may initially have higher social capital; in addition, participation may increase levels of social capital over time.

(1) Background: Medical teams are at the forefront of the COVID-19 pandemic. Decision making among medical staff is important for promoting and maintaining the health of patients and staff. This study examines factors associated with physicians’ decision making and preventive behavior during the COVID-19 pandemic in Israel. (2) Methods: An online survey was conducted among 187 Israeli physicians in April and May 2020 during the COVID-19 pandemic. The questionnaire included the levels of physicians’ perceived threat and perceived risk during the epidemic, trust in the health system, emotions, and the degree of compliance with hygiene rules and mandated behaviors. (3) Results: Most physicians reported complying with the rules of hygiene at work (73%) and full compliance with Ministry of Health guidelines (61%). The findings show that higher levels of trust, positive emotions, and threat and risk perceptions were associated with a higher degree of compliance with Ministry of Health guidelines and more careful decision making among physicians. (4) Conclusions: Levels of trust in the health system and positive emotions among healthcare staff during the pandemic are related to careful adherence to guidelines. Taking steps to maintain physical and mental health among healthcare staff is important for their functioning and for maintaining public health.

The COVID-19 pandemic has created a sustained state of emergency, causing uncertainty and risk taking. Israeli nurses were required to follow new regulations and safety measures issued by the Israeli Ministry of Health (MOH). This study aimed to examine nurses’ compliance with MOH regulations and its association with their risk and threat perceptions and their positive and negative emotions. A cross-sectional online survey was conducted among 346 Israeli nurses. The study model was examined with path analysis. Most nurses reported complying with MOH regulations either fully (49%) or very often (30%). Negative emotions were positively associated with perceptions of both threat and risk, yet only risk perception was positively associated with nurses’ compliance. A significant mediated relationship was found between negative emotions and nurses’ compliance, with the possible mediator being risk perception. Hence, higher negative emotions were associated with a greater risk perception, which was associated with higher compliance. Health systems leaders must strategize to deal with the wave-like character of the pandemic. Solutions to nursing teams’ negative emotions must be provided to keep the balance between feelings of complacency and a situation of high-level, intense negative feelings, which might lead to abstention, burnout, or emotional injury.

Background Frontline medical staff, combating the Covid-19 pandemic are forced to make clinical and behavioral decisions daily. Their decision-making process and the factors associated with it, are of utmost importance in preserving and supporting their own health and their patient's health. Aims Tto explore the factors associated with physicians' decision-making during the first wave of the COVID-19 pandemic in Israel Methods Cross- sectional data were collected among 200 physicians at the Israeli health care system between March and May 2020 via an online questionnaire. A multiple hierarchical regression was calculated to assess the contribution of the study variables to the physicians' decision making. Results Most physicians reported that they complied with hygiene guidelines at work, issued by the Israeli ministry of health (MOH), fully (42%) or very often (31%), and with the MOH COVID-19 behavior guidelines fully (27%), very often (34%), or in general (23%). According to the study Results trust, positive emotions, perception of COVID-19 threat, and risk perceptions were found significant and positive. In other words, higher trust, more positive emotions, and perceptions of greater threat and risk, were associated with higher compliance with the MOH guidelines and more cautious decision making. Conclusions While threat and risk perceptions may be inevitable during the pandemic, trust and positive emotions may act as protective factors, encouraging cautious decision making among physicians. Key messages Physicians' decision making is a complex process affected by their perceptions, emotions, and trust levels. High levels of trust and positive emotions may facilitate carful decision making.

The role of social capital in the association between team sports and health-related outcomes has not been well established in the literature. The purpose of this study was to explore whether social capital components (social support, trust, and social involvement) mediate the association between team sports and health-related outcomes (self-reported health, psychosomatic symptoms, and depressive symptoms). In a cross-sectional research design, we obtained data from 759 participants in the Mamanet Cachibol League, a community team sports model for women in Israel, as well as a comparison group of 308 women who did not participate in any team sports. Team captains were sent a link with an online questionnaire, which were then delivered to team members via text message. Using three parallel mediation models, we found that social support mediated the association between team sports and self-reported health, psychosomatic symptoms, and depressive symptoms. Trust mediated the association between team sports and both psychosomatic symptoms and depressive symptoms. Social involvement was not found to be a mediator in the association between team sports and any of the health-related outcomes. Our findings reveal the important role of social capital, specifically social support and trust, in promoting the health of women who participate in team sports.

Summary Health Exercise Nutrition for the Really Young (HENRY) is a UK community–based early childhood obesity prevention intervention that was adopted and implemented in Israel between 2013 and 2018. The aim of this study was to explore the implementation process in Israel and compare it with that of the ‘parent’ programme in the UK, in order to throw light on the challenges of introducing complex interventions into different countries and cultures. Published reports from HENRY and Haifa University’s evaluation of the Israeli implementation were reviewed and comparisons between the UK and Israel were carried out utilizing the RE-AIM framework. In both countries, the intention was to implement in lower SES communities. When comparing the individual items, Reach and Effectiveness, we found a difference in the Reach although Effectiveness was similar: Reach was proportionally lower in Israel, but parent and professional changes in behaviour were positive in both countries. For the organizational items Adoption, Implementation and Maintenance, we found large differences between the countries. Major challenges identified in Israel included: failing to take adequate account when planning and implementing the intervention of the different ways social and health services are organized and how local authorities are structured and provide services. In addition, differences in culture beyond language and professional variations were challenges, when trying to transfer the intervention with high fidelity from the UK to Israel. Lessons learnt may benefit others in attempting cross-country implementation of complex interventions

Social distancing was found to prevent COVID-19 contagion. Therefore, understanding the factors associated with the public’s adherence is important. Acknowledging the importance of emotional wellbeing regarding older people’s health, and understanding their emotional state during the pandemic, are crucial. This study assessed factors associated with older people’s adherence to social distancing and their emotional status. A cross-sectional online survey was conducted among 1822 respondents above the age of 60. Distancing adherence, negative emotion, trust, social support, threat perception, attitudes, and subjective norms were assessed, and a path analysis was performed. Adherence was positively associated with attitudes (β = 0.10, p &lt, 0.001), and with subjective norms (β = 0.19, 0.001). Negative emotions were positively associated with threat perception (β = 0.33, 0.001), and negatively associated with social support (β = −0.13, 0.001) and subjective norms (β = −0.10, 0.001). Attitudes mediated the relationship of threat perception (95% CI = 0.009, 0.034), trust (95% CI = 0.008, 0.029), and social support (95% CI = 0.006, 0.023) with distancing adherence. Subjective norms mediated the relationship between threat perception (95% CI = 0.014, 0.034), trust (95% CI = 0.026, 0.055), and social support (95% CI = 0.002, 0.048) with distancing adherence. Subjective norms mediated the relationship between threat perception (95% CI = −0.022, −0.006), trust (95% CI = −0.034, −0.010), and social support (95% CI = −0.029, −0.009) with negative emotions. When promoting social distancing adherence, subjective norms and attitudes must be considered, as they play a role in promoting adherence and negative-emotion regulation.

Even with the advent of the COVID-19 vaccine, masks and social distancing are recommended as a precautionary measure to suppress SARS-CoV-2 infection and disease. In Israel, as in many other countries, despite official regulations and widespread availability and accessibility to affordable effective masks, the use of face masks is not consistent or universal. Physicians and other medical and health professionals have a vital role to play in communicating to the public about the importance of masking and encouraging people to wear face masks correctly and consistently. This review underscores the importance of masking as a protective public health mitigation measure. It describes types of face masks mainly used by the public and their effectiveness. It emphasizes the importance of identifying and addressing barriers (e.g., physical, social, economic) to encourage widespread and sustained appropriate use of masks. The article also proposes strategies to enhance masking, such as changing social norms through targeted local interventions and governmental control of mask quality and price.

During pandemics, minorities may experience high stress levels, which could harm their mental and physical health. However, to the best of our knowledge, this has not been examined among minorities in Israel during the COVID-19 pandemic. This study, therefore, explores stress among the Arab minority in Israel during the first wave of the COVID-19 outbreak, and its association with the population's perceived COVID-19 threat, trust in the healthcare system, adherence to preventative guidelines, and perceived discrimination.The study analyzed a cross-sectional online survey of 626 Israeli Arabs. Most participants (65%) reported moderate levels of stress, and 10% reported severe levels. The Bedouin population reported significantly higher levels of stress compared to other minority groups. The participants also reported a high degree of perceived threat, a moderate-to-high level of discrimination, a moderate level of trust in the healthcare system, and very high adherence to guidelines.Hierarchical regression analysis showed that age, religion, trust in the healthcare system, perceived threat, and adherence to guidelines were all significant predictors of stress [

The Israeli Mamanet Cachibol League (MCL) serves as a community model that incorporates physical activity and amateur team sports among women. Team sports have been shown to bridge gaps and build positive relationships between communities. There is a paucity of data regarding the advantages of team sports to promote the health and well-being of women from different ethnic backgrounds. The purpose of this study was to examine the association of participation in MCL with social capital, health, and well-being across two ethnic groups: Jewish and Arab women. A cross-sectional survey was conducted among women aged 25&ndash, 64: 102 Jewish and 96 Arab MCL participants, and 102 Jewish and 81 Arab non-MCL participants. Data regarding social capital (trust, social support and social involvement) and well-being (self-reported health and psychosomatic and depressive symptoms) were analyzed using two-way analyses of covariance and multiple regression models with sequential entry of the variables. MCL participants from both ethnic groups reported higher social capital (p &lt, 0.001), better self-reported health (p &lt, 0.001), and lower psychosomatic symptoms (p &lt, 0.001) compared to non-participants. Jewish MCL participants reported lower depressive symptoms (p &lt, 0.001) than non-participants, however no difference was found between Arab MCL participants and non-participants (p &lt, 0.160). Amateur team sports such as MCL are related with higher levels of well-being and social capital. Future research should focus on longitudinal studies that examine the change in social capital and well-being over time.

Background Risk behaviors such as smoking, alcohol consumption, and drug use are prevalent among adolescents worldwide, and are a major concern due to their harmful effects. Scientific literature presents no agreement as to whether belonging to a youth movement is a risk factor or a protective factor for risk behaviors. The current analysis aimed at evaluating the role of participating in youth movements (i.e., protective or risk factor) in substance use among Israeli adolescents. Methods Based on the 2015 Health Behavior in School-aged Children Survey (HBSC), The current analysis included 2197 participants aged 16-18, who answered the questions addressing participating in youth movements and questions regarding their risk behaviors. Results Overall, 17% of respondents reported smoking cigarettes, 39% consuming alcohol, 14% getting drunk, and 6% using drugs in the past 30 days. Of those respondents, 27% were members or guides in youth movements. Multiple logistic regression analysis showed that members of youth movements were significantly more at risk for drug use (OR = 3.54, 95%CI: 1.41, 8.90), and guiding was significantly associated with higher risk for alcohol consumption (OR = 1.90, 95%CI: 1.24, 2.91) and drunkenness (OR = 2.39, 95%CI: 1.50, 3.81) among 16-year-old respondents. No association was found between participation in youth movements and risk behaviors among 17-18year-olds. Family support was found to be a protective factor for cigarette smoking (OR = 0.83, 95%CI: 0.72, 0.97) and drug use (OR = 0.70, 95%CI: 0.58, 0.86) among 16-year-olds. Social norms were associated with all four risk behaviors among all age groups, showing, as expected, that the greater the social pressure, the higher the risk for participation in risk behaviors. Conclusions Social and family influence play an important role in the prevention of risk behaviors among adolescents. Youth movement settings should be monitored to ensure they do not become a supportive environment for risk behaviors. Key messages Social and family influence are important in preventing risk behavior in adolescents. Youth movements should be monitored to ensure they do not become a supportive environment for risk behavior.

Background Smoking and alcohol consumption during pregnancy is a major public health concern. The aims of this study were: 1) to examine smoking and alcohol consumption during pregnancy and to investigate their association with maternal attitudes and socio-demographic characteristics; 2) to explore maternal attitudes regarding smoking and alcohol consumption during pregnancy among pregnant and postpartum women in Israel. Methods This mixed methods study is comprised of a self-reported questionnaire for measuring attitudes and behaviors regarding smoking and alcohol consumption among 676 Jewish women, up to 9 months postpartum; and semi-structured interviews with 17 women who smoked cigarettes and/or consumed alcohol during their pregnancy. Results Sixty-four women (9.6%) reported drinking alcohol during pregnancy, and 30 (4.8%) reported smoking. Women with a fewer children (OR 2.25; 99% CI: 1.30, 3.92) and those whose attitudes supported alcohol avoidance (OR 0.52; 99.9% CI: 0.36, 0.74) consumed less alcohol while pregnant. Educated women (OR 0.31; 99% CI: 0.14- 0.71) and women with anti-smoking attitudes (OR 0.50; 99% CI: 0.30, 0.82) were more likely to avoid smoking during pregnancy. Qualitative analyses reveals three major themes: 1) 'A good enough mom': The mothers presented risk-management practices in line with the conflict between their perception of ideal motherhood and that of being an independent person; 2) 'Social acceptance of smoking and alcohol consumption during pregnancy': Social attitudes of spouses, family and friends; 3) 'Lack of reliable information' from healthcare professionals. Conclusions Women's attitudes have a significant impact on their decision to drink alcohol and/or smoke during pregnancy. These attitudes may be a result of their risk management practices and the social acceptance of risk behaviors during pregnancy, and information provided (or not) by healthcare professionals. Key messages The results highlight the importance of creating a supportive environment and shaping health promoting attitudes among pregnant women. Reliable information given by healthcare professionals regarding risk behaviors during pregnancy is needed.

Background Although vaccination against pertussis and seasonal influenza during pregnancy is the safest and most efficient strategy to protect mothers and infants from related morbidity and mortality, maternal vaccination is unfortunately suboptimal. The aim of the current study is to assess vaccination compliance during pregnancy and the factors associated with adherence with the relevant Ministry of Health recommendations. Methods The study included 344 women in a maternity ward of a hospital in northern Israel. After receiving approval from the Helsinki Commission and with the mothers' consent, data was collected through a self-administrated questionnaire from June to September 2019. Results Eighty-three percent of participants reported having been vaccinated against pertussis during pregnancy, and 44% reported having been vaccinated against influenza. The main reasons for not being vaccinated were distrust in vaccine efficiency, fear of vaccination during pregnancy, and lack of recommendations from health professionals. Multivariate logistic regressions analysis showed that compliance with influenza and pertussis vaccinations were significantly explained by women's attitudes (influenza: OR 2.88; 99% CI: 2.05, 4.05; pertussis: OR 4.77; 99% CI: 3.04, 7.47) and norms (influenza: OR 1.55; 95% CI: 1.15, 2.08; pertussis: OR 2.09; 99% CI: 1.46, 2.99). Process procedure for mediation reveals that the greater the level of trust in the healthcare system, the more positive the attitudes and subjective norms toward vaccination during pregnancy, and the greater the likelihood of complying with both vaccination requirements during pregnancy. Conclusions Efforts should focus on raising women's trust in the healthcare system as an important part of shaping attitudes and creating a supportive environment for vaccination. Key messages Trust in the healthcare system is associated with positive attitudes and norms, which in turn contribute to vaccination compliance. Explicit recommendations for vaccinations among pregnant women made by health professionals are needed, including reassurance of vaccine safety and effectiveness.

Background Vaccines are administered for free in Israel. Yet, despite experts' agreement that vaccinations are important, some parents choose not to vaccinate their children - in part due to lack of trust in the health system. This study examines factors that predict mothers' intention to vaccinate their infants as per recommendations of the Israeli Ministry of Health. Methods The study included 344 women in a maternity ward of a hospital in northern Israel. After receiving approval from the Helsinki Commission, and with the mothers' consent, data were collected through a self-administrated questionnaire, from June to September 2019. Results Participants were aged 19-47 (M = 30.77), 96% were married, and 70% had 1-2 children. About 78% reported that their children had been vaccinated for hepatitis B upon birth and had received vitamin K by injection. About 20% did not know if their newborns had received the injection and vaccination, meaning that they probably did as part of the hospital routine. Only 1.5-3% of the mothers said they would vaccinate their child later or not at all. Overall, the mothers' intention to vaccinate their infants was high (4.33 on a 1-5 scale). A hierarchical linear regression model for predicting mothers' intentions to vaccinate their infants was significant, explaining 36% of the variance. Factors that predict mothers' intentions to vaccinate their infants as recommended include mothers' adherence to the pertussis vaccination administration during their pregnancy (P = 0.037), lower trust in non-medical factors (P Conclusions Mothers' adherence to vaccinations during pregnancy could help identify at-risk populations. Interventions for encouraging vaccinations should focus on information sources and levels of trust, as trust in authoritative sources could assist in shaping attitudes and create a supportive environment for vaccinations. Key messages Mothers' adherence to vaccinations during pregnancy could help identify at-risk populations. Lower trust in non-medical factors, positive attitudes, and subjective norms are important predictors of mothers' intention for vaccinating their newborns.

Background Brucellosis is a zoonotic disease endemic in the Middle East and in Israel, with hundreds of cases each year, mostly in the Arab population. Aim To identify solutions for reducing the spread of brucellosis that are acceptable among the Arab community in Israel. Methods The study comprised two stages and involved farmers, non-industrial cheese-makers, and the general public recruited from towns previously exposed to brucellosis in the North (majority Arab non-Bedouin) and South (majority Bedouin population) of Israel. In the first qualitative stage, interviews and focus groups were conducted with 88 individuals, to collect suggested solutions for reducing the spread of brucellosis. Based on qualitative findings, a quantitative survey was conducted to assess the acceptability of proposed solutions. Results In the qualitative stage, diverse solutions were proposed regarding infrastructure, economic and regulatory issues as well as education. Six hundred and thirteen people rated the proposed interventions. Solutions rated highly were routine free veterinary visits (preferred solution for 27 % respondents), increasing control on illegal trade in animals from affected areas (18 %), the option to insure flocks, guaranteeing compensation after culling (18 %), support and guidance for small businesses which may facilitate adherence to regulations, lectures provided by the healthcare services or the Ministry of Health (24 %). Differences were found between communities in the north and south of Israel in the solutions suggested. Conclusions Several possible strategies were identified that could enhance reduced disease spread. A multifaceted approach is required, combining raising public awareness, better disease reporting in both animals and humans, improvements in infrastructure and better surveillance for livestock. Highlighting how different sectors contribute to the spread of the disease may raise awareness of the agricultural, technological and regulatory aspects and improve willingness to change.

Introduction and aims Subjective drunkenness measures may be useful screening tools for alcohol-related problems. However, if self-reported drunkenness is influenced by social and cultural understandings, the measure may not predict drinking patterns equally across different sociocultural groups. The current study aims to determine whether the two main sociocultural groups in Israel (Arabs and Jews) are equally likely to report drunkenness at comparable levels of breath alcohol content (BrAC). Design and methods A cross-sectional study was conducted among 901 Jewish and 225 Arab Israeli pub patrons. Respondents were interviewed as they exited pubs between midnight and 4 am. In addition to sociodemographic data, respondents reported whether they felt drunk at the time of the interview, after which they provided breath samples to determine BrAC. A logistic regression model tested whether there were differences in the probability of reporting drunkenness between Arabs and Jews holding BrAC levels and other background variables constant. Results Arabs had higher BrAC levels than Jews (M = 0.19 vs. M = 0.13, P ≤ 0.0001) but a lower proportion of Arabs reported drunkenness than Jews (22% vs. 43%). Adjusted logistic regression showed that at all levels of BrAC, Jews had a higher probability of reporting drunkenness than Arabs (odds ratio = 6.40, P ≤ 0.0001). Discussion and conclusions Subjective drunkenness is likely to be influenced by cultural factors and may thus not reflect objective drinking patterns equally across different groups within the same society. This is likely to limit its usefulness as a screening tool for alcohol abuse and problems. [Sznitman SR, Bord S, Elias W, Gesser-Edelsburg A, Shiftan Y, Baron-Epel O. Examining the sociocultural sensitivity of subjective drunkenness: Comparing Arab and Jewish Israeli pub patrons.

Alcohol-Impaired Driving (AID) is rarely studied among Arab communities. As contacts between Arab and Western cultures grow, alcohol consumption and safety-related issues are emerging as a major public health concern. This paper examines factors influencing the decision to engage in AID in a sample of young Arab-Israeli bar patrons ( n = 300, age 17–34), including both Muslims ( n = 77) and Christians ( n = 176); alcohol is prohibited for the former, but is normative for the latter. Studies of AID often use agent-oriented models, most notably the theory of planned behavior (TPB). The current study complements this tradition using the structure-oriented Social-Cultural (SC) model. Over 70% of participants reported engaging in AID after consuming 3–4 portions of alcohol. The TPB model proved to have significant explanatory power while most cultural factors, including religion, failed to gain statistical significance. The latter finding is counter-intuitive given the different status of alcohol in the cultures investigated. The TPB variable Personal Behavioral Control (PBC) and a specific sub-component of the subjective norms variable emerged as providing the greatest contribution to the model. The results support the robustness of TPB and demonstrate that beyond identifying idiosyncratic patterns structure-based models can be useful in refuting pre-conceived conceptions. Thus, both approaches should be utilized to inform policymaking. Governmental authorities, particularly in Israel, must consider the neglected issue of AID among Arab communities, including both Christians and Muslims.

Because the rate of injury and mortality from car crashes among Arab children is higher than among Jewish children in Israel, this study assesses the patterns of age-appropriate child restraint system (CRS) use in Arab towns in Israel.From October 2010 to September 2011, 4396 children ages 0 to 14 were observed while seated in vehicles in 9 Arab towns and villages in Israel.Among infants aged 0 to 1 year old, 31.2 percent were observed in an age-appropriate restraint, whereas among children aged 1 to 4 years, only 12.4 percent were age-appropriately restrained. Children aged 5 to 9 were observed to have the lowest levels of age-appropriate restraint use (1.3%). The variation between the various villages was large and dependent on the age of the child.The low rates of CRS use may explain to some degree the high rates of injury and mortality of Arab children in car crashes. These low rates indicate that previous interventions have not been successful in increasing restraint use in the Arab community in Israel and there is a need to plan targeted interventions specifically for this population. Supplemental materials are available for this article. Go to the publisher's online edition of Traffic Injury Prevention to view the supplemental file.

The rate of alcohol-impaired driving (AID) increases during the college years and students who have reported adverse rearing environments appear to be at increased risk for the development of alcohol and drug use behaviors. Alcohol and cannabis are the most commonly used drugs by college students, and these substances are particularly predictive of substance-impaired driving.The present study aimed to investigate whether adverse rearing environment experiences and level of alcohol and cannabis use are related to the frequency of alcohol-impaired driving and whether anxiety might buffer or accelerate this effect.Data regarding adversity, drug use, anxiety, and AID were obtained from 1,265 students annually, from first to final year of college, over four waves (Mean Age at wave 1 = 18.5 years).Structural equation modeling supported associations among childhood adversity, alcohol, cannabis, and anxiety symptoms. A significant mediation effect was found such that adversity was predictive of AID via alcohol use and cannabis use. Among men, anxiety symptoms accelerated the path from increased cannabis use and decelerated the path from increased alcohol use to AID frequency. Conclusions/Importance: Childhood adversity is a developmental risk precursor to drug use and AID, whereas anxiety might serve a risk or protective factor to AID, contingent on the drug used.

AIM To describe the relationships between non-alcoholic fatty-liver disease (NAFLD) patient’s disease consequences and treatment perceptions, self-efficacy, and healthy lifestyle maintenance. METHODS A cross-sectional study among 146 ultrasound diagnosed NAFLD patients who visited the fatty liver clinic at the Tel-Aviv Medical Center. Eighty-seven of these individuals, participated in a clinical trial of physical activity and underwent fasting blood tests, analyzed at the same lab. Exclusion criteria included positivity for serum HBsAg or anti-HCV antibodies; fatty liver suspected to be secondary to hepatotoxic drugs; excessive alcohol consumption (≥ 30 g/d in men or ≥ 20 g/d in women) and positive markers of genetic or immune-mediated liver diseases. Patients were asked to complete a self-report structured questionnaire, assembled by the Israeli Center for Disease Control. Nutrition habits were measured using six yes/no questions (0 = no, 1 = yes) adopted from the national survey questionnaire. Participants in the clinical trial completed a detailed semi-quantitative food frequency questionnaire (FFQ) reporting their habitual nutritional intake during the past year. Self-efficacy was assessed by the Self-Efficacy Scale questionnaire, emotional representation, degree of illness understanding, timeline perception, treatment perception and symptoms were measured by the Brief Illness Perception questionnaire. Illness consequences were measured by the Personal Models of Diabetes Interview questionnaire. A path analysis was performed to describe the interrelationships between the patients’ illness perceptions, and assess the extent to which the data fit a prediction of nutritional habits. RESULTS The study sample included 54.1% men, with a mean age of 47.76 ± 11.68 years (range: 20-60) and mean body mass index of 31.56 ± 4.6. The average perceived nutrition habits score was 4.73 ± 1.45 on a scale between 0-6, where 6 represents the healthiest eating habits. Most of the study participants (57.2%) did not feel they fully understood what NAFLD is. Better nutritional habits were positively predicted by the degree of illness understanding (β = 0.26; P = 0.002) and self-efficacy (β = 0.25; P = 0.003). Perceptions of more severe illness consequences were related with higher emotional representation (β = 0.55; P < 0.001), which was related with lower self-efficacy (β = -0.17; P = 0.034). The perception of treatment effectiveness was positively related with self-efficacy (β = 0.32; P < 0.001). In accordance with the correlation between self-efficacy and the perceived nutrition habits score, self-efficacy was also correlated with nutrient intake evaluated by the FFQ; negatively with saturated fat (percent of saturated fat calories from total calories) (r = -0.28, P = 0.010) and positively with fiber (r = 0.22, P = 0.047) and vitamin C intake (r = 0.34, P = 0.002). In a sub analysis of the clinical trial participants, objectively measured compliance to physical activity regimen was positively correlated with the self-efficacy level (r = 0.34, P = 0.046). CONCLUSION Self-efficacy and illness understanding are major determinants of lifestyle-modification among NAFLD patients. This information can assist clinicians in improving compliance with lifestyle changes among these patients.

Background and Aim: Little evidence is available on whether respondents from divergent sociocultural populations report alcohol consumption in systematically similar ways. Therefore, this study examined whether the validity of self-reported alcohol use differed between Arab and Jewish Israeli pub patrons. Methods: The analytical sample consisted of 227 Arab and 900 Jewish Israeli pub patrons who were approached as they left pubs and asked to record their Breath Alcohol Content (BrAC) value and complete a questionnaire that probed into their alcohol use. Validity of self-reported alcohol use across the 2 groups was examined by testing the discrepancy in concordance between the self-reported number of drinks and BrAC scores through simple Pearson correlations and by performing a multi-group measurement invariance (MI) comparison. Results: The Pearson correlation between the self-reported number of drinks and BrAC by the ethno-cultural group was almost identical across groups (Jews: r = 0.47, p < 0.01, df = 898; Arabs: r = 0.42, p < 0.01, df = 225). MI test results further confirmed that the factor loadings of the 2 drinking measures are similar across the 2 ethno-cultural groups. Conclusions: Self-reported alcohol consumption gives cross-culturally valid and acceptable estimates of alcohol consumption in this sample of Israeli Arabs and Jews.

Subjective drunkenness measures may be useful screening tools for alcohol-related problems. However, if self-reported drunkenness is influenced by social and cultural understandings, the measure may not predict drinking patterns equally across different sociocultural groups. The current study aims to determine whether the two main sociocultural groups in Israel (Arabs and Jews) are equally likely to report drunkenness at comparable levels of breath alcohol content (BrAC).A cross-sectional study was conducted among 901 Jewish and 225 Arab Israeli pub patrons. Respondents were interviewed as they exited pubs between midnight and 4 am. In addition to sociodemographic data, respondents reported whether they felt drunk at the time of the interview, after which they provided breath samples to determine BrAC. A logistic regression model tested whether there were differences in the probability of reporting drunkenness between Arabs and Jews holding BrAC levels and other background variables constant.Arabs had higher BrAC levels than Jews (M = 0.19 vs. M = 0.13, P ≤ 0.0001) but a lower proportion of Arabs reported drunkenness than Jews (22% vs. 43%). Adjusted logistic regression showed that at all levels of BrAC, Jews had a higher probability of reporting drunkenness than Arabs (odds ratio = 6.40, P ≤ 0.0001).Subjective drunkenness is likely to be influenced by cultural factors and may thus not reflect objective drinking patterns equally across different groups within the same society. This is likely to limit its usefulness as a screening tool for alcohol abuse and problems. [Sznitman SR, Bord S, Elias W, Gesser-Edelsburg A, Shiftan Y, Baron-Epel O. Examining the sociocultural sensitivity of subjective drunkenness: Comparing Arab and Jewish Israeli pub patrons.

The Israeli Health Promoting School Network (HPSN) is actively committed to enhancing a healthy lifestyle for the entire school population. This study aimed to explore the contribution of school participation in the HPSN and students' individual characteristics to healthy eating and physical activity habits among Israeli school children aged 10-12 years. A cross-sectional survey was conducted among 4166 students in grades 4-6 from 28 schools. The schools were selected from a sample of HPSN affiliated and non-HPSN schools. The contribution of individual characteristics (grade, gender and subjective self-reported health education activities at school) and school characteristics (school type, population group, deprivation score) to healthy eating and physical activity habits was analyzed using multi-level hierarchical models. Multi-level analysis indicated that student's individual characteristic was significantly associated with healthy eating and physical activity habits. The subjective self-reported health education received at school was statistically significant factor associated with students' health behaviors. The school's affiliation with the HPSN was not associated with higher healthy eating and physical activity scores after adjusting for individual factors. These findings suggest that Israeli HPSN schools do not contribute to children's health behaviors more than other schools. Therefore, health promoting activities in HPSN schools need to be improved to justify their recognition as members of the HPS network and to fulfill their mission.

Background The availability of public transportation has been studied mainly regarding promoting an active lifestyle and encouraging physical activity. Accessible public transportation near entertainment areas including pubs and restaurants may prevent alcohol-impaired driving (AID) by offering a safe alternative to get back home, as alcohol-impaired driving is a well known risk factor for car crashes and injuries, especially among young adults. The aim of this study was to examine the association between availability of public transportation and young adult pub patrons' intent to drive under the influence of alcohol after exiting pubs. Methods The current study is a cross-sectional survey conducted among 1079 pub patrons between the ages 19-35, exiting one of 31 surveyed pubs in 13 Israeli cities. Sidewalk interviews and breath alcohol tests were performed outside the pubs during weekend nights. Each interviewee was asked first to fill out a paper and pencil survey questionnaire, and then to blow into a Drager Alcotest® 6510 Breath Alcohol Screening Device. In addition, the interviewers also fill in an observation protocol for each pub, including information on the pub's physical environment, and on whether there is an accessible bus station near the pub area operating during the night and on weekends. Results Nine percent of all respondents reported that they intend to drive, although according to their BrAC test they were impaired (BAC >0.05%). The study results indicate that the availability and accessibility of public transportation within the immediate vicinity of the pub may be a protecting factor against AID (OR=0.27, 95%CI=0.08-0.87). Patrons exiting pubs in which there was an accessible public transportation nearby were less likely to intend to drive under the influence of alcohol. Conclusions This study suggests that the existence of public transportation near drinking locations may decrease AID rates among young adult pub patrons.

The Israeli society is a unique setting in which the Arabs are exposed to western alcohol consumption norms while living in Arab communities where alcohol consumption is not accepted.To characterize Arab Muslim, Druze and Christian alcohol consumption behaviors and contingencies while being exposed to western style alcohol consumption.This study was a phenomenological qualitative study interviewing six focus groups and 13 individual Arab Muslims, Christians and Druze. Themes and categories were identified using qualitative methodology analysis.Two concurrent contingencies exist for Arab Muslim men: on the one hand they describe pressure to drink because of social norms, and on the other hand they are reprehended for drinking, because of the religious interdiction. Therefore, they hide their drinking in secluded places. In addition, participants reported more heavy drinking among Muslim Men. Arab Christians reported drinking openly especially among men. Women do not drink and are looked down upon if they drink. Drinking may be viewed as a stage in life that a Muslim boy or young man goes through, he is expected to grow out of this stage and stop drinking while becoming religious. Conclusions/importance: Due to Muslim laws prohibiting alcohol consumption, alcohol consumption is not high, however it does exist especially among young men and when they drink they tend to drink heavily, more than the Arab Christians. Therefore, there is a need for interventions targeting younger Muslim men, to establish moderate drinking behaviors, if they chose to drink.

Worldwide there is a dearth of studies examining drinking patterns in Arabs and how these compare to other populations. The few studies that exist have suggested distinct drinking patterns in Arabs, with not only high rates of abstinence but also high rates of heavy drinking among current drinkers. No studies have yet examined potential socio-cognitive mechanisms that may contribute to this distinct drinking pattern. Israel represents a unique and valuable resource for studying Arab population drinking patterns because Israeli Arabs are nonimmigrants living in areas where exposure to Western lifestyles, including alcohol consumption, is prevalent. The current study was set out to examine differences in alcohol consumption in a convenience sample of 1310 Jewish and Arab students from Israeli universities and colleges and to explore alcohol expectancies as potential mediators of ethno-religious differences.Logistic regressions were used to produce odds ratios and 95% confidence intervals to test differences between Jewish and Arab students on binary outcomes (lifetime, last month, and heavy drinking). Mediation of ethno-religious differences by alcohol expectancies was tested with bootstrapping procedures.Results show that while Israeli Arab students tend to be more likely to abstain from alcohol than Israeli Jewish students, among current drinkers, Israeli Arab students are at a particular high risk of heavy drinking. Results also show that this is partly mediated by the expectancy that alcohol only influences the drinker at high levels of intake.The current study confirms distinct Arab drinking patterns found in previous studies. The present study is the first demonstration that drinking expectations mediate ethno-religious differences in heavy drinking among Israeli Arabs and Jews. This work contributes to the understanding of ethno-religious group differences in harmful drinking, potentially informing future etiologic research and public health interventions aimed at reducing alcohol-related harm.

Background In most countries rates of immunizations of health care workers with recommended vaccines are not satisfactory. Objectives To identify reasons behind the low rates of compliance of Israeli nurses in Mother and Child Healthcare Centers (MCHC) with an official request for pertussis vaccination. Methods Three focus groups were conducted. Qualitative analysis identified themes that could explain the nurses’ non-compliance. Results Trust in health authorities was low, mainly following the A/H1N1 purported influenza pandemic. In addition, nurses did not see the importance of being role models for the public and demanded the autonomy to decide whether to receive vaccinations. The nurses differentiated between their role as nurses and their personal life, expressed fear of new vaccines and exhibited low levels of risk perception. Misconceptions regarding vaccinations were expressed by the nurses. Conclusions Antivaccinationist ideas were expressed by MCHC nurses and these attitudes may have led to non-compliance with vaccination guidelines.

During pandemics, minorities may experience high stress levels, which could harm their health. This study explores stress among the Arab minority in Israel during the first wave of the COVID-19 outbreak, and its association with the population's perceived COVID-19 threat, trust in the healthcare system, adherence to guidelines, and perceived discrimination. The study analyzed a cross-sectional online survey of 626 Israeli Arabs. Most participants (65%) reported moderate levels of stress, and 10% reported severe levels. The Bedouin population reported significantly higher levels of stress compared to other minority groups. The participants also reported a high degree of perceived threat, a moderate-to-high level of discrimination, a moderate level of trust in the healthcare system, and very high adherence to guidelines. Structural equation modeling (SEM) revealed that the participants' perceived threat and trust mediated the association between their perceived discrimination and stress [indirect effect=0.13, SE = 0.03 CI = (0.08, 0.18)], whereby discrimination was negatively associated with trust (β=-0.52), which, in turn, was negatively associated with stress (β=-0.10). Furthermore, discrimination was positively associated with perceived threat (β = 0.21), which, in turn, was positively associated with stress (β = 0.35). Discrimination is an important social determinant of health - especially during health emergencies when trust in healthcare systems and perceived threats are crucial. Our findings could assist policymakers in developing fair policies, that are tailored to various population groups and that may reduce stress levels among minorities, thereby improving their mental and physical health. Key messages The results highlight the relationships between discrimination, trust, perceived threat and stress. To reduce minorities’ stress, it is vital to create a credible and fair atmosphere during pandemics.