What is Known About Health and Morbidity in the Pediatric Population of Muslim Bedouins in Southern Israel: A Descriptive Review of the Literature from the Past Two Decades

A novel questionnaire for evaluating digital tool use (DTUQ-D) among individuals with type 2 diabetes: exploring the digital landscape

INTRODUCTION

Effective healthcare currently incorporates a patient-centric system and accessible technology for patient self-management. This study aimed to develop and validate a novel questionnaire titled the Digital Tool Use Questionnaire for Diabetes (DTUQ-D) - a screening tool identifying the type, number, and frequency of digital tools used by Type 2 Diabetes Mellitus (T2DM) patients with within HMOs, online, and via applications.

METHODS

The questionnaire was administered to two ethnic groups and both genders. A mixed-methods approach was used. In the qualitative phase, the questionnaire was developed through phone surveys of 29 T2DM patients, two endocrinologists and two technology experts. In the quantitative phase, involving 367 participants, convergent validity, construct validity, and reliability were examined.

RESULTS

Findings indicated that the DTUQ-D is valid and reliable, successfully identifying digital tools utilized by T2DM patients, notwithstanding variations in factor structures between ethnic groups. This questionnaire provides a foundation for future research, offering a standardized approach to evaluating digital tool usage.

DISCUSSION

The study enhances understanding of the role of digital tools in healthcare, especially for T2DM self-management. It also can be easily adapted to assess digital tool use for other illnesses by adjusting instructions and the wording of certain items.

Health services utilization by fibromyalgia patients from two ethnic groups

AIM

The cost to the healthcare system of management and treatment for fibromyalgia patients is high. The aims of the study were to identify and compare factors associated with the use of healthcare services among fibromyalgia patients in southern Israel from two ethnic groups.

METHODS

A cross-sectional study of patients insured in the southern district of the Clalit Healthcare Services in Israel in 2019-2020. The data were collected from the central computerized system. Multivariable regression models were developed for healthcare services utilization.

RESULTS

During the study period, 7686 members were diagnosed with fibromyalgia. The median for specialist consultations was 47 and for imaging tests was eight. About 47% made emergency room visits and 25% were hospitalized. The median of imaging tests was significantly higher in Jewish patients than in Arab patients (8 vs. 6; p = .000). In contrast, a significantly higher rate of Arab patients visited the Emergency Room at least once (51.6% vs. 46.75%; p = .000) and they had a higher median number or Emergency Room visits (2 vs. 1; p = .003), compared with Jewish patients. In the Arab group there was a strong effect coefficient for another localized pain syndrome with specialist consultations (odds ratio [OR] 1.699; 95% confidence interval [CI] 1.266-2.241) and imaging tests (OR 2.511; 95% CI 1.496-4.146).

CONCLUSIONS

The utilization rate of healthcare services is high among fibromyalgia patients. The factors associated with high healthcare utilization are different in the two ethnic groups. Future studies could show if interventions designed to address modifiable factors could reduce the overutilization of healthcare services.

Medication use and factors associated with opiate use among patients with diagnosed fibromyalgia from two ethnic sectors in southern Israel

BACKGROUND

Our aims were to compare fibromyalgia (FM) rate, drug treatment and factors associated with the use of opiates in two ethnic sectors.

METHODS

A retrospective cross-sectional study in southern district of Israel was performed on diagnosed FM patients in 2019-2020 [7686 members (1.50%)]. Descriptive analyses were conducted and multivariable models for the use of opiates were developed.

RESULTS

There were significant differences between the two ethnic groups in FM prevalence at 1.63% and 0.91% in the Jewish and Arab groups, respectively. Only 32% of the patients used recommended medications and about 44% purchased opiates. Age, BMI, psychiatric co-morbidity, and treatment with a recommended drug were similarly associated with an increased risk for opiate use in both ethnic groups. However, male gender was associated with × 2 times reduced risk to use opiates only among the Bedouins (aOR = 0.552, 95%CI = 0.333-0.911). In addition, while in both of ethnic groups the existence of another localized pain syndrome was associated with an increased risk for opiates use, this risk was 4 times higher in the Bedouin group (aOR = 8.500, 95%CI = 2.023-59.293 and aOR = 2.079, 95%CI = 1.556-2.814).

CONCLUSIONS

The study showed underdiagnosis of FM in the minority Arab ethnicity. Female Arab FM patients in low or high, compared to middle socio-economic status, were a risk group for excess opiate use. Increased use of opiates and very low rate of purchase of recommended drugs point to a lack of effectiveness of these drugs. Future research should assess whether the treatment of treatable factors can reduce the dangerous use of opiates.

Ethnic and socioeconomic disparities in survival of children and adolescents with CNS tumors in Southern Israel

Background

This study sought to evaluate survival of pediatric and adolescent patients with central nervous system (CNS) cancer in southern Israel, outline disparities between ethnic and socioeconomic groups (Bedouin Arabs compared to Jews) and evaluate the role of socioeconomic status (SES) in ethnic disparities.

Methods

A retrospective study was conducted among 91 patients aged one to 20 years, who were diagnosed with CNS tumors between 2001 and 2017, and followed-up through 2020. Ethnic differences in survival were measured by age, sex, stage, histology and SES. One and 3-year survival rates were calculated. Multivariable regression analysis was used to estimate adjusted ethnic differences in survival rates.

Results

Ethnic differences in survival existed within all studied variables. All Bedouin patients lived in low SES settlements (All Bedouin settlement in Southern Israel are ranked in lower socioeconomic deciles). Twenty-eight patients had medulloblastoma. Seven (25%) presented with leptomeningeal disease or distant metastases. Medulloblastoma molecular subgroups were not assessed for logistic reasons. Three-year overall survival of Bedouins was 50% compared to 92.3% for Jews. Adjusted risk of death at 3 years was significantly higher for Bedouin patients (aHR 3.36, 95% CI 1.41–7.98, P = .006).

Conclusions

We conclude that Bedouin children with CNS tumors have significantly lower survival rates compared to Jewish children, and SES seems to play a major part in these disparities. Factors influencing these disparities should be addressed and public health interventions to eliminate these disparities should be developed.

Air pollution and meteorological conditions during gestation and type 1 diabetes in offspring

BACKGROUND

Growing evidence indicates that air pollution is capable of disrupting the immune system and therefore, might be associated with an onset of Type 1 diabetes (T1D).

OBJECTIVES

We explored possible links of T1D with ambient exposures in the population of southern Israel, characterized by hot and dry climate and frequent dust storms.

METHODS

We conducted a matched nested case-control study where exposure to environmental pollutants during gestation in T1D cases was compared to that of healthy children. Up to 10 controls were matched to every case by age, gender and ethnicity, in all 362 cases and 3512 controls. Measurements of pollutants' concentrations, nitrogen dioxide (NO₂), sulphur dioxide (SO₂), ozone (O₃) and particulate matter of size less than 10 and 2.5 μm in diameter (PM₁₀ and PM_2.5), as well as the mean daily measurements of meteorological conditions were obtained from the local monitoring stations. The association between T1D and pollution, solar radiation (SR), temperature and relative humidity was adjusted for socioeconomic status, temperature, maternal age and pre-gestational maternal DM, using conditional logistic regression. The environmental exposures were presented as indicators of quartiles averaged over whole pregnancy and by trimesters.

RESULTS

Exposure to ozone and solar radiation during gestation were both associated with the T1D in offspring, although at borderline significance. Compared to the lowest quartile, the odds ratio (OR) for exposure to 3rd and 4th quartile of O₃ was equal 1.61 (95%CI: 0.95; 2.73) and 1.45 (95%CI: 0.83; 2.53), respectively. Likewise, the ORs for exposure to SR were equal 1.83 (95%CI: 0.92; 3.64), 2.54 (95%CI: 1.21; 5.29) and 2.06 (95%CI: 0.95; 4.45) for to 2nd, 3rd and 4th quartiles, respectively. Exposure to SO₂ followed a dose-response pattern, but was not statistically significant. Other environmental factors were not independently related to T1D. Analysis of exposures one year prior to the disease onset indicated a positive association between T1D and SR.

CONCLUSIONS

We showed that exposure to high ozone levels and solar radiation during gestation might be related to the T1D. More scientific evidence needs to accumulate to support the study findings.

Maternal metal concentration during gestation and pediatric morbidity in children: an exploratory analysis

Background

The majority of studies linking exposure to metals with certain health outcomes focus on known toxic metals. Alternatively, this study assesses the extent to which exposure to a wider range of metals during gestation is associated with childhood morbidity.

Methods

We analyzed the concentrations of 25 metals found in urine samples of 111 pregnant women of Arab-Bedouin origin collected prior to birth. In addition, we collected medical records on their offspring for six years following birth, including every interaction with HMOs, local hospitals, and pharmacies.

Results

The main types of morbidities diagnosed and treated during this period were preterm births, malformations, asthma-like morbidity, cardiovascular and behavioral problems, and obesity. Multivariable analysis showed that offspring born before term were more likely to have been exposed to elevated maternal concentrations of zinc, thallium, aluminum, manganese, and uranium, all with adjusted relative risk above 1.40 for an increase by each quintile. Likewise, children with asthma had been exposed to higher levels of magnesium, strontium, and barium at gestation, while behavioral outcomes were associated with elevated biometals, i.e., sodium, magnesium, calcium, selenium, and zinc, as well as higher levels of lithium, cobalt, nickel, strontium, cadmium, vanadium, arsenic, and molybdenum. A heatmap of adjusted relative risk estimates indicates the considerable implications that exposure to metals may have for preterm birth and developmental outcomes.

Conclusions

The current study shows that perinatal exposure to metals is adversely associated with pediatric morbidity. Further such analyses on additional samples are warranted.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12199-021-00963-z.

Area-level socioeconomic disparity trends in nutritional status among 5-6-year-old children in Israel

OBJECTIVE

This study aimed to assess area-level socioeconomic position (SEP) disparities in nutritional status, to determine whether disparities differed by sex and to assess whether nutritional status and disparities changed over time.

DESIGN

We used repeated cross-sectional data from a national programme that evaluates the quality of healthcare in Israel to assess children's nutritional status.

SETTING

The study included all Israeli residents aged 7 years during 2014-2018 (n=699 255).

METHODS

SEP was measured based on the Central Bureau of Statistics' statistical areas, and grouped into categories, ranging from 1 (lowest) to 10 (highest). We used multivariable multinomial regression to assess the association between SEP and nutritional status and between year and nutritional status. We included interactions between year and SEP to assess whether disparities changed over time.

RESULTS

Children in SEP 1, comprised entirely of children from the Bedouin population from Southern Israel, had drastically higher odds of thinness compared with those in the highest SEP (Girls: OR 5.02, 99% CI 2.23 to 11.30; Boys: OR 2.03, 99% CI 1.19 to 3.48). Odds of obesity were highest in lower-middle SEPs (OR_{SEP 5 vs 10} 1.84, 99% CI 1.34 to 2.54). Prevalence of overweight and obesity decreased between 2014 and 2018, normal weight increased and thinness did not change. SEP disparities in thinness decreased over time in boys but showed a reverse trend for girls. No substantial improvement was seen in SEP disparities for other weight categories.

CONCLUSIONS

Our study demonstrates the need to consider initiatives to combat the considerable SEP disparities in both thinness and obesity.

The effect of exposure to particulate matter during pregnancy on lower respiratory tract infection hospitalizations during first year of life

BACKGROUND

Lower respiratory tract infections (LRTI) in early life, including pneumonia, bronchitis and bronchiolitis, can lead to decreased lung function, persistent lung damage and increased susceptibility to various respiratory diseases such as asthma. In-utero exposure to particulate matter (PM) during pregnancy may disrupt biological mechanisms that regulate fetal growth, maturation and development. We aimed to estimate the association between intrauterine exposure to PM of size < 2.5 μm in diameter (PM_2.5) and incidence of LRTIs during the first year of life.

METHODS

A retrospective population-based cohort study in a population of mothers and infants born in Soroka University Medical Center (SUMC) in the years 2004-2012. All infants < 1 year old that were hospitalized due to LRTIs were included. The main exposure assessment was based on a hybrid model incorporating daily satellite-based predictions at 1 km² spatial resolution. Data from monitoring stations was used for imputation of main exposure and other pollutants. Levels of environmental exposures were assigned to subjects based on their residential addresses and averaged for each trimester. Analysis was conducted by a multivariable generalized estimating equation (GEE) Poisson regression. Data was analyzed separately for the two main ethnic groups in the region, Jewish and Arab-Bedouin.

RESULTS

The study cohort included 57,331 deliveries that met the inclusion criteria. Overall, 1871 hospitalizations of infants < 1 year old due to pneumonia or bronchiolitis were documented. In a multivariable analysis, intrauterine exposure to high levels of PM_2.5 (> 24 μg/m³) in the first and second trimesters was found to be adversely associated with LRTIs in the Arab-Bedouin population (1st trimester, RR = 1.31, CI 95% 1.08-1.60; 2nd trimester: RR = 1.34, CI 95% 1.09-1.66).

CONCLUSION

Intrauterine exposure to high levels of PM_2.5 is associated with a higher risk of hospitalizations due to lower respiratory tract infections in Arab-Bedouin infants.

Contraception Use among Women of Childbearing Age in Southern Israel: A Comparison Between Two Ethnic Populations

PURPOSE

Two populations with different socio-demographic characteristics reside in southern Israel: the traditional Muslim Bedouin population and the Jewish population that leads a western lifestyle. The aim of the study was to assess the rate, pattern, and dynamics of the use of contraception in these two ethnic populations from 2006 to 2016 and to identify factors associated with the practice of effective and safe contraception.

METHODS

A retrospective study based on a computerized medical database. We recorded actual purchases of different forms of contraception by women of childbearing age (15-49 years) from the two populations in the southern Negev region of Israel.

RESULTS

Contraceptives were purchased by 7588 Bedouin women and 30,482 Jewish women. The rate of purchase ranged from 5.2 to 9.7% in the Bedouin sector and from 12.9 to 28.2% in the Jewish sector. Oral contraceptives were the most common type. In the Jewish sector, their use remained relatively stable over the years. In the Bedouin sector, in contrast, the rate increased. The only factor that was associated with the use of intrauterine devices was age (OR = 1.063, P < 0.001). Among women who used combined hormonal contraception, Jewish ethnicity (OR = 5.835, P < 0.001), age (OR = 0.926, P < 0.001), and comorbidity (OR = 0.87, P = 0.001) were associated with the use of newer, low-dose estrogen drugs.

CONCLUSIONS

Our findings, such as the lower rate of contraception practice in the Bedouin sector in general and the use of the new and safer hormonal contraceptives in particular, can help focus the efforts of medical teams in programs for women's health promotion.

Quantification and Characterization of Antimicrobial Resistance in Greywater Discharged to the Environment

In disenfranchised communities, untreated greywater (wastewater without sewage) is often environmentally discharged, resulting in potential human exposure to antimicrobial-resistant bacteria (ARB), including extended-spectrum beta-lactamase (ESBL) producers. We sought to examine the abundance of ARB, specifically ESBLs, and antimicrobial resistance genes (ARGs) in greywater from off-grid, pastoral Bedouin villages in Southern Israel. Greywater samples (n = 21) collected from five villages were analyzed to enumerate fecal coliforms and Escherichia coli. ESBL producers were recovered on CHROMagar ESBL and confirmed by VITEK®2 (bioMerieux, Marcy l’Etoile, France) for identification and antimicrobial susceptibility testing. Total genomic DNA was extracted from greywater samples and quantitative PCR (qPCR) was used to determine relative abundance (gene copies/16S rRNA gene) of class 1 integron-integrase intI1, blaTEM, blaCTX-M-32, sul1, and qnrS. The mean count of presumptive ESBL-producing isolates was 4.5 × 106 CFU/100 mL. Of 81 presumptive isolates, 15 ESBL producers were recovered. Phenotypically, 86.7% of ESBL producers were multi-drug resistant. Results from qPCR revealed a high abundance of intI1 (1.4 × 10−1 gene copies/16S rRNA), sul1 (5.2 × 10−2 gene copies/16S rRNA), and qnrS (1.7 × 10−2 gene copies/16S rRNA) followed by blaTEM (3.5 × 10−3 gene copies/16S rRNA) and blaCTX-M-32 (2.2 × 10−5 gene copies/16S rRNA). Results from our study indicate that greywater can be a source of ARB, including ESBL producers, in settings characterized by low sanitary conditions and inadequate wastewater management.

Association between human brucellosis and adverse pregnancy outcome: a cross-sectional population-based study

To investigate the association between the incidence of human brucellosis (HB) and adverse pregnancy outcomes (APOs), a population-based, cross-sectional aggregate data study was conducted in Israel between 2010 and 2014. HB-endemic localities were matched by ethnicity, population size and socioeconomic status to localities with a low incidence of HB. We compared APO rates in high-incidence vs low-incidence localities. The primary outcome was intrauterine fetal demise (IUFD). Secondary outcomes were premature birth (less than 37 weeks), early or threatened labour and poor fetal growth. APOs are expressed as events per 1,000 live or dead births. Eleven high-incidence localities, all Arab villages or cities, were matched to 11 low-incidence localities. Localities were well-matched with regard to the matching criteria, fertility indices, health insurance access and education, but were imbalanced geographically. All defined APOs occurred significantly more frequently in the high-incidence localities. The associations translated to an absolute increase of 3.6 cases of IUFD (95% CI 1.6-5.3), 11.7 preterm births (4.8-18.3), 6.6 cases of early or threatened labour (2.2-10.9) and 7 cases of poor fetal growth (3-10.8), per 10,000 live or dead births. Owing to a geographic imbalance between high- and low-incidence localities, we conducted an analysis restricted to Southern localities of Arab Bedouins showing a significant association between yearly HB incidence and IUFD incidence, odds ratio 1.05 (1.03-1.06). HB incidence is epidemiologically linked to serious pregnancy complications. Early detection of infection through active surveillance during pregnancy followed by appropriate treatment should be evaluated as additional public heath strategy in endemic settings.

Traditional Cautery for Medical Treatment Among the Bedouins of Southern Israel

Traditional cautery for the cure of disease is an ancient and widespread mode of treatment in various cultures and is a central modality among Israeli Bedouins. To date the use of this treatment has not been assessed systematically. A personal interview was conducted among Muslim Bedouin patients who came to clinics in the Negev region in southern Israel. There were 250 participants including 128 women (51.2 %). The mean age was 45.16 ± 16.2 (range 18-86). Eighty nine (35.7 %) of the participants declared that they had personally undergone curative cautery therapy in the past. Two hundred and five (82 %) were familiar with this mode of therapy. Two thirds of those who underwent the treatment in the past said that it helped them a great deal and another 19 % said that it helped them somewhat. More men underwent the therapy than women (P = 0.034), believed in its effectiveness (P = 0.013), and declared that they were prepared to use it again in the future (P < 0.0001). Elderly patients, over the age of 61, used this therapy more than younger ones (P = 0.001). The majority of the Bedouin population in the Negev is familiar with cautery and a significant part of the population has personally undergone this therapy and believes that it is effective.

Maternal perceptions of social context and adherence to maternal and child health (MCH) clinic recommendations among marginalized Bedouin mothers

National maternal and child health (MCH) care systems often deliver universal health care recommendations that do not take into consideration the social context of infant care (IC) for marginalized groups. We examined associations between maternal perceptions of social context (MPSC) and adherence by minority Bedouin mothers in Israel to three commonly recommended IC practices. We conducted personal interviews with 464 mothers visiting 14 MCH clinics using a structured questionnaire based on findings from a previous focus-group study, and guided by constructs of the Health Beliefs Model. Items were tested for validity and reliability. We used multivariate analysis to identify MPSC constructs associated with adherence to MCH clinic recommendations (timely postnatal first visit, sustaining breastfeeding, and use of infant car seat). Social context, when perceived as a barrier to IC, was negatively associated with adherence to timely first postnatal MCH clinic visit (odds ratio, 95 %, confidence intervals (OR 1.45, 95 % CI 1.24, 1.70) and use of infant car seat (OR 1.43, 95 % CI 1.21, 1.69). However, social context was positively associated with sustained breastfeeding (OR 0.54, 95 % CI 0.37, 0.79). Perceptions of the severity of infant health problems, and family financial and relationship problems had less significant associations with adherence to MCH clinic recommendations. Adherence by marginalized mothers to MCH clinic recommendations is related to their perceptions of social context. When there are higher financial and other living conditions barriers mothers tend toward lower adherence to these recommendations. MCH policy makers and service providers must consider MPSC in planning and delivery of MCH recommendations.

Literature review of type 2 diabetes mellitus among minority Muslim populations in Israel

This review surveys the literature published on the characteristics and implications of pre-diabetes and type 2 diabetes mellitus (T2DM) for the Arab and Bedouin populations of Israel. T2DM is a global health problem. The rapid rise in its prevalence in the Arab and Bedouin populations in Israel is responsible for their lower life expectancy compared to Israeli Jews. The increased prevalence of T2DM corresponds to increased rates of obesity in these populations. A major risk group is adult Arab women aged 55-64 years. In this group obesity reaches 70%. There are several genetic and nutritional explanations for this increase. We found high hospitalization rates for micro and macrovascular complications among diabetic patients of Arab and Bedouin origin. Despite the high prevalence of diabetes and its negative health implications, there is evidence that care and counseling relating to nutrition, physical activity and self-examination of the feet are unsatisfactory. Economic difficulties are frequently cited as the reason for inadequate medical care. Other proposed reasons include faith in traditional therapy and misconceptions about drugs and their side effects. In Israel, the quality indicators program is based on one of the world’s leading information systems and deals with the management of chronic diseases such as diabetes. The program’s baseline data pointed to health inequality between minority populations and the general population in several areas, including monitoring and control of diabetes. Based on these data, a pilot intervention program was planned, aimed at minority populations. This program led to a decrease in inequality and served as the basis for a broader, more comprehensive intervention that has entered the implementation stage. Interventions that were shown to be effective in other Arabic countries may serve as models for diabetes management in the Arab and Bedouin populations in Israel.