Matching Digital Intervention Affordances with Tasks: The Case of a Zoom and WhatsApp Mental Health Intervention for Seniors during the COVID-19 Pandemic

During the first COVID-19 wave, we conducted a Zoom and WhatsApp digital group intervention that promoted community-dwelling seniors' mental health. A total of 82 community-dwelling adults participated in this intervention. Based on the media richness theory (MRT) and the affordances approach, we used netnography to explore how group moderators and technical support team members (n = 9), but not the seniors themselves, perceived the ways Zoom and WhatsApp technological affordances/constraints matched intervention tasks and increased intervention performance. We identified four Zoom and WhatsApp affordances: temporality, interactivity, multimediality, and portability. Empirically, our findings represent a first step in creating a conceptual framework for analyzing digital intervention performances that addresses users' perceptions of technologies and intervention goals. Theoretically, our synergic analysis of MRT and the affordances approach offers a cohesive framework that shifts from a focus on users' interactions with one type of media to their interactions with all media that are used in attaining intervention goals.

Medical choices regarding feeding tubes in patients with end-stage dementia in Israel: nasogastric vs. percutaneous endoscopic gastrostomy

A previous study conducted more than 15 years ago in Israel found a high overall use of tube-feeding for institutionalized end-stage dementia patients (52%) and a proportionally higher use (2:1) of naso-gastric tube (NG) over Percutaneous Endoscopic Gastrostomy (PEG) tubes for enteral feeding. This rate was markedly higher than that observed in other western countries (4.9-34%), and did not conform with clinical guidelines preferring spoon-feeding over tube-feeding for these patients, and PEG over NG for those in whom tube-feeding was initiated in long-term care. Over the past decade, the Israeli Ministry of Health conducted a policy reform to neutralize the administrative incentives presumed to be responsible for this situation. Further administrative and legislative developments followed suit. Despite these, we found no significant reduction in the prevalence of tube-feeding over spoon-feeding. However, we did observe a reduction in the proportional use of NG over PEG.

Age and Aging: Some Facts and a Lot of Hype

Aging is a universal phenomenon, only recently of broad interest to the scientific community, despite its importance to public health. The books under review here, Sinclair and LaPlante's Lifespan (2019) and Armstrong's Borrowed Time (2019), examine the various causes of the aging process. The first concentrates primarily on one family of the many theories in existence; the second offers a broader context. Neither adequately examines the sociopolitical implications of population aging that have already begun to affect the high-income countries of the world and will very soon roil the poorer regions of the planet as well. Both books suffer from a rosy view of how we might improve or slow the aging process, and neither offers serious solutions for the challenges that await us-demographic, clinical, and ethical. Unfortunately, although much serious scientific work is now evident, the field has become polluted by those who wish to take advantage of this newly discovered market. Although the authors of the books under review are not a part of this pernicious and cynical trend, neither do they adequately warn the readers if its imminence.

A Digital Intervention to Alleviate Loneliness and Depression Among Older Persons During the COVID-19 Outbreak

People with Alzheimer’s disease and related dementias (ADRD) frequently receive sub-optimal end-of-life care (EOLC), often enduring invasive procedures such as tube feeding, resuscitation, and surgery within days of their death. While advance care planning (ACP) has shown effectiveness in improving EOLC for those with ADRD, there are many barriers to ACP specific to the ADRD population. Research suggests that hospice care is optimal in reducing end of life suffering for ADRD patients. This study aimed to empirically assess hospice utilization and ACP for individuals with ADRD compared to individuals without ADRD, and to assess the impact of ACP on hospice utilization for individuals with ADRD. Data came from the 2016-2018 wave of the Health and Retirement Study (HRS), a national longitudinal study collecting health and demographic data on older Americans. This analysis evaluated survey responses from 1,224 proxy respondents for individuals who died during this period. In this sample, people with ADRD were both significantly more likely to have utilized hospice care (OR=1.37) and to have written EOLC instructions in place (OR=1.19). Those with ADRD were 22% less likely to have discussed their EOLC wishes with their proxy than those without ADRD. Having a written EOLC plan in place significantly increased the odds of hospice utilization (OR=1.37) but discussion around EOLC preferences increased odds of hospice utilization at a higher rate (OR=1.59). These results support policy to advance earlier ACP conversations around EOLC preferences and the implementation of written EOLC instructions to reduce suffering for individuals with ADRD diagnoses .

Age and Ageing During the COVID-19 Pandemic; Challenges to Public Health and to the Health of the Public

The distribution of the SARS-CoV-2 virus has reached pandemic proportions. While COVID-19 can affect anyone, it is particularly hazardous for those with "co-morbidities." Older age is an especially strong and independent risk factor for hospital and ICU admission, mechanical ventilation and death. Health systems must protect persons at any age while paying particular attention to those with risk factors. However, essential freedoms must be respected and social/psychological needs met for those shielded. The example of the older population in Israel may provide interesting public health lessons. Relatively speaking, Israel is a demographically young country, with only 11.5% of its population 65 years and older as compared with the OECD average of >17%. As well, a lower proportion of older persons is in long-term institutions in Israel than in most other OECD countries. The initiation of a national program to protect older residents of nursing homes and more latterly, a successful vaccine program has resulted in relatively low rates of serious COVID-19 related disease and mortality in Israel. However, the global situation remains unstable and the older population remains at risk. The rollout of efficacious vaccines is in progress but it will probably take years to cover the world's population, especially those living in low- and middle-income countries. Every effort must be made not to leave these poorer countries behind. Marrying the principles of public health (care of the population) with those of geriatric medicine (care of the older individual) offers the best way forward.

Academic activism on behalf of children during the COVID-19 pandemic in Israel; beyond public health advocacy

Among the challenges presented by the SARS-CoV2 pandemic are those related to balancing societal priorities with averting threats to population health. In this exceptional context a group of Israeli physicians and public health scholars (multidisciplinary academic group on children and coronavirus [MACC]) coalesced, examining the role of children in viral transmission and assessing the necessity and consequences of restricted in-class education. Combining critical appraisal and analytical skills with public health experience, MACC advocated for safe and monitored school re-opening, stressing the importance of education as a determinant of health, continuously weighing this stance against evolving COVID-19-risk data. MACC’s activities included offering research-based advice to government agencies including Ministries of Health, Finance, and Education. In a setting where government bodies were faced with providing practical solutions to both decreasing disease transmission and maintaining society’s vital activities, and various advisors presented decision-makers with disparate views, MACC contributed epidemiological, clinical and health policy expertise to the debate regarding school closure as a pandemic control measure, and adaptations required for safe re-opening. In this paper, we describe the evolution, activities, policy inputs and media profile of MACC, and discuss the role of academics in advocacy and activism in the midst of an unprecedented public health crisis. A general lesson learned is that academics, based on the rigor of their scientific work and their perceived objectivity, can and should be mobilized to pursue and promote policies based on shared societal values as well as empiric data, even when considerable uncertainty exists about the appropriate course of action. Mechanisms should be in place to open channels to multidisciplinary academic groups and bring their input to bear on decision-making.

Assessment of Global Health Education: The Role of Multiple-Choice Questions

Introduction: The standardization of global health education and assessment remains a significant issue among global health educators. This paper explores the role of multiple choice questions (MCQs) in global health education: whether MCQs are appropriate in written assessment of what may be perceived to be a broad curriculum packed with fewer facts than biomedical science curricula; what form the MCQs might take; what we want to test; how to select the most appropriate question format; the challenge of quality item-writing; and, which aspects of the curriculum MCQs may be used to assess.

Materials and Methods: The Medical School for International Health (MSIH) global health curriculum was blue-printed by content experts and course teachers. A 30-question, 1-h examination was produced after exhaustive item writing and revision by teachers of the course. Reliability, difficulty index and discrimination were calculated and examination results were analyzed using SPSS software.

Results: Twenty-nine students sat the 1-h examination. All students passed (scores above 67% - in accordance with University criteria). Twenty-three (77%) questions were found to be easy, 4 (14%) of moderate difficulty, and 3 (9%) difficult (using examinations department difficulty index calculations). Eight questions (27%) were considered discriminatory and 20 (67%) were non-discriminatory according to examinations department calculations and criteria. The reliability score was 0.27.

Discussion: Our experience shows that there may be a role for single-best-option (SBO) MCQ assessment in global health education. MCQs may be written that cover the majority of the curriculum. Aspects of the curriculum may be better addressed by non-SBO format MCQs. MCQ assessment might usefully complement other forms of assessment that assess skills, attitude and behavior. Preparation of effective MCQs is an exhaustive process, but high quality MCQs in global health may serve as an important driver of learning.

Evaluation of a Short-Term Digital Group Intervention to Relieve Mental Distress and Promote Well-Being Among Community-Dwelling Older Individuals During the COVID-19 Outbreak: A Study Protocol

Older individuals are at an increased risk of experiencing adverse social and health consequences due to both the COVID-19 pandemic and the measures taken to manage it, such as social distancing. To promote community-dwelling older individuals' well-being during this time, the aims of the current project are to develop effective strategies in order (a) to increase older individuals' digital literacy, and (b) to help them acquire behavioral and cognitive skills that will improve their coping abilities with the stressful situation created as a result of the pandemic, as well as reducing adverse mental health effects. The project comprises an intervention arm that includes digital group sessions for older individuals meant to improve their digital literacy, promote their effective coping, and relieve their mental distress and loneliness. Subjects receive a short-term (seven sessions), twice-weekly, digitally guided group intervention through Zoom (a video conferencing app), and WhatsApp (instant messaging app). The wait list control-group participants receive twice-weekly telephone calls from a research assistant during a parallel period. Web-based questionnaires are filled in pre- and post-participation. The effectiveness of the intervention will be analyzed by comparing pre- and post-measures, between intervention and control groups. This protocol offers a model for helping to support vulnerable populations during the COVID-19 pandemic. However, it is applicable regardless of the outbreak of a global health crisis or the imposition of lockdown rules; in fact, it has the potential to contribute to the social inclusion of vulnerable populations during routine times as well as during emergencies. Furthermore, ideas for future expansion include the integration of multilingual facilitators in order to reach seniors from underserved minority groups in various social contexts, even across borders.

A pilot randomized controlled trial of a group intervention via Zoom to relieve loneliness and depressive symptoms among older persons during the COVID-19 outbreak

While effective in reducing infections, social distancing during the COVID-19 outbreak may carry ill effects on the mental health of older adults. The present study explored the efficacy of a short-term digital group intervention aimed at providing seniors with the tools and skills necessary for improving their coping ability during these stressful times. A total of 82 community-dwelling adults aged between 65 aged 90 (Mage = 72 years, SD = 5.63) were randomized to either an intervention group (n = 64) or a wait-list control group (n = 18). The intervention comprised online guided sessions in small groups in which behavioral and cognitive techniques were learned and practiced via the ZOOM videoconferencing platform. Loneliness and depression levels were measured pre- and post-participation. The results demonstrated a significant improvement in the intervention group in terms of both loneliness and depressive symptoms, compared with the control group. Results of mixed effect models indicated a medium ameliorative effect on loneliness (d = 0.58), while that for depressive symptoms was only marginally significant and smaller in size (d = 0.43). Our intervention presents a relatively simple and effective technique that can be efficiently utilized to support older adults both during emergencies such as the COVID-19 outbreak, as well as in more routine times for older adults who live alone or reside in remote areas.

Age, ageing, ageism and "age-itation" in the Age of COVID-19: rights and obligations relating to older persons in Israel as observed through the lens of medical ethics

COVID-19, the illness caused by the SARS-CoV-2 virus, has reached pandemic proportions. Although the virus can cause disease in anyone, it is particularly dangerous for those with various "co-morbidities" such as heart disease, hypertension, diabetes, obesity and others. Furthermore, advancing age (from about 60 on), even in those older persons without any accompanying illnesses, is a strong and independent risk factor for pneumonia, need for an ICU bed and death from the virus. It is therefore essential to find ways to protect all at-risk persons (old or young) from the virus but at the same time not harming, more than absolutely necessary their essential freedoms as well as taking into account their social/psychological needs. Compared with other OECD countries, Israel's population is still relatively young, with only 11.5% being over 65+ with a smaller proportion of older persons in long-term institutions than that found in most other comparable jurisdictions. These factors might explain a part of the country's (so far) relatively low rates of serious disease and mortality compared to those seen in other developed countries. However there are still over a million older citizens at risk and the numbers of infected, hospitalized and seriously ill persons are rising once again. This is no time for complacency.An analysis of the effect of age on the disease as seen through the principles of medical ethics is followed by a proposal as to how best to balance these sometimes conflicting goals. This paper relates mainly to older persons in the community since the Ministry of Health early on in the pandemic initiated an effective program (Magen Avot) meant to protect those older persons in long-term care institutions. Recommendations include the Ministry of Health publishing clear guidelines as to risk factors and offering sensible advice on how to practice physical (not "social") distancing without exacerbating an older person's sense of social isolation. In order to reduce the incidence of influenza (which can clinically be confused with COVID-19) and the potentially disastrous consequences of a "double pandemic" this coming winter, a robust flu vaccination program needs immediate implementation. Persons at all ages (but especially those 60+) should be encouraged and assisted to sign advance directives, especially those who do not wish to undergo invasive therapy. An individual older person's wish to "make way" for younger people should be respected as an expression of his/her autonomy. As we enter the second wave, triage mechanisms and protocols need to be circulated in readiness for and well before a situation in which an acute imbalance develops between the availability for acute resources and the population's need for them. The Ministry of Health, in cooperation with other relevant ministries and NGOs, should take the lead in developing plans, ensuring that they are carried out in an orderly, timely and transparent manner. The blanket is indeed not large enough but we must place it as judiciously as possible in order as much as possible to protect, cover and keep warm the body politic.

Implementing a Practical Global Health Curriculum: The Benefits and Challenges of Patient-Based Learning in the Community

Background: A growing number of medical schools across the world have incorporated global health (GH) into their curricula. While several schools focus GH education on lecture-based courses, our premise is that global health education should embody a holistic approach to patient care and medical education in local communities. Medical students may learn global health by focusing on real patients, their families and communities as part of a practical curriculum.

Aims and Objectives: A unique GH curriculum was devised to compare student learning outcomes on a practical vs. lecture-based course. The premise was that learning from patients would result in a greater breadth of coverage of the global health syllabus as compared to that from a lecture-based course.

Methods: A teaching and learning program was developed over 3 years to provide medical students interaction with real patients in the community on a first-preclinical-year Introduction to Global Health and Medical Anthropology course. Learning outcomes on the practical vs. lecture-based course were compared using thematic analysis of the written assignments of both courses: global health case reports and literature reviews, respectively. All members of three cohorts of students undertaking the course in successive academic years were compared (Group A: literature review; Groups B and C: case reports; n = 87).

Results: Case reports provided evidence of a greater breadth of learning outcomes when compared to the literature review (p < 0.001). The writing of the case report was enhanced by completion of a field journal and family health needs assessment tool (p < 0.001). Students demonstrated a closeness to their patients that added depth, understanding and motivation to assist patients in health activities and advocate for their needs.

Discussion: Placements with patients in the community provided students with a rich learning environment and facilitated the formation of relationships with patients to better understand the social determinants of health and advocate for improvements in their living and working conditions and access to healthcare.

Conclusions: Global health may be better learned experientially by following patients rather than from frontal lectures. Patient-based learning inspires a commitment to the individual and facilitates medical schools in meeting their obligations to the communities they serve.

Israel Ad Hoc COVID-19 Committee: Guidelines for Care of Older Persons During a Pandemic

Early on, geriatricians in Israel viewed with increasing alarm the spread of coronavirus disease 2019 (COVID‐19). It was clear that this viral disease exhibited a clear predilection for and danger to older persons. Informal contacts began with senior officials from the country's Ministry of Health, the Israel Medical Association, and the country's largest health fund; this was done to plan an approach to the possible coming storm. A group was formed, comprising three senior geriatricians, a former dean, a palliative care specialist, and a lawyer/ethicist. The members made every effort to ensure that their recommendations would be practical while at the same time taking into account the tenets of medical ethics. The committee's main task was to think through a workable approach because intensive care unit/ventilator resources may be far outstripped by those requiring such care. Recommendations included the approach to older persons both in the community and in long‐term care institutions, a triage instrument, and palliative care. Patient autonomy was emphasized, with a strong recommendation for people of all ages to update their advance directives or, if they did not have any, to quickly draw them up. Considering the value of distributive justice, with respect to triage, a “soft utilitarian” approach was advocated with the main criteria being function and comorbidity. Although chronological age was rejected as a sole criterion, in the case of an overwhelming crisis, “biological age” would enter into the triage considerations, but only in the case of distinguishing between people with equal non–age‐related deficits. The guideline emphasized that no matter what, in the spirit of beneficence, anyone who fell ill must receive active palliative care throughout the course of a COVD‐19 infection but especially at the end of life. Furthermore, in the spirit of nonmaleficence, the frail, very old, and severely demented would be actively protected from dying on ventilation. J Am Geriatr Soc 68:1370‐1375, 2020.

Giving a voice to medically vulnerable populations: A mixed-methods investigation of their unique perceptions and needs in emergency situations

Older adults in poor health represent a growing sector of the population worldwide. These medically vulnerable individuals often tend to be ill-prepared for emergencies. In times of crisis they are at higher risk of experiencing adverse health outcomes and are liable to place an additional burden on health and social care services. The aim of this study was to explore the unique perceptions and diverse needs of community-dwelling medically vulnerable individuals in Israel in order to gain insights that could be used to promote future preparedness. A mixed methods design was employed that included 16 in-depth interviews, followed by a quantitative survey of 179 participants. Data were collected between 2016 and 2017. The analysis process included thematic analysis for qualitative data. Quantitative data analysis focused on estimating associations between preparedness levels and participants' characteristics and perceptions. The results indicated low levels of preparedness-only 13.5% of participants reported having prepared a full emergency kit with supplies. Family members played a key role in almost every dimension related to emergency preparedness; alongside certain authorities perceived by the participants as responsible for initiating the preparedness process. Additional issues that emerged were related to information and communication and to the logistics of medication handling and special nutrition. The findings suggest that it is vital to adopt a proactive approach to the problem of preparedness in this population. This conclusion should be of value to health and social care practitioners in the community as well as to family members and caregivers. Practical and simple recommendations for enhancing preparedness based on these findings are provided. Viewing preparedness as a process that is the joint responsibility of the individual, the family, caregivers, and community health and social welfare services could contribute to maintaining continuity of care among vulnerable populations and mitigate adverse health outcomes in future events.

Structured medical electives: a concept whose time has come?

Background

Most international electives in which medical students from high-income countries travel abroad are largely unstructured, and can lead to problematic outcomes for students as well as sending and receiving institutions. We analyse the problems of unstructured medical electives and describe the benefits of an elective experience that includes more organisation and oversight from the sending medical school.

Results

A number of structured elective programmes have been developed, including those at the Medical School for International Health, Israel and the University of Dundee, United Kingdom. These programmes provide significant pre-departure training in global health and the ethical dimensions of electives, support and monitoring during the elective, and post-elective debrief. Crucially, the programmes themselves are developed on the basis of long-term engagement between institutions, and have an element of reciprocity.

We further identify two major problems in current medical electives: the different ethical contexts in which electives take place, and the problem of ‘voluntourism’, in which the primary beneficiary of the activity is the medical student, rather than the receiving institution or health system. These two issues should be seen in the light of unequal relations between sending and receiving institutions, which largely mirror unequal relations between the Global North and South.

Conclusion

We argue that more structured elective programmes could form a useful corrective to some of the problems identified with medical electives. We recommend that medical schools in countries such as the UK strongly consider developing these types of programmes, and if this is not possible, they should seek to further develop their pre-departure training curricula.

"Death is inevitable - a bad death is not" report from an international workshop

Palliative care is an approach meant to improve the quality of life of patients facing life-threatening illness and to support their families. An international workshop on palliative care took place in Caesarea, Israel under the auspices of the National Institute for Health Policy Research on July 4-5th, 2018, with the goal of discussing challenges to the development and integration of palliative care services in Israel. At the workshop, both national and international figures in the field of palliative care and health policy addressed several issues, including truth telling, religious approaches to end of life care, palliative care in the community, pediatric palliative care, Israel’s Dying Patient Act, the Ministry of Health’s National Plan for palliative care, and challenges in using advance directives. We summarize the topics addressed, challenges highlighted, and directions for further advancement of palliative care in the future, emphasizing the critical role of the Ministry of Health in providing a framework for development of palliative care.

Health and health care in Israel: an introduction

Starting well before Independence in 1948, and over the ensuing six decades, Israel has built a robust, relatively efficient public system of health care, resulting in good health statistics throughout the life course. Because of the initiative of people living under the British Mandate for Palestine (1922-48), the development of many of today's health services predated the state's establishment by several decades. An extensive array of high-quality services and technologies is available to all residents, largely free at point of service, via the promulgation of the 1994 National Health Insurance Law. In addition to a strong medical academic culture, well equipped (albeit crowded) hospitals, and a robust primary-care infrastructure, the country has also developed some model national projects such as a programme for community quality indicators, an annual update of the national basket of services, and a strong system of research and education. Challenges include increasing privatisation of what was once largely a public system, and the underfunding in various sectors resulting in, among other challenges, relatively few acute hospital beds. Despite substantial organisational and financial investment, disparities persist based on ethnic origin or religion, other socioeconomic factors, and, regardless of the country's small size, a geographic maldistribution of resources. The Ministry of Health continues to be involved in the ownership and administration of many general hospitals and the direct payment for some health services (eg, geriatric institutional care), activities that distract it from its main task of planning for and supervising the whole health structure. Although the health-care system itself is very well integrated in relation to the country's two main ethnic groups (Israeli Arabs and Israeli Jews), we think that health in its widest sense might help provide a bridge to peace and reconciliation between the country and its neighbours.