Reported morbidity in Israel is, comparatively, significantly lower than reported in the literature [3, 4]. Approximately 50% of the Israeli population reported morbidity during the past month as compared with the 70–75% described previously [1, 2], 86% in Japan, and 90.1% in Norway [5]. Actual service consumption, however, was paradoxically higher in our study (352/1000), as seen in Fig. 5, more than Norway (214/1000) [5], the United States, (217/1000) [2], Canada (238/1000) [14], and Japan (307/1000) [3], but not of Hong Kong (440/1000) [4].
It is possible that the perception of morbidity reported in Israel is lower than what is common in the world due to differences in cultural perceptions of illness. In a recent study on self-rated health among Israeli women, immigrants reported lower perceived good health than the veteran Israeli population [15]. Significant differences in healthcare usage have also been seen between other European countries; for example, French citizens were much more likely to visit their physician and receive symptomatic treatment for an upper respiratory infection, than the Dutch [16]. High consumption of medical services indicates good availability of public health system, probably thanks to universal health care coverage. Our findings suggest that Israelis who perceive themselves as sick will usually consider medical assistance and are very likely to receive it. On the other hand, the discrepancy between the peripheral versus central populations seeking out care seems to imply that the health care system in Israel allows for medical assistance when needed but in an unequal fashion. That is, morbidity perception and the rate of those considering pursuing medical assistance were similar between the center of the country and the geographic periphery; however, residents of the periphery forewent seeking out healthcare services significantly more than the rest of the population. In Israel, discrepancies in healthcare usage and barriers to access due to distance and lack of tertiary medical centers have been documented in the past [17, 18]. Interestingly, Arab Israelis reported lower levels of illness perception, morbidity and consumption, despite well documented studies that demonstrate increased morbidity and mortality among the Arab Israeli population and increased risk factors for developing disease [17,18,19,20,21,22,23]. The discrepancy found between health perception compared to the high prevalence of morbidity and its complications in Arab society has also been demonstrated in other studies [24, 25]. For example, Arab Israeli women reported relatively high rates of good self-rated health, yet the same population had the highest rate of frequent use of family physician (45%), the same percentage of chronic illness as the Jewish population, and the highest level of depressive symptoms [15]. Self-health perception is related to a variety of factors such as economic well-being, level of education, knowledge, social security and culture. Studies conducted in Israel have shown that all of these have some contribution in creating this gap between Arab and Jewish populations [26,27,28,29]. Lack of medical services in the periphery may also widen the gap between known morbidity and consumption of medical services. All these foster frustration, underutilization of medical services and, as a result, poorermedical outcomes. About a decade ago, the Ministry of Health in Israel promoted a strategic plan designed to reduce the gaps between periphery and center and between the various sectors of Israeli society [30]. Funds have been invested in improving access to medical services and bringing advanced technologies to the periphery, promoting health education, publishing information in various languages and implementing an index program to examine the quality of medicine [31]. Change has apparently begun, but there is still a long way to go. Most of the interventions described above have been designed to improve the accessibility of inpatient systems. However, our findings show that 98.5% of medical services are consumed in the community and 80% of all family physician consultations are contained within primary care setting. When a person in the periphery is considering getting medical advice he seeks out his family physician and at this point he is probably facing the most common barrier. Promoting healthy lifestyle such as exercise and smoking prevention, addressing common medical problems and managing chronic diseases such as hypertension and diabetes—are all processes that take place in the community. The pattern of consumption described in this work (the "ecology" of medical care consumption) along with the preferences expressed by the study participants show that investing in primary care may be of great benefit in improving the accessibility of medical services in the periphery and reducing disparities.
Methodological changes and limitations
Low response rate may create a selection bias. Overall response rate to this survey was 15.6% (calculated by dividing the number of respondents by the number of calls that had to be made until the desired number of respondents was reached, including missed calls and refusals to participate). The response rate was highest among the Arab population (21.8%) and lowest among the immigrant population (12.7%). Young people (under the age of 45) were not available on a landline, which greatly increased the number of calls and affected the overall response rate. For over a decade, it has been evident that landline purchase is declining, especially among those under forty, and being replaced by increased cell phone line usage. This trend is seen in the United States [32, 33], Europe [34], and Israel [35]. Therefore, our decision to modify our sampling methods, midway through the study, and use internet-based questionnaires for this population, was reasonable and necessary given the circumstances. After receiving approval from the Ethics Committee, an online survey was distributed among this stratum using the "I PANEL" database, a large database, with about 100,000 members containing the diverse population strata. 767 questionnaires were distributed in this way to the younger age groups, 402 were completed and returned (52.4%). Due to the difference in reporting styles, self-completed as compared with interview, as well as possible selection bias of the e-mail database, our results may not be representative of the overall 15–44 age group in Israel. In order to reduce memory bias we asked about the incidence of morbidity and consumption of medical services in two stages: first about the last two weeks and then about their incidence during the last month. In order to test the reliability of our results a comparison was made with the 2009 Health Survey of the Central Bureau of Statistics (published in 2013). More than 20,000 participants aged 15 and over took part in this National Survey and their response rate was very high (82%). Still, the results of the surveys are very similar.19.2% of survey participants conducted by the Central Bureau of Statistics reported consulting a physician during the past two weeks compared to 21.3% who sought medical assistance during the same period in our work.