Orientation to the care of CALD patients: Optimising the role of the practice nurse Wednesday 17 February 2010 NiGP

1.  Orientation to the care of CALD patients: Optimising the role of the practice nurse Wednesday 17 February 2010NiGP Conference – Sebel Hotel Albert Park Annette Dupont CALD Immunisation Consultant a.dupont@gpv.org.au (03) 9341 5240 (Weds & Thurs)

2. 2 Proposal Aim: improve quality of care for culturally and linguistically diverse (CALD) patients by optimising and broadening the existing role of practice nurses Design: 3-hour module providing overview to immigrant health; case studies; clinical resources and practical strategies for the delivery of culturally appropriate care Role of Practice Nurses: repositories of cultural and clinical knowledge; key agents of connectivity between practice staff, specialist providers, patients and families

3. 3 Principles Alma Ata Declaration (1978) Health is a human right Discrimination and health inequalities are unacceptable Empowerment of individuals and their communities Community participation and multisectoral collaboration

4. 4 Rationale Current formal provision of orientation to care of CALD patients remains uneven across Australia (Pinikahana et al, 2003) Addressing existing CALD health disparities requires access to specialised knowledge and/or resources Providing culturally-appropriate care can support increased engagement and improve health outcomes Meeting ANF competency standards (2006) on right to have spiritual, emotional and cultural needs met

5. 5 Outline of Module Introduction to immigrant health (1.5 hours) Background information, policies and statistics Immigrant healthcare expectations, experiences and selected health issues Case studies, vignettes, strategy options, relevant agencies and resources Good practice in using onsite and telephone interpreters Explanatory models; culturally inclusive health assessment Introduction to refugee health (1.5 hours) Background information, policies and statistics Refugee healthcare expectations, experiences, trauma and torture issues Case studies, vignettes, strategy options and relevant agencies and resources Collaboration with health and settlement service providers Refugee health assessments; investigations and approaches

6. 6 Introduction to Immigrant Health Approximately 25% of our population is overseas-born and/or of immigrant background English proficiency may be poor and culturally-informed beliefs may influence health behavior Not only newly-arrived but well-established immigrants may experience multiple barriers to healthcare Studies indicate that immigrants may be at higher risk of poor health outcomes than other Australians

7. 7 “The Healthy Migrant Effect” “But immigrants are generally healthier than Australian-born populations aren’t they?” Theory: Health requirements and eligibility criteria ensure only those in good health migrate to Australia Not all migrants: Some migrants are at higher risk for certain diseases and this disadvantage may persist Picture changes over time: Initial health advantages decrease with increasing length of residence (Young, 1992)

8. 8 How does a non-English speaking cultural background impact on health status? Proficiency in written and spoken English Health literacy and understanding of the Australian healthcare system Health beliefs and health-seeking behaviour Treatment preferences and dietary practices Culture shapes views of illness and wellness Possible reticence to ask questions or complain Patients may wish to involve the whole family in decision-making and care

9. 9 Introduction to Immigrant Health Illnesses for which immigrants are often at higher risk e.g. Vitamin D deficiency - Middle Eastern nursing home residents at 4-fold risk and Vietnamese a 3-fold risk compared to other Australians (Brock et al, 2004) Hepatitis B - Infection prevalence SE Asia (5.4%); NE Asia (4.9%); Middle East/Africa (0.9%) compared to Aust.-born (traditionally low prev. <1%) (Matthews & Robotin, 2008) Diabetes – Some immigrants from Europe, Asia and Pacific Islands have higher diabetes mortality (AIHW, 2002)

10. 10 Introduction to Immigrant Health Explanatory Models of Health: Asthma Ability to meet needs in a culturally competent manner is facilitated when nurses ask families how they explain their children's asthma (Reece et al, 2009) Formal knowledge of asthma may reflect biomedical models but explanatory models (of origin, natural history, and prognosis) are more responsive to personal experience, anecdote, cultural beliefs (Rich et al, 2002) Understanding and responding to explanatory models of asthma management may be more important than education to improve asthma-related behaviors and adherence to medical plans. (Rich et al, 2002)

11. 11 Introduction to Immigrant Health Using interpreters Practical aspects of arranging on-site and telephone interpreters and guidelines for use e.g. Importance of seating arrangements, hands-free speaker phones, maintaining eye contact with patient, gender and dialect concordance Sensitivity to requests for personal information revelations in front of interpreter who may be a member of the patient’s community Allowing interpreter and patient to leave together and follow-up debriefing with interpreter by phone afterwards (VFST, 2007; CEH, 2006)

12. 12 Introduction to Immigrant Health Culturally inclusive health assessments Screening for conditions which may be under-recognised in CALD patients e.g. inadequate vaccinations; TB, Hepatitis A, B, C etc. Reflecting on one’s own cultural values, beliefs, health behaviors and care preferences; and being sensitive to those of others Being aware of the possible impact of cultural or language differences - without overlooking considerable similarities e.g. Recent study of maternal depression in immigrants found marked cross-cultural similarities to Australian-born mothers (Small et al, 2003)

13. 13 Introduction to Refugee Health Who is a refugee? A refugee is a person who "owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion, is outside the country of his nationality, and is unable to or, owing to such fear, is unwilling to avail himself of the protection of that country…" Article 1, The 1951 Convention Relating to the Status of Refugees

14. 14 Introduction to Refugee Health Who is an Asylum Seeker? An asylum seeker is a person who has left their country of origin, has applied for recognition as a refugee in another country, and is awaiting a decision on their application. Definitions and Obligations United Nations High Commissioner for Refugees http://www.unhcr.org.au/basicdef.shtml

15. 15 Introduction to Refugee Health Refugees may be at higher risk for some conditions than non-refugees: Traumatized persons (refugees) have a higher prevalence of hypertension and diabetes (Kinzie et al, 2008) Dietary changes, limited nutritional knowledge of Western foods, a sedentary lifestyle, and barriers to participating in physical activity programs may increase vulnerability to obesity and cardiovascular disease in West African refugee women (Drummond et al, 2009) Refugee children may be at increased risk of mental health problems and have greater difficulty accessing mental health care (de Anstiss et al, 2009)

16. 16 Integrated Humanitarian Settlement Strategy Services provided to refugees and other humanitarian entrants under the IHSS include: Case Coordination, Information and Referrals On Arrival Reception and Assistance Accommodation Services Short Term Torture and Trauma Counselling Services Fact Sheet 66. National Communications Branch Department of Immigration and Citizenship, Canberra. Revised 23 April 2009.

17. 17 Trauma and Torture Issues “Torture is a strategic means of limiting, controlling, and repressing basic human rights of individuals and communities - often covert and denied by authorities ...” (Alayarian, 2009). Refugees have their own way of conceptualizing their problems e.g. West Papuans in North Queensland use the term dua sakit (“two sicknesses”) to refer to the twin challenges posed by overcoming past traumas and trying to cope with present resettlement stresses. (Rees, Silove & Kareth, 2009).

18. 18 Trauma and Torture Many Burmese, Africans and Middle Easterners have experienced trauma, dislocation and loss Many are victims of genocide, war, and torture Pre-migration experiences and re-settlement stresses can significantly affect individual and family well-being and parenting practices Important for providers to be well informed about how best to support refugee families using culturally competent approaches (Lewig et al, 2009)

19. 19 Introduction to Refugee Health Health Care for Refugees and Asylum Seekers (RACGP,2002) The following health problems are likely to be common: post traumatic stress disorder, anxiety, depression and psychosomatic disorders physical consequences of torture (e.g. musculoskeletal pain or deafness) under recognised and/or under managed conditions (e.g. hypertension, diabetes and chronic pain) poor oral health resulting from poor nutrition, diet, dental hygiene practices and limited prior dental care infectious diseases including TB and intestinal parasites delayed growth or development in children

20. 20 Introduction to Refugee Health Refuge health assessments Engaging interpreters and accessing templates to guide screening and health assessment of patients with refugee backgrounds Mindfulness that cultural values may impact on the expression of pain or discomfort e.g. even young children in Somali culture are expected to control facial expressions of pain (Finnstrom et al, 2006) Reflecting on one’s own cultural values, beliefs, health behaviors and care preferences; and being sensitive to those of others Recognising patients may be unfamiliar with the primary health care system and with preventive health concepts and practices

21. 21 A culturally sensitive approach Dealing with the effects of trauma and torture and the stresses of re-settlement / anxieties about deportation Encountering patients who may have a distrust of authority figures, including health professionals Managing clinical encounters with patients of diverse cultural, educational and religious backgrounds Understanding patient’s lack of familiarity with the Australian health care system or preventive healthcare Equity in care not about “treating everyone the same” but about patient-centred care to meet CALD needs e.g. engaging interpreters; female GPs in some cases

22. 22 Infectious diseases in refugees Malaria Tuberculosis Hepatitis B and C Schistosomiasis Strongyloides Rubella Eosinophilia Iron deficiency Vitamin A deficiency Vitamin D deficiency HIV* Chlamydia Gonorrhoea / Syphilis Helicobacter Pylori Chronic diseases Cancer screening *ASID recommends HIV testing for ALL refugees*ASID recommends HIV testing for ALL refugees

23. 23 ResourcesGPV Refugee Health Assessment Template (a helpful picture)

24. 24 ResourcesFoundation House – Desktop Guide Versions available for all jurisdictionsVersions available for all jurisdictions

25. 25

26. 26 Cultural competence principles for Australian community nurses Omeri & Malcolm (2004:184) willingness to recognize expert family skill and knowledge of situation and negotiate as appropriate; acknowledgement of own and other nurses’ strengths and weaknesses; taking the time to establish rapport and acceptance and looking for cues to acceptable behaviors; assessing influences on health and healthcare while being flexible in approach; providing care which meets the CALD needs of clients and is appropriate in context; developing competence relating to diversity in one’s own clinical practice and advocating for appropriate culturally and linguistically diverse resources and expertise.

27. 27 References ASID (2008) Guidelines for Diagnosis, Management and Prevention of Infection in Recently Arrived Refugees, July 2008, Australasian Society for Infectious Diseases. http://www.asid.net.au Victorian Foundation for Survivors of Torture (2007) Promoting refugee health: A guide for doctors and other health care practitioners. http://www.foundationhouse.org.au Victorian Foundation for the Survivors of Torture (2007) Caring for refugee patients in general practice: A desktop guide. http://www.foundationhouse.org.au Department of Human Services Victoria - Making the Connection: Language Services in the human services sector. CD Resource kit available from www.dhs.vic.gov.au Thomas, P, Milne, B, Raman, S, & Shah, S. (2007). Refugee youth- immunisation status and GP attendance. Aust Fam Physician, 36(7), 568-570. Tiong, A, Patel M, Gardiner J, Ryan R, Linton K, Walker K, Scopel J, & Biggs B-A (2006) Health issues in newly arrived African refugees attending general practice clinics in Melbourne, MJA; 185 (11/12): 602-606 Lewig, K., Arney, F., & Salveron, M. (2009). Challenges to parenting in a new culture: Implications for child and family welfare. Eval Program Plann.

28. 28 References Benson, J, & Donohue, W. (2007). Hepatitis in refugees who settle in Australia. Aust Fam Physician, 36(9), 719-727. Downs, K, Bernstein, J, & Marchese, T. (1997). Providing culturally competent primary care for immigrant and refugee women. A Cambodian case study. J Nurse Midwifery, 42(6), 499-508. Franco-Paredes, C, Dismukes, R, Nicolls, D, Hidron, A, Workowski, K, Rodriguez-Morales, A, et al. (2007). Persistent and untreated tropical infectious diseases among Sudanese refugees in the United States. Am J Trop Med Hyg, 77(4), 633-635. Tangermann, R H, Hull, H F, Jafari, H, Nkowane, B, Everts, H, & Aylward, R B. (2000). Eradication of poliomyelitis in countries affected by conflict. Bull World Health Organ, 78(3), 330-338 Omeri, A. (1997). Care: what it means to Iranian immigrants in New South Wales, Australia. Hoitotiede, 9(5), 239-245. VicHealth (2007) Making the link between cultural discrimination and health http://www.vichealth.vic.gov.au Henry, B R, Houston, S, & Mooney, G H. (2004). Institutional racism in Australian healthcare: a plea for decency. Med J Aust, 180(10), 517-520.

29. 29 References Young C (1992) Mortality, the ultimate indicator of survival: the differential experience between birthplace groups. In: Donovan J, d’Espaignet ET, Merton C and van Ommeren N (eds). Immigrants in Australia: a health profile. Canberra: AGPS Brock, K., Wilkinson, M., Cook, R., Lee, S., & Bermingham, M. (2004). Associations with Vitamin D deficiency in "at risk" Australians. J Steroid Biochem Mol Biol, 89-90(1-5), 581-588. Alayarian, A. (2009). Children, torture and psychological consequences. Torture, 19(2), 145-156. Rees, S., Silove, D., & Kareth, M. (2009). Dua sakit (double sick): trauma and the settlement experiences of West Papuan refugees living in North Queensland. Australas Psychiatry, 17 Suppl 1, S128-132. Grodin, M. A., Piwowarczyk, L., Fulker, D., Bazazi, A. R., & Saper, R. B. (2008). Treating survivors of torture and refugee trauma: a preliminary case series using qigong and t'ai chi. J Altern Complement Med, 14(7), 801-806. Finnstrom, B., & Soderhamn, O. (2006). Conceptions of pain among Somali women. J Adv Nurs, 54(4), 418-425. Omeri, A., & Malcolm, P. (2004). Cultural diversity: a challenge for community nurses. Contemp Nurse, 17(3), 183-19

30. 30 References Pinikahana, J., Manias, E., & Happell, B. (2003). Transcultural nursing in Australian nursing curricula. Nurs Health Sci, 5(2), 149-154. Reece, S. M., Silka, L., Langa, B., Renault-Caragianes, P., & Penn, S. (2009). Explanatory models of asthma in the southeast asian community. MCN Am J Matern Child Nurs, 34(3), 184-191. Rich, M., Patashnick, J., & Chalfen, R. (2002). Visual illness narratives of asthma: explanatory models and health-related behavior. Am J Health Behav, 26(6), 442-453. Small, R., Lumley, J., & Yelland, J. (2003). Cross-cultural experiences of maternal depression: associations and contributing factors for Vietnamese, Turkish and Filipino immigrant women in Victoria, Australia. Ethn Health, 8(3), 189-206. Kinzie, J. D., Riley, C., McFarland, B., Hayes, M., Boehnlein, J., Leung, P., et al. (2008). High prevalence rates of diabetes and hypertension among refugee psychiatric patients. J Nerv Ment Dis, 196(2), 108-112. - 459 Drummond, P. D., Mizan, A., Burgoyne, A., & Wright, B. Knowledge of Cardiovascular Risk Factors in West African Refugee Women Living in Western Australia. J Immigr Minor Health. de Anstiss, H., Ziaian, T., Procter, N., Warland, J., & Baghurst, P. (2009). Help-seeking for mental health problems in young refugees: a review of the literature with implications for policy, practice, and research. Transcult Psychiatry, 46(4), 584-607.