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J Paprckova 1,2 , K Zwi 1,2 , K Williams 1,2 , L Woodland 3 , J Lane 3,4

J Paprckova 1,2 , K Zwi 1,2 , K Williams 1,2 , L Woodland 3 , J Lane 3,4 1 Department of Community Child Health, Sydney Children’s Hospital 2 School of Women & Children's Health, University of New South Wales 3 Multicultural Health Service, SE Sydney and Illawarra Area Health

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J Paprckova 1,2 , K Zwi 1,2 , K Williams 1,2 , L Woodland 3 , J Lane 3,4

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  1. J Paprckova1,2, K Zwi1,2, K Williams1,2, L Woodland3, J Lane3,4 1 Department of Community Child Health, Sydney Children’s Hospital 2 School of Women & Children's Health, University of New South Wales 3 Multicultural Health Service, SE Sydney and Illawarra Area Health 4 University of Wollongong Assessment of the health and well being of refugee children on arrival and at 6 - 12 months of their settlement

  2. SCH Department of Community Child Health

  3. Overview • SCH Department of Community Child Health • Refugees in the world • Refugees in Australia • SESIAH Model of care • Progress at 18 and 30 months • New longitudinal study of refugee children

  4. Who is a Refugee? • UN Definition: "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 of the country of his nationality and is unable, or owing to such a fear is unwilling to avail himself of the protection of that country…“ Article 1A, 1951 Convention on the Status of Refugees

  5. How do they get here? • People are displaced from their country (or internally) 31 million classified by UNHCR as ‘people of concern’ - including 11 million refugees worldwide • They may end up at a refugee camp • They are determined to be “refugee” by the UN • Australia advises UNHCR re: wish to accept a certain No of refugees • The refugees are interviewed and receive a health screen • If they pass, then they get on the list for those who are granted a visa

  6. Refugee experience • Conflict, forced exile, deprivation, unhealthy environmental conditions • Limited healthcare in country of origin and in refugee camps • Minimal health intervention prior to embarkation – especially children

  7. Rwandan refugee camp, East Zaire

  8. No country - stateless No home No privacy No contact with family No / minimal education Difficult conditions in a refugee camp Mandatory detention in ‘safe’ country Extremely unsafe Poor sanitation Infectious diseases Poor diet, hunger Limited health care Witnessing death, rape, murder, self-abuse, torture Refugee Camp

  9. Burmese refugee camp

  10. Humanitarian program • Australia accepts around 13,500 humanitarian entrants / year • 50% children and young people • NSW gets 40%; 85% settle around Sydney • Change in nature of refugee intake 2005: 70% African refugees Now: 1/3 from Africa, Middle East, SE Asia • Middle East: Iraqi refugees • Asia: long term Burmese and Bhutanese refugees

  11. Refugee Distribution by area in NSW 2004 - 2009

  12. Visa • Visa 200 – Humanitarian entrantRefugees, usually family groups - travel paid by government. Mandatory link to Settlement service and case worker (min. 6 months) • Visa 204 – Women at risk programLike 200, but are classified as Women and Children at risk • Visa 202 – Sponsored by family already in AustraliaProposer responsible. Not linked to a case worker. • “Asylum seekers”Arrived either on a visitors visa, or with no visa and awaiting determination of their status

  13. Refugees in Australia • Permanent residents - Medicare but not channelled to screening routinely • Australian Government support after arrival - Settlement services: assist with initial housing, Centrelink etc - English language (520 hours) - Mental health assessment

  14. Prior to arrival • Minimal screening prior to arrival - General medical check • CXR as TB screen for those over 11 years • HIV testing for those over 15 years & unaccompanied minors • Hep B screening only on unaccompanied minors or pregnant women • Syphilis screening for those over 15 years, living in refugee camp • Urinalysis for those over 5 years • No previous requirement for immunisation • Changes in 2007: - MMR immunisation for those under 30 years - Malaria screening and treatment as required - Albendazole anti-helminthic treatment

  15. Growth & Development issues Under-immunisation Vitamin D deficiency Iron deficiency, Anaemia Poor dental health Infectious diseases - Tuberculosis - Schistosomiasis - Malaria - Hepatitis B - Intestinal parasites Undetected chronic disease Hemoglobinopathies - Sickle Cell, Thalassemia Psychological disorders - PTSD, anxiety, depression - detention, child soldiers, sex slaves Physical consequences of war, torture - shrapnel injures - limb deformities - musculoskeletal pain - hearing loss Health problems

  16. Burundian Family 37 44 20 19 18 15 13 10 8 5 2 Vitamin D insufficient in all 11, 3 with borderline hypocalcaemia Newborn was at risk of Vit D deficiency at birth Microcytic anaemia – 1 Low ferritin - 1 Hep B Acute Infection – 3 Hep B Previous Infection – 4 Hep B Not Immune – 2 Strongyloides infection – 2 Schistosomiasis infection – 5

  17. What is available in NSW? • Health care for newly arrived refugees is provided predominantly by GPs • Refugee Health Clinics - NSW Refugee Health Service: GP clinics, family focused, community based - HARK, Children’s Hospital at Westmead: tertiary based, child focused - Hunter Clinic, Newcastle: Family focused, multi-discipl., community based - GP clinics in Coffs Harbour and Wagga Wagga - SESIH GP Hospital Collaborative Care mode: Refugee Child Health Clinic

  18. Refugee Children in NSW Survey in 2005: 21% Refugee Children in NSW are being screened Raman et al. Australian and NZ Journal of Public Health,2009

  19. Recommendations • RACP Policy Statement 2007: - Comprehensive health assessments for every refugee - Provision of publicly funded health care to all refugees which is of high quality, accessible, culturally respectful & affordable • Australian Society for Infectious Diseases / ASID Guidelines 2008: - Screening and management guidelines of Infectious Diseases for newly arrived refugees

  20. Illawarra area2007…. Collaborative Care Model • Innovative model of care • GP-Hospital Collaborative Care Model • Provide screening program to capture all new arrivals • Community based - refugee friendly GP’s as centre of care • Partnerships: settlement services, primary & tertiary health care services • Developed by Sydney Children’s Hospital (SCH) The Wollongong Hospital (TWH) Multicultural Health Service (MHS)

  21. Methods GP-Hospital Collaborative Care Model for refugee children and their families Child/Family Settlement Services • Conduct routine comprehensive health assessment on arrival as per guidelines provided by Wollongong Hospital & Sydney Children’s Hospital • Refer to Refugee Child Health Clinic and/or Adult services as required • Provide ongoing family-centered care Linked GPs • Liaise with GPs • Provide tertiary referral service • Maintain database/track health status • Proactive in follow-up and support through Refugee Health Nurse Sydney Children’s Hospital Refugee Child Health Clinic • Wollongong Hospital • Chest Clinic • Multicultural Health Service

  22. FBC + Ferritin EUC, LFT Vit-D, Ca, P04 Malaria T/T, Ag HepBsAg, cAb, sAb HepCAb Quantiferon gold* Chest clinic: CXR, Mantoux Urine M/C/S HIV (pre & post discussion) Measles Rubella* Varicella Schistosomiasis Strongyloides Syphilis Gonorrhoea, Chlamydia PCR & ßHCG Females >15 years Screening tests SESIH guidelines All recommended by ASID except* Cost: $323.51

  23. What has happenedafter 18 months… For the period March 2007 – August 2008 • 100% of 81 children arriving on Visa 200 & 204 wereseen by GPs • 100% had recommended screening blood tests • 28% were referred to the Sydney Children’s Hospital Refugee Health Clinic and / or Private Paediatricians • 5% were hospitalised

  24. Results Conditions detected • 100% under-immunised • 37% low Vitamin D (25-OH-Vit D<50nmol/L) • 25% Schistosomiasis • 11% anaemic • 8% latent Tuberculosis • 7% active Hepatis B infection (and 56% non-immune) • 6% Strongyloides • 5% Malaria • 10% Entamoeba & other parasites • Mean number of health problems per child = 3 • Range of health problems per child = 0–7

  25. Progress... • Further evaluation over time (a larger cohort) was needed to allow analysis of differences in disease burden between groups within the cohort. • Can this Model work elsewhere or for larger populations?

  26. After 30 months… • Information on refugees settling in SESIAHS on class 200 and 204 (refugee) visas provided by the Department of Immigration &Citizenship • Settlement services link families with designated GPs: - 138 (100%) screened - 12 children of refugee background on sponsored visas also screened • Of 150 children screened in the first 30 months (to September 2009): - 85 of African origin - 59 of South East Asian origin - 5 of Middle Eastern origin

  27. Health problems detected High rates of treatable and largely asymptomatic conditions in a complete cohort of newly arrived refugee children reinforces the need for a universal national screening program in Australia.

  28. Can we improve ? • Screening of mental and developmental health? • What about long term? • A longitudinal study of refugee children has commenced to assess the long term physical and mental health, as well as the developmental progress.

  29. Assessment of the health and well being of refugee children on arrival and at 6 - 12 months of their settlement J Paprckova1,2, K Zwi1,2, K Williams1,2, L Woodland3, J Lane3,4 1 Department of Community Child Health, Sydney Children’s Hospital 2 School of Women & Children's Health, University of New South Wales 3 Multicultural Health Service, SE Sydney and Illawarra Area Health 4 University of Wollongong

  30. Significance • Existing research suggests that, while many refugee children display remarkable resilience and adaptability, mental health problems are often persistent, especially PTSD. • Little is known, about the contribution that physical ill health make to the psychological outcomes in this population. • The assessment at 6-12 months and broadens the comprehensiveness of the evaluation to include standardised development and mental health measures.

  31. Significance • Extends the follow-up period to 1 year, as opposed to the initial screening only. • This will provide a more complete view of the child’s health status and better understanding of the holistic health needs of refugee children. • Study will add valuable information to the existing evidence base in this group of children. • Opportunity to identify any requirements to develop appropriate services especially, in the mental health area.

  32. Objectives • Describe the health status of refugee children on arrival to Australia and assess their physical health, psychological well-being and development at 6 to12 months after their arrival. • Document their existing health conditions, evaluate their health care requirements and access to the services in our area. • Explore which pre- and post- arrival factors contribute to favourable health outcomes. • Address the health needs identified with recommendations for development of appropriate services, and further enhancement of existing programs.

  33. Study population • Approximately 60 children (0-16 years) • Arriving in Australia from June 2009 • Settling within the catchment area of SESIH • Recruited through the existing SESIH Refugee Health Program

  34. Methods • Prospectively following a cohort of newly arrived refugee children for 12 months. • Describing health status, development and psychological wellbeing of refugee children on arrival and at 6 -12 months after the arrival. • Prevalence of identified conditions will be compared with Australian prevalence data and with the evidence reported in the international literature.

  35. Methods • Explore factors contributing to the physical health & psychological well-being outcomes, analyse this data, and describe any particular patterns that emerge. • Potentially modifiable factors will be identified from those factors found to contribute to physical and / or psychological health outcomes. • Use this information to develop recommendations to improve refugee health services in the area.

  36. Physical health Pre arrival health assessments • Health Manifests via DIAC • Past Medical History

  37. Physical health Baseline assessment on recruitment • Performed by GP • Entered onto a database as per current routine screening program • Pathology screening as described earlier • Other investigations & routine physical examinations undertaken by GPs, Paediatricians and / or other specialists

  38. Physical health Reassessment at 6-12 months • Weight • Height • Head circumference • Calculated BMI • Mid arm muscle circumference • Blood pressure

  39. Psychological wellbeing Strengths & Difficulties Questionnaire (SDQ): • Emotional & behavioural problems • Children and young people (4-16 years) • Administered by Refugee Health Nurse

  40. Development Australian Developmental Screening test (ADST): • Children 0-5 years of age • Administered by Refugee Health Nurse and Registrar • 5 domains of development - Personal & Social - Language - Cognitive - Fine Motor - Gross Motor

  41. Pre-arrival factors Comprehensive range of socio-demographic information • Name, DOB, gender, language • Country of birth, country of origin (parent/guardian’s country of birth) • Transit countries, time in refugee camps and/or detention centres • Family composition, Family history of health conditions • Information obtained from - Health Manifests - General Practitioners - Refugee Health Nurse

  42. Post - arrival factors Semi-structured interview (SSI): • Interview with parents at 6 - 12 months • Administered by Refugee Health Nurse • Access to health services • Socioeconomic resources • Community support • Exposure to racism / discrimination

  43. Post - arrival factors Social Readjustment Rating Scale (SRRS): • Parent report at 6 - 12 months • Administered by Refugee Health Nurse • Life events experienced over the preceding 12 month period • Changes in family composition • Employment of parent/s • Stability of residence and school placements

  44. Screening tools • Instrument we chose are readily available to mainstream clinicians • No specific training required • Recommendations that we will develop can be used in practice

  45. Limitations • Although the instruments for assessment of development and psychological wellbeing of children are internationally accepted, they haven’t been used in this population before. • Completing these questionnaires through the interpreter affects might affect the understanding and accuracy of the answers. • We have organised a specific training for the health interpreters that we are collaborating with during these assessments.

  46. Limitations • Cultural, differences and stigmatism may have an effect on admitting and acknowledging any mental health problems. • Refugee families are likely to be a challenging group to follow up as they are known to be a population with high mobility.

  47. Anticipated outcomes • A significant proportion of physical health problems resolve over the initial settlement period • Psychological health problems can be documented 6-12 months post arrival. • 25 children enrolled in the study so far • Analysis aspect will be presented later

  48. Multicultural Health Unit The Financial Markets Foundation for Children SCH Foundation GESCHN SCH Management Group: Jonny Taitz, Virginia Binns, Les White SCH Departments - Infectious Diseases, Cardiology, Gastroenterology, Endocrine, Haematology, Genetics; Pharmacy TWH: Craig Boutlis, Allan James Wollongong Community Paediatricians Allied Health Teams Wollongong Chest Clinic, Wollongong & SCH Immunisation Clinic SCH SEALS: Roger Wilson Public Health Unit SESIH GP Division: Linda Blackmore DIMIA Case Management Team Acknowledgements

  49. Remember, every encounter with a refugee is an opportunity to heal the past and bring hope or the future…

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