Refugee Health Changes and Challenges Dr Anthea Rhodes

1. Refugee Health Changes and ChallengesDr Anthea Rhodes

2. Objectives Paediatric Refugee Health • Understanding the journey • Understanding the problems • Making a difference, role of MCHN

3. Context • Refugee Status Report (DEECD) Paxton et al, July 2011 • Census 2011 • Accessing MCH services: Reflections from refugee families Riggs et al, May 2012 • Report of expert panel on asylum seekers Houston et al, August 2012

5. Understanding the journey…

6. Understanding the journey • Who are we talking about? • “Refugee” • Demographic statistics relate to this group • In reality think more broadly • Refugee-like • Immigrant • CALD • Where do they come from?

7. VISAS REFUGEE/ HUMANITARIAN ENTRANT ON SHORE OFF SHORE ORPHAN RELATIVE VISA ONSHORE 837 OFFSHORE 117 ASYLUM SEEKERS AIR ARRIVALS IRREGULAR MARITIME ARRIVALS REFUGEE HUMANITARIAN ENTRANT REFUGEE VISA (200) SPECIAL HUMANITARIAN PROGRAM (201, 202) EMERGENCY RESCUE (203) WOMEN AT RISK (204) BRIDGING VISA E PROTECTION VISA 866

9. Numbers settled- Australia HOUSTON REPORT RECOMMENDATION Increase from 13,000 to 20,000 Family reunion places 4000 per year Possibly, within 5 years, to 27,000

10. Numbers settled- Victoria • Around 4,000 Humanitarian entrants/year Victoria => planned increase to 6600 • 46.6% children/young people (0 – 19 years) • approx 250 Unaccompanied Humanitarian Minors in any year, big increase past 2 years • Lots of children, many parentless

11. Numbers- awaiting settlement Current National estimates Detention: 7000 Community detention: 1400 IMA’s on BVE: 2300

14. Source country

15. Pre-departure process DHC (Voluntary – 3 d prior to travel) Exam, parasite check RDT and Rx if positive CXR and HIV if PHx TB Albendazole MMR 9m – 54y +/- YF vaccine Ax local conditions +/- repeat visa medical Visa health assessment (Compulsory, 3–12 m prior to travel) Hx/Exam CXR ≥ 11 yrs HIV VDRL FWTU ≥ 5 yrs Character requirement AUSCO Outcomes +/- Visa HU +/- delay travel Outcomes Fitness to fly assessment Health manifest Alert (Red, general) +/- HU Australia Post arrival health screening voluntary

16. Post-arrival process • Varies depending on Visa type • Health, Education, Daily life, Housing • Health screening • No centralised process • Local GPs and RHN coordinate and undertake screening • Quality and uptake is variable

18. Understanding the problems…

19. Post-arrival screening tests • FBE • Ferritin • Vit A • Vit D, ALP (Ca, PTH) • HBV • HCV • Schistosoma serology • Strongyloides serology • Malaria • Faeces micro • TST (IGRA > 13 years) • STI screen/HIV • (No immunisation serology)

20. Prevalence (Australian data) Anaemia Iron deficiency Low Vitamin D Low Vitamin A Hepatitis B Hepatitis C HIV Schistosoma Strongyloides Malaria Faecal parasites Mantoux test + H. pylori 9 – 30% all groups 13 – 34% all groups 60 - 90% African, 33 - 37% Karen 40% African sAg 2 – 16%, sAb 26 – 60% 1% <1% 2 – 39% 1 – 21% 5 – 10% African, (still get cases) 16 – 40% all groups 18 – 63% 82% African

21. Clinical red flags Vit D deficiency Prolonged cough, fever, night sweats, poor growth Rickets, bone pain, muscle pain, late teeth late fontanelle closure (low dairy) TB (active vs latent) Anaemia Irritability, lethargy, developmental delay (high dairy) Gastrointestinal infections Diarrhoea, abdominal pain, epigastric pain, vomiting, poor appetite, poor growth Heavy metal toxicity Traditional medicines, developmental delay, gastrointestinal upset Mental Health Concerns Behavioural disturbance: sleep, eating, play, somatisation

22. Don’t miss rickets…

24. Key Points- Immunisation • Assume under immunised • Extra doses rarely result in complication • Tetanus, local reaction • Seek advice if need be • ACIR

25. Key Points- Nutrition • Post arrival dietary patterns • Consider access to food, cooking and food preparation skills • Evolving obesity epidemic • Anaemia • Consider pre arrival diet • Gastrointestinal pathology • Lead

26. Vitamin D- Risk groups • No or limited sun exposure • Naturally dark skin • Babies born to women with low vit D

28. Management • Targeted screening if risk factors • Urgent specialist assessment rickets • Low levels – replace to normal range • Balance season, risk, cost consider high dose • Advice sun exposure/protection • Adequate calcium BF babies with risk factors 400 IU daily at least 12m

29. Developmental assessment • Multiple risk factors developmental issues • Providers: not a priority in early settlement • No local prevalence data • Study from WA: Janet Geddes • No data Early Intervention service use • No data School Entry Health Questionnaire • Development still notably absent in refugee research

30. Janet Geddes MD thesis • Developmental screening complex • Suggests: • Using a tool that assesses child’s skills • Rather than parent report • Surveillance (as screening tools intend) • Parenting support

31. Development - kindergarten • No data kindergarten participation • Providers – often missed • Complexity kindergarten enrolment • Recommended, but less direct support at settlement stage • FKA referral criteria

32. Key points- development • Assessment is difficult & research is limited • Listen to parents- experienced with children • Focus on function • Establish links to early intervention: playgroup, kinder • Encourage first language • Explore & encourage culturally appropriate play • Regular review, reassessment

33. Making a difference…

34. MCHN – well placed to make a difference

35. Unique health care delivery Culturally responsive practice • Practitioner level • Interpreters, cultural awareness • Knowledge of potential problems • Service level • Enhanced versus universal • Policy level • funding

36. Culture is an iceberg…. Gary R. Weaver (1986)Culture Communications and Conflict External Internal

38. Culturally responsive practice • Barriers extend far beyond language • Culture and ethnicity impact on the way people understand health and wellbeing, and access health services • Understand explanatory models of illness • Recognise and respect diverse belief systems

39. Culturally responsive practice Parenting practices • Parenting styles and expectations • Attachment • Collectivist • Individualist • Breastfeeding rates • Bed sharing • Confinement

40. NEGOTIATING SHARED UNDERSTANDING Knowledge Values Beliefs Child (Patient) CLINICIAN FAMILY SUPPORT NETWORK

41. MCH services and refugee clients Riggs et al, 2011 • BARRIERS • referral process • transport • phone booking service • unfamiliar with preventative health model • FACILITATORS • Group appointments with bicultural playgroups • Home visits/ enhanced service • Continuity of nurse and interpreter

42. Practical tips for making a difference • Know and make use of the system • Know your refugee health service providers • Keep data on COB and preferred language • Work with interpreters • Consider timing of engagement • Service delivery models- think laterally

43. Pulling it all together…

44. Take Home Messages • Children of CALD background are growing in number • Pre and Post arrival screening is variable and inconsistent • Look for medical problems; they are common and often easily treated • Developmental and behavioural assessment is a challenging area • Engage in culturally sensitive practice and consider targeted service delivery models

45. Resilience "There are three cures for all human pain and all involve salt--the salt of tears, the salt of sweat from hard work, and the salt of the great open seas.” Mary Pipher, The Middle of Everywhere

46. Acknowledgements • Dr Georgia Paxton • Dr Joanne Gardiner • Dr Elisha Riggs • Dr Janet Geddes • Helen Milton • The children and families that keep us on our toes… Resources www.immi.gov.au www.rch.org.au/immigranthealth/ www.refugeehealthnetwork.org.au www.foundationhouse.org.au www.vtpu.org.au