1. Refugee Health Changes and Challenges Dr Anthea Rhodes

2. Objectives Paediatric Refugee Health Understanding the journey
Understanding the problems
Making a difference, role of MCHN
Capture the essence of refugee health and its place within MCH services in next 30 minutes
2 key objectives: To convey
Understanding of the journey: visa categories (include asylum seekers), country of origin, settlement numbers, pre and post arrival screening
Understanding of the (health) problems: (ID, including immunisation, nutrition, learning dev behav, greater psychosocial)
How to make a difference: the role of MCHN: culturally repsonsive practice (practitioner, services, policy)

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
A number of key reports/publications over past months which have highlighted the importance and needs of children from refugee background. Houston report: increasing intake, Census: multicultural Victoria (49% >=one parent born OS, 31% born OS, 25% LOTE at home) Issue at the fore. Grateful for the opportunity to share changes and challenges in this field with such a large and valuable audience.

4. Impact of Housten report

5. Understanding the journey…
Afghanistan

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?
Not only ‘refugees’ specifically which has this similar collection of health care issues. Also other migrants and children born here to refugee/migrant parents. Much broader term “CALD” probably more useful in application in your practice, service delivery etc

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
BVE: in community, 400 per month at current rates, 6/52 accom, 89% centrelink equiv, medicare, can work
Orphan relative VISA: This visa is for children under 18 years of age whose parents are unable to care for them. It allows the child to travel to and live in Australia with an Australian relative.
REFUGEE VISA (200)
SPECIAL HUMANITARIAN PROGRAM (201, 202)
EMERGENCY RESCUE (203)
WOMEN AT RISK (204)
BRIDGING VISA E
PROTECTION VISA 866

8. Asylum seekers
In community (plane)
In detention
In community detention
In community post detention
Permanent residents – 866
New category – BVE 1a-met – basically families from community detention, favourable path – different medicare entitlements to single men – big numbers – 1400 nationally, 800 to Vic in next months

9. Numbers settled- Australia
Boat arrivals
Total numbers
Current refusal rates
Current community detention issues
HOUSTEN:The recommended policy ‘carrot’ is to increase Australia’s annual humanitarian intake from 13,000 to
20,000 (and possibly, within 5 years, to 27,000) to give asylum seekers in Malaysia and Indonesia
confidence that they have a real chance of being resettled in Australia within a reasonable period
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
Figures from status report ( )
UHM wards (previously called unattached minors) – no parent or relative aged > 21 to care for them
Increase to 6600 anticipated in Vic, with further 1300 family reunion => impact on service provision, as less supported

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

12. 547 0-5 year olds settled regionally in past decade
year olds settled regionally in past decade. Top 6 regions for age 0-5 years permanent arrivals (fairly consistent over past 1 through 10 years): Shep, Geelong, Mildura, Bendigo, Latrobe, Ballarat, Then, Wodonga, Swan Hill, Moira

13. Top 8 LGA with 0-5 yr permanent arrivals metro melbourne past 10 years: Dandenong (just under 1000 in past decade), Hume, Brimbank, Casey, Wyndham, Maribyrnong, Maroondah, Whittlesea

14. Source country
Offshore areas of origin – decrease proportion African source countries, prior to 2006 – 80%
and increase Asia and Middle east
IMA shown
Victoria - top 5 Iran, Iraq, Burma, Sri Lanka, Afghanistan (>80%)

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
All people > 1 yr old who have stayed 1 night+ in YF country within 6 days of flight to australia need YF certificate
Uptake PDMS – 2007 – 80% nationally, 50% Victoria, higher in refugee compared to SHP
This process has been recently simplified
The Australian Cultural Orientation (AUSCO) program is provided to refugee and humanitarian visa holders over the age of five who are preparing to settle in Australia. The program provides practical advice and the opportunity to ask questions about travel to and life in Australia. It is delivered over five days before the visa holders begin their journey to ensure that all topics are covered in sufficient detail.
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

17. One of the first examples of service mapping
AMES worker
Refugee Health Nurse GP
MCHN

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 % African, % 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
Synthesis of 17 Australian studies/reports
All jurisdictions except Qld, NT
7000 people detainees
4000 kids
Predominantly African data
Also mental health and educational issues more common
If these conditions left untreated
poorer immediate quality health (anaemia, low D, gut symptoms)
Long term effects
end stage organ failure (parasites/hepatitis)
cancers – hepatitis/helicobacter
conditions of public health significance (TB, blood borne viruses, vaccine preventable disease)

21. Clinical red flags Rickets, bone pain, muscle pain, late teeth
Vit D deficiency
Rickets, bone pain, muscle pain, late teeth
late fontanelle closure (low dairy)
TB (active vs latent)
Prolonged cough, fever, night sweats, poor growth
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 Anaemia
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

27. 6 – 7 minutes morning or afternoon tea summer, 7 – 40 minutes lunchtime

28. BF babies with risk factors 400 IU daily at least 12m
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
Family/community disruption
Migration/language transitions
Trauma
Education access, quality, continuity
Physical health/nutrition
Mental health/attachment
Undiagnosed developmental/physical disability
Antenatal infections
Perinatal complications
Settlement and family function

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
Potentially very significant role in aiding acculturation process

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
Multiple levels at which Culturally responsive practice can (and needs to) occur

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

37. Culture is pervasive. The effect on our consultation process cannot be underestimated

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
MCHN seen by some cultures as unnecessary…’doctors are for when you are sick’ No framework for understanding well child care or preventative health care

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
CLINICIAN
Child (Patient)
FAMILY SUPPORT NETWORK
Elicit clients explanatory health model. What is the model of their support network
Clinician communicates their model in plain english
Acknowledge and respect clients framework and discrepancies
Family support network very important in cultures with collective parenting
Look for common ground
Room for both

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