Refugee Health Changes and Challenges Dr Anthea Rhodes

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)

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 12-18 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.

Impact of Housten report

Understanding the journey… Afghanistan

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

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

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

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

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 (1996-2007) 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

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

547 0-5 year olds settled regionally in past decade 547 0-5 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

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

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%)

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

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

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

Understanding the problems…

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)

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 Synthesis of 17 Australian studies/reports All jurisdictions except Qld, NT 7000 people + 7000 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)

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

Don’t miss rickets…

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

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

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

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

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

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

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

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

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

Making a difference…

MCHN – well placed to make a difference Potentially very significant role in aiding acculturation process

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

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

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

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

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

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

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

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

Pulling it all together…

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

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

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