refugee health changes and challenges dr anthea rhodes
TRANSCRIPT
Refugee Health Changes and Challenges
Dr Anthea Rhodes
Objectives
Paediatric Refugee Health• Understanding the journey• Understanding the problems• Making a difference, role of MCHN
Context• Refugee Status Report (DEECD)
Paxton et al, July 2011
• Census 2011
• Accessing MCH services: Reflections from refugee familiesRiggs et al, May 2012
• Report of expert panel on asylum seekersHouston et al, August 2012
Understanding the journey…
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?
VISASREFUGEE/ HUMANITARIAN ENTRANTREFUGEE/ HUMANITARIAN ENTRANT
ON SHOREON SHORE OFF SHOREOFF SHORE
ASYLUM SEEKERS
AIR ARRIVALSIRREGULAR MARITIME
ARRIVALS
BRIDGING VISA EPROTECTION VISA 866
BRIDGING VISA EPROTECTION VISA 866
REFUGEE
HUMANITARIAN ENTRANT
REFUGEE VISA (200)SPECIAL HUMANITARIAN
PROGRAM (201, 202)EMERGENCY RESCUE
(203)WOMEN AT RISK (204)
REFUGEE VISA (200)SPECIAL HUMANITARIAN
PROGRAM (201, 202)EMERGENCY RESCUE
(203)WOMEN AT RISK (204)
ORPHAN RELATIVE
VISAONSHORE 837OFFSHORE 117
ORPHAN RELATIVE
VISAONSHORE 837OFFSHORE 117
Numbers settled- Australia
HOUSTON REPORT RECOMMENDATIONIncrease from 13,000 to 20,000 Family reunion places 4000 per year Possibly, within 5 years, to 27,000
HOUSTON REPORT RECOMMENDATIONIncrease 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 yearsLots of children, many parentless
Numbers- awaiting settlement
Current National estimatesDetention: 7000
Community detention: 1400IMA’s on BVE: 2300
Source country
Pre-departure process
Visa health assessment(Compulsory, 3–12 m prior to travel)
Hx/ExamCXR ≥ 11 yrs
HIVVDRL
FWTU ≥ 5 yrs
Visa health assessment(Compulsory, 3–12 m prior to travel)
Hx/ExamCXR ≥ 11 yrs
HIVVDRL
FWTU ≥ 5 yrs
DHC(Voluntary – 3 d prior to travel)
Exam, parasite checkRDT and Rx if positiveCXR and HIV if PHx TB
AlbendazoleMMR 9m – 54y+/- YF vaccine
Ax local conditions+/- repeat visa medical
DHC(Voluntary – 3 d prior to travel)
Exam, parasite checkRDT and Rx if positiveCXR and HIV if PHx TB
AlbendazoleMMR 9m – 54y+/- YF vaccine
Ax local conditions+/- repeat visa medical
OutcomesFitness to fly assessment
Health manifestAlert (Red, general)
+/- HU
OutcomesFitness to fly assessment
Health manifestAlert (Red, general)
+/- HU
Character requirement
Character requirement
AustraliaPost arrival health screening
voluntary
AustraliaPost arrival health screening
voluntary
AUSCOAUSCO
Outcomes+/- Visa
HU +/- delay travel
Outcomes+/- Visa
HU +/- delay travel
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
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)
AnaemiaIron deficiencyLow Vitamin DLow Vitamin AHepatitis BHepatitis CHIVSchistosomaStrongyloidesMalariaFaecal parasites Mantoux test +H. pylori
9 – 30% all groups13 – 34% all groups60 - 90% African, 33 - 37% Karen40% AfricansAg 2 – 16%, sAb 26 – 60%1%<1%2 – 39% 1 – 21%5 – 10% African, (still get cases)16 – 40% all groups18 – 63%82% African
Clinical red flags
Prolonged cough, fever, night sweats, poor growth
Heavy metal toxicityHeavy metal toxicity
Gastrointestinal infections
Gastrointestinal infections
AnaemiaAnaemia
Vit D deficiencyVit D deficiency
TB (active vs latent)TB (active vs latent)
Rickets, bone pain, muscle pain, late teethlate fontanelle closure (low dairy)
Irritability, lethargy, developmental delay (high dairy)
Diarrhoea, abdominal pain, epigastric pain, vomiting, poor appetite, poor growth
Traditional medicines, developmental delay, gastrointestinal upset
Mental Health ConcernsMental Health ConcernsBehavioural 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• 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
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 12mBF 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
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
Unique health care deliveryCulturally responsive practice• Practitioner level• Interpreters, cultural awareness• Knowledge of potential problems
• Service level• Enhanced versus universal
• Policy level• funding
Culture is an iceberg….
Gary R. Weaver (1986)Culture Communications and Conflict
External
Internal
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
Culturally responsive practiceParenting practices• Parenting styles and expectations• Attachment• Collectivist• Individualist
• Breastfeeding rates• Bed sharing• Confinement
MCH services and refugee clients
Riggs et al, 2011
BARRIERS•referral process•transport•phone booking service•unfamiliar with preventative health model
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
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…
Resourceswww.immi.gov.auwww.rch.org.au/immigranthealth/www.refugeehealthnetwork.org.auwww.foundationhouse.org.auwww.vtpu.org.au