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