Refugee Health Changes and Challenges Dr Anthea Rhodes

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Refugee Health Changes and ChallengesDr Anthea
Rhodes
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Objectives

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

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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

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Understanding the journey
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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?

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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
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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
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Numbers settled- Victoria

• Around 4,000 Humanitarian entrants/year Victoria
  gt 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

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Numbers- awaiting settlement

• Current National estimates
• Detention 7000
• Community detention 1400
• IMAs on BVE 2300

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Source country
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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, 312 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
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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

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Understanding the problems
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Post-arrival screening tests

• FBE
• Ferritin
• Vit A
• Vit D, ALP (Ca, PTH)
• HBV
• HCV
• Schistosoma serology
• Strongyloides serology
• Malaria
• Faeces micro
• TST (IGRA gt 13 years)
• STI screen/HIV
• (No immunisation serology)

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Prevalence (Australian data)

• 9 30 all groups
• 13 34 all groups
• 60 - 90 African, 33 - 37 Karen
• 40 African
• sAg 2 16, sAb 26 60
• 1
• lt1
• 2 39
• 1 21
• 5 10 African, (still get cases)
• 16 40 all groups
• 18 63
• 82 African

• Anaemia
• Iron deficiency
• Low Vitamin D
• Low Vitamin A
• Hepatitis B
• Hepatitis C
• HIV
• Schistosoma
• Strongyloides
• Malaria
• Faecal parasites
• Mantoux test
• H. pylori

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Clinical red flags
Vit D deficiency
Rickets, bone pain, muscle pain, late
teeth late fontanelle closure (low dairy)

• Prolonged cough, fever, night sweats, poor
  growth

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
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Dont miss rickets
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Key Points- Immunisation

• Assume under immunised
• Extra doses rarely result in complication
• Tetanus, local reaction
• Seek advice if need be
• ACIR

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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

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Vitamin D- Risk groups

• No or limited sun exposure
• Naturally dark skin
• Babies born to women with low vit D

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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
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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

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Janet Geddes MD thesis

• Developmental screening complex
• Suggests
• Using a tool that assesses childs skills
• Rather than parent report
• Surveillance (as screening tools intend)
• Parenting support

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Development - kindergarten

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

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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

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Making a difference
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MCHN well placed to make a difference
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Unique health care delivery

• Culturally responsive practice
• Practitioner level
• Interpreters, cultural awareness
• Knowledge of potential problems
• Service level
• Enhanced versus universal
• Policy level
• funding

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Culture is an iceberg.
External
Internal

• Gary R. Weaver (1986)Culture Communications and
  Conflict

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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

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Culturally responsive practice

• Parenting practices
• Parenting styles and expectations
• Attachment
• Collectivist
• Individualist
• Breastfeeding rates
• Bed sharing
• Confinement

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NEGOTIATING SHARED
UNDERSTANDING Knowledge Values Beliefs
CLINICIAN

• Child (Patient)

FAMILY SUPPORT NETWORK
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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

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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

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Pulling it all together
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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

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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

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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