Health service delivery for newly arrived refugee children: a framework for good practice

Hear Our Voice: Pediatric Communication Barriers From the Perspectives of Refugee Mothers With Limited English Proficiency

BACKGROUND

Adverse health outcomes are more common for health consumers with limited English proficiency (LEP). This study examines the consumer experience of refugee mothers with LEP when communicating with paediatric health services.

METHOD

A community-based participatory qualitative study engaging participants from refugee-like backgrounds. Focus groups and in-depth individual interviews (using professional interpreters) were conducted in community settings and analysed using Grounded Theory principles.

RESULTS

Fifty ethnolinguistically diverse participants reported universal communication barriers; (i) "Negative health care experiences" (fear, helplessness, lack of safety, trust and dignity), (ii) "Ineffective health service communication and adverse outcomes", (iii) "Logistical access barriers" and (iv) self-sourced solutions". The "importance of professional interpreter utilisation" and subsequent "sense of empowerment" was unanimous.

CONCLUSIONS

This study highlights gaps in current health interactions which negatively impact care, inclusion, and culturally safe engagement. Recommendations include orgainzational reform enhancing language services, increased cultural competency, long term support, and research with LEP populations.

Health literacy and cultural responsiveness of primary health care systems and services in Australia: reflections from service providers, stakeholders, and people from refugee backgrounds

BACKGROUND

Primary health care [PHC] services with general practitioners (GPs) as the first point of access to health care services for people from refugee backgrounds in Australia can play a crucial role in building health literacy and promoting access to culturally appropriate services. To achieve equitable access and engagement, services and systems must be responsive to diverse health literacy and cultural needs. This study aims to explore how primary health services respond as a system and organisation to the health literacy and cultural needs of people from refugee backgrounds in Australia.

METHODS

This exploratory qualitative study involved 52 semi-structured interviews among 19 Africans from refugee backgrounds, 14 service providers, including GPs and nurses, and 19 other stakeholders, such as service managers/directors. Participants resided in New South Wales, Victoria, and Queensland. Interviews were audio-recorded, transcribed, and coded into QSR NVivo 12. Data analysis was guided by reflexive thematic analysis.

FINDINGS

Three interrelated themes were identified from the data relating to the health literacy and cultural responsiveness of PHC systems and services. The first theme, 'variable and ad hoc organisational response to health literacy and culturally responsive care,' demonstrated that some organisations did not systematically address the inherent complexity of navigating the health system nor the capacity of services and providers to respond to the cultural needs of people from refugee backgrounds. The second theme, 'individual provider responsibility,' captured the individual providers' interpersonal and relational efforts in supporting the health literacy and cultural needs of people from refugee backgrounds based on their motivation and adaptation. The third theme, 'refugee patient responsibility,' encapsulated people from refugee backgrounds' adaptations to and learning of the health system to navigate and access services.

CONCLUSION

Health literacy and culturally responsive practices need to be systematised by PHC organisations to be implemented and sustained over time. There is a need for diversity in the organisational leadership and health care workforce, organisational commitment, health literacy and culturally responsive care policies, provider training, and auditing practice as essential components of the change process. Engaging with refugee communities would allow services to focus on people from refugee backgrounds' needs by design.

Measuring the Optimal Time Interval Between Arrival and First Mental Health Evaluation's for Refugees in Québec: A Scoping Review

To map the state of the existing literature to identify the optimal time frame between the arrival of refugees in a host country and psychosocial assessments. We conducted scoping review using the method of Arksey and O'Malley (2005). A systematic search of 5 databases including PubMed, Psycinfo (OVID), PsycINFO BD APA, Scopus and Web of Sciences) and grey literature identified 2698 references. Thirteen studies published between 2010 and 2021 were considered eligible. A data extraction grid was designed and tested by the research team. It is not so ease to identify the most appropriate time interval to assess the mental health of newly settled refugees. All the studies selected agree on the need to carry out an initial assessment when refugees arrive in their host country. Several authors agree on the need to carry out screening at least twice during the resettlement period. However, what is less clear is the best time to perform the second screening. This scoping review mainly helped in highlighting the lack of probing data on the mental health indicators focused on during the assessment and on the optimal timeline for the assessment of refugees. Further research is needed to determine whether developmental and psychological screening is beneficial, the right time to perform the screening, and the most appropriate collection instruments and interventions.

Fluctuating power: an exploration of refugee health nursing within the resettlement context in Victoria, Australia

Background

The Refugee Health Program (RHP) is a nurse-led community initiative, introduced in 2005 with the aim of responding to complex health issues of refugees arriving in Victoria, Australia. Little is known about refugee health nursing in the resettlement context and the impact of dedicated refugee healthcare.

Aim

To explore the experiences and perspectives of Refugee Health Nurses (RHNs), Refugee Health Managers (managers) and refugees, gaining insight into professional relationships and the complexities of offering a specialised refugee health service.

Method

A focused ethnographic approach incorporated semi-structured interviews with five RHNs, two managers and eight refugees, two focus groups with refugees and participant observation within the RHP during April 2017 to December 2017. Data collection was undertaken across two sites and interviews, focus groups and observations were transcribed and thematically analysed. Social constructionism asserts that the focus of enquiry should be on interaction, group processes and social practices. Emphasis is placed upon relationships between RHNs, managers and refugees, with knowledge viewed as relational and interactional.

Results

Professional relationships between RHNs and refugees are complex, with power oscillating between them. Contrary to discourses of ‘vulnerability’ of refugees, both RHNs and refugees demonstrated power in their relationships with each other. Nurses also suggested that these relationships were stressful and could lead to burnout. Key themes were developed: (1) nursing autonomy and gatekeeping; (2) vicarious trauma and burnout; and (3) refugee negotiation of care.

Conclusions

The balance of power is central to therapeutic relationships. In relationships between RHNs and refugees, power fluctuates as RHNs are exposed to vicarious trauma and symptoms of burnout, while refugees exercise agency by recognising benefits to specialised care. In developing effective therapeutic relationships between RHNs and refugees, attention should be paid to how care is delivered to protect RHNs from burnout while ensuring that refugees receive appropriate care.

Description and evaluation of a pathway for unaccompanied asylum-seeking children

OBJECTIVE

(1) To describe a novel integrated pathway for unaccompanied asylum-seeking children (UASC).(2) To evaluate a population engaged with this service.

DESIGN

Description of the integrated pathway (objective 1) and retrospective evaluation, using data from community paediatrics, infectious diseases (IDs) screening and a sexual health (SH) service (objective 2).

SETTING

Unlinked data were collected from three services across three National Health Service (NHS) trusts in London.

PATIENTS

All Camden UASC engaged with the service from 01 January 2016 to 30 March 2019.

INTERVENTIONS

A multidisciplinary approach prioritising the health needs of UASC including a childre and adolescent mental health service (CAMHS) clinican and a health improvement practitioner. There are low thresholds for onward referral and universal asymptomatic screening of UASC for ID.

MAIN OUTCOME MEASURES

Data on demographics, unmet health needs and known outcomes.

RESULTS

Data were available for 101 UASC, 16% female, median age 16 years (range 14-17). Physical assault/abuse was reported in 67% and 13% disclosed sexual assault/abuse, including 38% of female UASC. Mental health symptoms were documented in 77%. IDs warranting treatment were identified in 41% including latent tuberculosis (25%) and schistosomiasis (13%). Interpreters were required for 97% and initial non-attendance rates at follow-up were 40% (ID) and 49% (SH).

CONCLUSIONS

These data demonstrate high rates of historical physical and sexual assault/abuse, unmet physical, mental and emotional health needs among UASC and significant barriers to engaging with services. An integrated pathway has been successfully implemented and shown to deliver appropriate, joined-up care for UASC, consistent with current recommendations, with the potential to improve outcomes.

Facilitators and barriers to implementation of integrated community case management of childhood illness: a qualitative case study of Kapiri Mposhi District

Background

Zambia adopted the Integrated Community Case Management (ICCM) of childhood illness strategy in May 2010, targeting populations in rural communities and hard-to-reach areas. However, evidence suggests that ICCM implementation in local health systems has been suboptimal. This study sought to explore facilitators and barriers to implementation of ICCM in the health system in Kapiri Mposhi District, Zambia.

Methods

Data were gathered through 19 key informant interviews with district health managers, ICCM supervisors, health facility managers, and district health co-operating partners. The study was conducted in Kapiri Mposhi district, Zambia. Interviews were translated and transcribed verbatim. Data were were analyzed using thematic analysis in NVivo 11(QSR International).

Results

Facilitators to implementation of ICCM consisted of community involvement and support for the program, active community case detection and timeliness of health services, the program was not considered a significant shift from other community-based health interventions, district leadership and ownership of the program, availability of national and district-level policies supporting ICCM and engagement of district co-operating partners. Program incompatibility with some socio-cultural and religious cotexts, stock-out of prerequisite drugs and supplies, staff reshuffle and redeployment, inadequate supervision of health facilities, and nonpayment of community health worker incentives inhibited implementation of ICCM.

Conclusion

The study findings highlight key faciliators and barriers that should be considered by policy-makers, district health managers, ICCM supervisors, health facility managers, and co-operating partners, in designing context-specific strategies, to ensure successful implementation of ICCM in local health systems.

Variation in initial health assessment of unaccompanied asylum-seeking children: a cross-sectional survey across England

OBJECTIVE

To assess variation in current practice of initial health assessments (IHAs) for unaccompanied asylum-seeking children (UASC) across England.

DESIGN

Cross-sectional survey.

MAIN OUTCOMES MEASURES

Type of routine assessment carried out, threshold to specialist referrals and facilities available to complete IHA.

RESULTS

Eighty-six health professionals responded across England; 47% had received training in UASC IHA and 33% in UASC mental health issues. The majority (80%) of IHAs were conducted with translator support and 7% of participants reported Child and Adolescent Mental Health Services (CAMHS) input. Around half of clinicians (53%) performed tuberculosis and bloodborne virus screening for all UASC, while other infectious diseases (IDs) screening was symptom and risk factor dependent. Overall, 14% of clinicians routinely comment on age assessment and 76% share the IHA report and health plan with UASC. The time allocated for assessment range between 30 and 90 min.

CONCLUSION

There is significant variation in practice around UASC IHAs across England, notably around CAMHS input, time allocated, translation facilities and ID screening. The results suggest that, an increase in resources available for UASC teams, improved access to specialist services and further training on UASC health are all needed. Guidance that aims to set a best practice framework for UASC IHA delivery such as a 'one-stop shop' model would help to standardise UASC IHA across the country.

Improving primary health care quality for refugees and asylum seekers: A systematic review of interventional approaches

Background

It has been widely acknowledged that refugees are at risk of poorer health outcomes, spanning mental health and general well‐being. A common point of access to health care for the migrant population is via the primary health care network in the country of resettlement. This review aims to synthesize the evidence of primary health care interventions to improve the quality of health care provided to refugees and asylum seekers.

Methods

A systematic review was undertaken, and 55 articles were included in the final review. The Preferred Reporting Items for Systematic Reviews was used to guide the reporting of the review, and articles were managed using a reference‐management software (Covidence). The findings were analysed using a narrative empirical synthesis. A quality assessment was conducted for all the studies included.

Results

The interventions within the broad primary care setting could be organized into four categories, that is, those that focused on developing the skills of individual refugees/asylum seekers and their families; skills of primary health care workers; system and/or service integration models and structures; and lastly, interventions enhancing communication services. Promoting effective health care delivery for refugees, asylum seekers and their families is a complex challenge faced by primary care professionals, the patients themselves and the communication between them.

Conclusion

This review highlights the innovative interventions in primary care promoting refugee health. Primary care interventions mostly focused on upskilling doctors, with a paucity of research exploring the involvement of other health care members. Further research can explore the involvement of interprofessional team members in providing effective refugee/migrant health.

Patient or Public Contribution

Patient and public involvement was explored in terms of interventions designed to improve health care delivery for the humanitarian migrant population, that is, specifically refugees and asylum seekers.

Health needs of accompanied refugee and asylum-seeking children in a UK specialist clinic

AIM

To identify health needs and healthcare access barriers of accompanied refugee and asylum-seeking (RAS) children in the North East of England, and pilot a new service model to address these.

METHODS

Mixed-methods study (retrospective analysis of routinely collected service data, qualitative data from focus groups) of children who attended a hospital-based specialist clinic.

RESULTS

Over two years, 80 children were referred to this service. Most frequent diagnoses (total n = 104) were anaemia (n = 17), neurodevelopmental (n = 12), respiratory (n = 12) and mental health (n = 9) conditions. Mild-moderate stunting (23%), overweight and obesity (41%), stunting with obesity (9%) and micronutrient deficiencies (vitamin D (66%), vitamin A (40%) and manifest (14%) or latent (25%) iron deficiency anaemia) were highly prevalent. 62% of children had experienced psychological trauma, and 39% had abnormal results in psychosocial wellbeing screening. 21% of children required secondary or tertiary care, 8% mental health referrals, and 47% were followed up in this specialist clinic. Focus groups with families and the community report unaddressed health needs and substantial barriers of access to health care.

CONCLUSION

Refugee and asylum-seeking children have substantial health needs and healthcare access barriers that are not routinely addressed. The authors propose a service model for healthcare provision.

Perceived quality of primary healthcare post-National Health Insurance pilot implementation

Background

Contracting private medical practitioners for the National Health Insurance pilot project in 2012 by the National Department of Health in South Africa was envisaged to reduce workload at referral district hospitals by reducing self-referral by clients as the perceived quality of care at the primary healthcare level improves.

Aim

To describe the effect of contracting private medical practitioners at primary healthcare facilities on the self-referral rate of clients at district hospitals as a proxy for perceived quality of care in a National Health Insurance pilot district.

Setting

The study was set in Tshwane National Health Insurance pilot district compared to Ekurhuleni district.

Methods

We compared findings before and after implementing the National Health Insurance private medical practitioners contracting between a pilot and a non-pilot district. A quasi-experimental ecological study design was used to compare district hospital outpatient department indicators of clients follow-up, self-referral, self-referral rate and referred in the two districts from June 2012 to May 2014 using single and controlled interrupted time-series analyses.

Results

Controlled interrupted time series analysis found decreases in self-referral rate (-1.8 [-2.2, -1.1] [p < 0.0001]) and the initial trend of headcounts of self-referral (-516 [-969, -66] [p = 0.0260]), but an increase in headcounts of referred clients (1293 [77, 2508] [p = 0.0376]) in the pilot compared with the non-pilot district.

Conclusion

We concluded that the implementation of contracting private medical practitioners in primary healthcare facilities might have resulted in an improved perceived quality of care at primary health care facilities. However, the higher number of outpatient department headcounts for follow-up and the increase in referred cases in the pilot district would need to be investigated.

Health outcomes in international migrant children: protocol for a systematic review

INTRODUCTION

Migration status is a key determinant of health, but health outcomes among migrant children and young people (CYP), that is, those aged under 18 years, are poorly understood. A 'healthy migrant' effect has been demonstrated among adults, but evidence for the same effect in CYP is lacking. No large studies or reviews exist reporting comprehensive or holistic health outcomes among migrant CYP. We aim to identify and synthesise original quantitative research on health of migrant CYP to explore the relations between migration status and health outcomes.

METHODS AND ANALYSIS

A search of PubMed/Medline, Embase, Cochrane and grey literature sites will be undertaken for any original quantitative research on health outcomes of migrant CYP from 01 January 2000 onwards. Outcomes addressed: mortality, communicable diseases, non-communicable diseases, nutritional status, mental health, disability, vaccine coverage, and accidental and non-accidental injuries (including assault and abuse). Search results will be screened and presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram.The Newcastle-Ottawa Scale assessment tool will be used to assess study quality. If feasible, depending on study availability data heterogeneity (explored using I² statistic), results will be pooled for meta-analysis. If sufficient data are available, a priori defined subgroup analyses will be undertaken. A narrative quantitative synthesis will be presented, taking account of study quality and assessed risk of bias.The anticipated search completion date is 01 June 2021 with write-up completed by 01 April 2022.

ETHICS AND DISSEMINATION

Formal ethical approval will not be sought as we will be accessing data already in the public domain. This review will be submitted for publication in a high-impact journal and presented at international conferences. The results of this work will be shared with groups of migrant children as part of an ongoing engagement project.

PROSPERO REGISTRATION NUMBER

CRD42020166305.

Exploring interprofessional teamwork at a tertiary public hospital in South Africa

The landscape of health in South Africa has changed dramatically with the unprecedented rise in the burden of disease. Public health care facilities struggle to provide quality, patient-centered care to patients with complex health needs. Interprofessional teamwork is strongly advocated to improve the quality and patient-centeredness of care. This study explored the barriers and facilitators of interprofessional teamwork amongst health professionals working at a tertiary level public hospital in South Africa. The study employed a qualitative, descriptive, exploratory design. Data were collected during three focus group discussions with 14 purposively selected participants from several health professions. Barriers such as high patient turnover, lack of human resources, time, hierarchy, referral process, lack of knowledge of the roles and scopes of practice, negative attitudes, communication inefficiencies, language barriers, and professional jealousy were found to impede interprofessional teamwork. Facilitators of interprofessional teamwork included increased human resources, communication technology, respect, and relationship building. Although health professionals understand the barriers and facilitators of interprofessional teams in the provision of patient care, this study concludes that interprofessional capacity building is needed for successful interprofessional teamwork at a tertiary level public hospital setting.

Tuberculosis infection in under-2-year-old refugees: Should we be screening? A systematic review and meta-regression analysis

AIM

Refugees are at increased risk of tuberculosis infection due to time spent in crowded camps, decreased nutrition and originating from countries whose own tuberculosis control systems may have been disturbed. In Australia, tuberculosis is screened for in for all refugees aged 11-34 years old and in those aged 2-10 years arriving from high-incidence countries. Our aims were to determine if refugee children aged under 2 years of age should also be screened.

METHODS

A systematic literature review and meta-regression was carried out on studies in refugee children under 18 years old, involving screening for tuberculosis (active or latent tuberculosis infection (LTBI)). Studies were extracted from the last 10 years from a range of bibliographic databases using the search terms 'tuberculosis', 'children', 'screening' and 'refugee', which tested for tuberculosis using the tuberculin skin test (TST) or QuantiFERON-Gold (Interferon Gamma Release Assay (IGRA)).

RESULTS

Of the 15 included studies, prevalence of LTBI in < 2-year-olds was 5% using IGRA and 15% using TST (P < 0.05). Prevalence increased with age (odds ratio 1.12; 95% confidence interval: 1.06-1.17) cumulatively and decreased where IGRA was used for screening compared to TST (odds ratio 0.38; 95% confidence interval: 0.25-0.58). Prevalence of LTBI did not differ between general versus clinic refugee cohorts.

CONCLUSIONS

Refugees are a particularly vulnerable group in their susceptibility to tuberculosis, and LTBI management is a critical part of tuberculosis disease control due to the lifetime risk of developing active tuberculosis. A prevalence of 5-15% for LTBI in the under 2 years age group would support them being included in screening programmes.

Infectious Diseases among Refugee Children

In recent years, there has been a substantial increase in refugee and asylum-seeking adults, adolescents and children to high-income countries. Infectious diseases remain the most frequently identified medical diagnosis among U.S.-bound refugee children. Medical screening and immunization are key strategies to reduce the risk of infectious diseases in refugee, internationally adopted, and immigrant children. Notable infectious diseases affecting refugee and other newly arriving migrants include latent or active tuberculosis, human immunodeficiency virus type 1 (HIV), hepatitis B, hepatitis C, vaccine-preventable diseases, malaria, and other parasitic infections. The U.S. Centers for Disease Control and Prevention and the American Academy of Pediatrics have published guidelines for health assessment of newly arriving immigrant, refugee, and internationally adopted children. Although, data on the health risks and needs of refugee exists in some high-income countries, there is an urgent need to develop robust evidence-informed guidance on screening for infectious diseases and vaccination strategies on a broader scale to inform national policies. Innovative approaches to reach migrant communities in the host nations, address health and other complex barriers to improve access to high-quality integrated health services, and strong advocacy to mobilize resources to improve health, safety, and wellbeing for refugee children and their families are urgent priorities.

Intersectoral and integrated approaches in achieving the right to health for refugees on resettlement: a scoping review

BACKGROUND

Better understanding, documentation and evaluation of different refugee health interventions and their means of health system integration and intersectoral collaboration are needed.

OBJECTIVES

Explore the barriers and facilitators to the integration of health services for refugees; the processes involved and the different stakeholders engaged in levaraging intersectoral approaches to protect refugees' right to health on resettlement.

DESIGN

Scoping review.

METHODS

A search of articles from 2000 onward was done in MEDLINE, Web of Science, Global Health and PsycINFO, Embase. Two frameworks were applied in our analysis, the 'framework for analysing integration of targeted health interventions in systems' and 'Health in All Policies' framework for country action. A comprehensive description of the methods is included in our published protocol.

RESULTS

6117 papers were identified, only 18 studies met the inclusion criteria. Facilitators in implementation included: training for providers, colocation of services, transportation services to enhance access, clear role definitions and appropriate budget allocation and financing. Barriers included: lack of a participatory approach, insufficient resources for providers, absence of financing, unclear roles and insufficient coordination of interprofessional teams; low availability and use of data, and turf wars across governance stakeholders. Successful strategies to address refugee health included: networks of service delivery combining existing public and private services; system navigators; host community engagement to reduce stigma; translation services; legislative support and alternative models of care for women and children.

CONCLUSION

Limited evidence was found overall. Further research on intersectoral approaches is needed. Key policy insights gained from barriers and facilitators reported in available studies include: improving coordination between existing programmes; supporting colocation of services; establishing formal system navigator roles that connect relevant programmes; establishing formal translation services to improve access and establishing training and resources for providers.

Practitioner Review: Mental health problems of refugee children and adolescents and their management

BACKGROUND

Since 2010, the numbers of refugees have increased and around half are under 18 years of age. It is known that experience of organised violence, displacement and resettlement increases the risk for psychiatric disorders and psychosocial impairment. This review integrates recent research into the risk and protective factors for psychopathology with service and treatment issues.

METHODS

We draw on and critically evaluate key systematic reviews in the selected areas, innovative robust studies and relevant government reports.

RESULTS

Many refugee children show resilience and function well, even in the face of substantial adversities. The most robust findings for psychopathology are that PTSD, and posttraumatic and depressive symptoms are found at higher prevalence in those who have been exposed to war experiences. Their severity may decrease over time with resettlement, but PTSD in the most exposed may show higher continuity. More severe psychiatric disorders including psychosis may also occur. Service delivery needs to take into account socioeconomic and cultural influences but, given the high level of unmet need even in high-income countries, stepped care delivery is required. The evaluation of psychological interventions, often delivered in group settings, suggests that they can be effective for many distressed children; however, for the more impaired, a greater range of disorder-specific therapies will be required.

CONCLUSIONS

Child and adolescent mental health clinicians and service providers need to be aware of the specific needs of this population and systems for service delivery. There are significant knowledge gaps in understanding risk and vulnerability, service delivery and treatment effectiveness.

Health examinations of child migrants in Europe: screening or assessment of healthcare needs?

BACKGROUND

More than 800 000 asylum-seeking children were registered in Europe during 2015-2017. Many of them arrived with accumulated needs of healthcare. In this study, we examined the legislation for health examinations on arrival for migrant children in the EU/EAA area.

METHODS

We did a survey to child health professionals within the EU-funded MOCHA project, supplemented by desktop research of official documents.

RESULTS

In all but three surveyed countries in the EU/EEA, there were systematic health examinations of newly settled migrant children. In most eastern European countries and Germany, this health examination was mandatory; while in the rest of western and northern Europe it was mostly voluntary. All countries that had a mandatory policy of health examinations screened for communicable diseases to protect the host population. Almost all countries with a voluntary policy also aimed to assess a child's individual healthcare needs, but this was rarely the case in countries with a mandatory policy.

CONCLUSION

Systematic health examinations of migrant children are routinely performed in most countries in the EU/EEA; but in many countries, it could be improved considerably by extending the focus from screening for communicable diseases to assessing and addressing individual needs of healthcare.

Identification of health risk behaviours among adolescent refugees resettling in Western Australia

OBJECTIVE

Adolescent refugees encounter traumatic stressors and are at risk of developing psychosocial health problems; limited research data exist internationally. This study aims to identify health risk behaviours among adolescent refugees resettling in Western Australia and assess the feasibility of using a standardised adolescent health questionnaire for this purpose.

DESIGN

Refugees aged 12 years and above attending a tertiary Refugee Health Service (RHS) were recruited over 12 months. Sociodemographic data were collected. Psychosocial assessments based on the 'Home, Education/Eating, Activities, Drugs, Sexuality, Suicide/mental health' (HEADSS) framework were undertaken utilising interpreters where required. Health concerns identified were managed through the RHS.

RESULTS

A total of 122 adolescents (20 ethnicities) participated; 65% required interpreters. Median age (range) was 14 (12-17) years. Most (80%) had nuclear family separation. Almost half (49%) had a deceased/missing family member. A third (37%) had lived in refugee camps and 20% had experienced closed detention. The median time (range) since arrival in Australia was 11 (2-86) months. Every adolescent had at least one health concern identified during the psychosocial assessment. Frequency of health concerns identified in each domain were 87% for home, 66% for education, 23% for eating, 93% for activities, 5% for drugs, 88% for sexuality and 61% for suicide/mental health. Most adolescents (75%) required intervention, consisting of counselling for health risk behaviours and/or referral to health or community services.

CONCLUSION

It is feasible to use a standardised adolescent health questionnaire to identify health risk behaviours among a cohort of ethnically diverse adolescent refugees. Use of the questionnaire identified a large burden of psychosocial health issues requiring multidisciplinary intervention.

Immunisation for refugees in Australia: a policy review and analysis across all States and Territories

OBJECTIVE

Although people of refugee background are likely to be under-immunised before and after resettlement, no study to date has evaluated refugee specific immunisation policies in Australia. We developed a framework to analyse immunisation policies across Australia to highlight the strengths and gaps so as to inform development of more effective refugee specific immunisation policies.

METHODS

We sourced publicly available immunisation policy documents from state and territory government websites. Content analysis of seven policy documents was undertaken using a developed framework comprising crucial policy determinants.

RESULTS

Immunisation policy differed substantially across the jurisdictions. While most policies did not highlight the importance of data collection on immunisation for refugees and the public funding of vaccines for refugees, policy determinants such as accessibility and obligations were fulfilled by most jurisdictions.

CONCLUSION

Our findings indicate stark differences in immunisation policy for people of refugee background across Australia. Highlighted gaps demonstrate the need to revise current policies so that they are aligned with their intended outcome of enhancing uptake of vaccines and improving immunisation coverage among resettled refugees in Australia. Implications for public health: Immunisation policy development for refugees needs to be robust enough to ensure equitable health services to this group.

Refugee children and their health, development and well-being over the first year of settlement: A longitudinal study

AIM

This study aimed to describe refugee children, their families and settlement characteristics, and how their development and social-emotional well-being change over time.

METHODS

We conducted a longitudinal study of 61 refugee children (6 months to 15 years) in an Australian setting, over 2009-2013 and measured child, family and settlement factors as well as physical health, development and social-emotional well-being (Strengths and Difficulties Questionnaire, SDQ).

RESULTS

Questionnaires were completed with parents of 54 (89%) children at year 2 and 52 (100%) at year 3. Forty percent of parents had low levels of education, 30% of fathers were absent on arrival, 13% of children were born in refugee camps and 11% of parents self-disclosed previous trauma. Over time, there was increased parental employment (P = 0.001), improved English proficiency for partners (P = 0.02) and reduced stressful life events in the last 12 months (P = 0.003). At years 2 and 3, parents were studying English (96%; 76%), accessing government financial support (96%; 100%) and primary health care (98%; 87%), and feeling supported by their own (78%; 73%) or the general (69%; 63%) community. Fifteen percent of children had a chronic disease, and 13% were obese and overweight. In pre-school children, 27% had mild developmental problems in year 2; all were normal by year 3. Abnormal SDQ total difficulties scores reduced over time from 13 to 6% of children but this did not reach significance.

CONCLUSION

Most refugee children have developmental and well-being outcomes within the normal range by year 3. However, a minority of children have persistently poor social-emotional outcomes.

Challenges in immunisation service delivery for refugees in Australia: A health system perspective

BACKGROUND

Refugees are at risk of being under-immunised in their countries of origin, in transit and post-resettlement in Australia. Whilst studies have focused on identifying barriers to accessibility of health services among refugees, few focus on providers' perspectives on immunisation service delivery to this group. Health service providers are well placed to provide insights into the pragmatic challenges associated with refugee health service delivery, which can be useful in identifying strategies aimed at improving immunisation coverage among this group.

METHODS

A qualitative study involving 30 semi-structured interviews was undertaken with key stakeholders in immunisation service delivery across all States and Territories in Australia between December 2014 and December 2015. Thematic analysis was undertaken.

RESULTS

Variability in accessing program funding and vaccines, lack of a national policy for catch-up vaccination, unclear roles and responsibilities for catch-up, a lack of a central immunisation register and insufficient training among general practitioners were seen as the main challenges impacting on immunisation service delivery for refugees.

CONCLUSIONS

This study provides insight into the challenges that impact on effective immunisation service delivery for refugees. Deliberate strategies such as national funding for relevant vaccines, improved data collection nationally and increased guidance for general practitioners on catch-up immunisation for refugees would help to ensure equitable access across all age groups.

Screening and Primary Care Access for Newly Arrived Paediatric Refugees in Regional Australia: A 5 year Cross-sectional Analysis (2007-12)

This study aimed to determine the prevalence of health conditions in newly arrived refugee children and access to timely heath screening. Methods: Cross-sectional data from screening of refugee children in regional Australia (2007-12) were analysed for health conditions and timeliness of primary care access. The health of 376 newly arrived refugee children (0-15 years) was assessed. Refugee children came from African (45%), Southeast Asian (29%) and Eastern Mediterranean (10%) regions. Access to primary care screening was present in 367 children (97% of arrivals). Completion of all recommended screening tests was 72%. Of 188 children with arrival and screening dates recorded, 88% were screened within 1 month and 96% within 6 months of arrival. Timely access of remaining children could not be assessed. Conclusion: Primary care was highly accessible to almost all newly arrived refugee children. Health screening was timely in those children with complete medical records.

Immigrant parents' experience with the Swedish child health care system: A qualitative study

Background

Immigration, particularly when it is involuntary, is known to be an emotional stressor, regardless of the reason behind it. It is always a challenge to be removed from the habitual and cultural action pattern of the person or family. This can make children more vulnerable, because they often arrive with an increased risk of poor physical health. Because of that, it is crucial that immigrant children have access to ongoing health care. The aim of this study is to shed light on the experience of non-European immigrants with Sweden’s Child Health Care system.

Methods

Qualitative semi-structured interviews were conducted, with parents of children who were patients of one of the four child health care centres. The centres were in four areas in a town in southern Sweden in which there are substantial immigrant populations. The interviews were conducted, transcribed and then analyzed with content analysis.

Results

The results were divided into two main categories: The first is “the sense of being cared for in another way,” which was divided into the following four subcategories: compare with the home country, getting a home visit, engagement and contentment and unfamiliarity with the language. The second main category. “The feeling of getting all the practical needs met through the child health care system” had the following four subcategories: The importance of advice and guidance, getting oral and written information, getting help when needed and getting support when needed.

Conclusions

The parents expressed contentment regarding the Swedish child health care and they were thankful for how it was organized, the engagement of the nurses, the information and advices given as well as for the opportunities of getting a home visit after birth. However, more research is needed in order to find out the extent to which the Swedish child health care system is culturally appropriate in the whole country.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-017-0604-6) contains supplementary material, which is available to authorized users.

People-centred integration in a refugee primary care service

Purpose

Services for refugees and asylum seekers frequently experience gaps in delivery and access, poor coordination, and service stress. The purpose of this paper is to examine the approach to integrated care within Companion House (CH), a refugee primary care service, whose service mix includes counselling, medical care, community development, and advocacy. Like all Australian refugee and asylum seeker support services, CH operates within an uncertain policy environment, constantly adapting to funding challenges, and changing needs of patient populations.

Design/methodology/approach

Interviews with staff, social network analysis, group patient interviews, and service mapping.

Findings

CH has created fluid links between teams, and encouraged open dialogue with client populations. There is a high level of networking between staff, much of it informal. This is underpinned by horizontal management and staff commitment to a shared mission and an ethos of mutual respect. The clinical teams are collectively oriented towards patients but not necessarily towards each other.

Research limitations/implications

Part of the service’s resilience and ongoing service orientation is due to the fostering of an emergent self-organising form of integration through a complex adaptive systems approach. The outcome of this integration is characterised through the metaphors of “home” for patients, and “family” for staff. CH’s model of integration has relevance for other services for marginalised populations with complex service needs.

Originality/value

This study provides new evidence on the importance of both formal and informal communication, and that limited formal integration between clinical teams is no bar to integration as an outcome for patients.

"Walking in a maze": community providers' difficulties coordinating health care for homeless patients

BACKGROUND

While dual usage of US Department of Veterans Affairs (VA) and non-VA health services increases access to care and choice for veterans, it is also associated with a number of negative consequences including increased morbidity and mortality. Veterans with multiple health conditions, such as the homeless, may be particularly susceptible to the adverse effects of dual use. Homeless veteran dual use is an understudied yet timely topic given the Patient Protection and Affordable Care Act and Veterans Choice Act of 2014, both of which may increase non-VA care for this population. The study purpose was to evaluate homeless veteran dual use of VA and non-VA health care by describing the experiences, perspectives, and recommendations of community providers who care for the population.

METHODS

Three semi-structured focus group interviews were conducted with medical, dental, and behavioral health providers at a large, urban Health Care for the Homeless (HCH) program. Qualitative content analysis procedures were used.

RESULTS

HCH providers experienced challenges coordinating care with VA medical centers for their veteran patients. Participants lacked knowledge about the VA health care system and were unable to help their patients navigate it. The HCH and VA medical centers lacked clear lines of communication. Providers could not access the VA medical records of their patients and felt this hampered the quality and efficiency of care veterans received.

CONCLUSIONS

Substantial challenges exist in coordinating care for homeless veteran dual users. Our findings suggest recommendations related to education, communication, access to electronic medical records, and collaborative partnerships. Without dedicated effort to improve coordination, dual use is likely to exacerbate the fragmented care that is the norm for many homeless persons.

Methods for a longitudinal cohort of refugee children in a regional community in Australia

PURPOSE

Few studies explore the long-term health and well-being of refugee children. A longitudinal cohort of refugee children was created to determine health and well-being outcomes over time. This article describes the methodology used to conduct this study, including sample characteristics and effectiveness of recruitment and retention strategies.

PARTICIPANTS

Newly arrived refugee children settling in a regional part of Australia aged 6 months to 15 years were recruited between 2009 and 2013 and 85% were followed for an average of 31 months.

METHOD AND DESIGN

General practitioners conducted health and pathology examinations shortly after arrival. Additional follow-up assessments were conducted by the research team at an average of 13 months after arrival for the first (year 2) and 31 months for the second (year 3) assessment. Children under 5 years had developmental and children aged 4-17 years had social-emotional screening. Families were assessed for risk and protective factors using a structured interview and the Social Readjustment Ratings Scale. Parent experience of the research was explored.

FINDINGS TO DATE

Eligibility criteria were met by 158 of 228 (69%) newly arrived children, 61 of whom (39%) were enrolled. Retention was 100% (n=61) at year 2 and 85% at year 3. The study sample was younger than and had an over-representation of African refugees as compared to the eligible population. Parents reported that the research was respectful.

FUTURE PLANS

This study demonstrates that a longitudinal cohort study in refugee children is feasible and acceptable, and retention rates can be high. The establishment of this cohort provides the opportunity to analyse valuable data about the early settlement experience, risk and protective factors and long-term health and well-being outcomes in refugee children. These are necessary to identify refugee children in need of additional support and to guide future service delivery.

Refugee child oral health

The number of people forced to flee their homes and move around the world is increasing rapidly. Such refugee populations are not only more likely to have poor physical, mental and social health outcomes but also to experience difficulties accessing health services in their new country. In particular, children from refugee backgrounds are at increased risk of poor oral health which in time is associated with poor adult oral health and impacts on child health (e.g. growth and development) and well-being. To date, there is little evidence about the nature and extent of their oral health problems nor interventions to improve their oral health status. This article summarises the evidence surrounding the oral health status of children from refugee backgrounds. In addition, a systematic review of the international literature over the past 10 years is presented which identifies interventions to improve the oral health of these vulnerable paediatric populations. Based on this evidence, potential strategies available to dental service providers to optimise provision of responsive dental care are discussed.

Health of adolescent refugees resettling in high-income countries

Adolescent refugees are a vulnerable population with complex healthcare needs that are distinct from younger and older age groups. Physical health problems are common in this cohort with communicable diseases being the focus of attention followed by an emphasis on nutritional deficiencies and other chronic disorders. Adolescent refugees have also often experienced multiple traumatic stressors and are at a heightened risk of developing mental health problems. Navigating these problems at the time of pubertal development adds further challenges and can exacerbate or lead to the emergence of health risk behaviours. Educational difficulties and acculturation issues further compound these issues. Adolescents who have had experiences in detention or are unaccompanied by parents are particularly at risk. Despite a constantly growing number of adolescent refugees resettling in high-income countries, knowledge regarding their specific healthcare needs is limited. Research data are largely extrapolated from studies conducted within paediatric and adult cohorts. Holistic management of the medical and psychological issues faced by this group is challenging and requires an awareness of the socioeconomic factors that can have an impact on effective healthcare delivery. Legal and ethical issues can further complicate their management and addressing these in a culturally appropriate manner is essential. Early identification and management of the healthcare issues faced by adolescent refugees resettling in high-income countries are key to improving long-term health outcomes and future healthcare burden. This review article aims to increase knowledge and awareness of these issues among paediatricians and other health professionals.

Fatherhood in a New Country: A Qualitative Study Exploring the Experiences of Afghan Men and Implications for Health Services

BACKGROUND

Fathers of refugee background are dealing with multiple, interrelated stressors associated with forced migration and establishing their lives in a new country. This has implications for the role of men in promoting the health and well-being of their families.

METHODS

Afghan community researchers conducted interviews with 30 Afghan women and men who had recently had a baby in Australia. Interviews and focus groups were conducted with health professionals working with families of refugee background.

RESULTS

Fourteen men, 16 women, and 34 health professionals participated. Afghan men reported playing a major role in supporting their wives during pregnancy and postnatal care, accompanying their wives to appointments, and providing language and transport support. Although men embraced these roles, they were rarely asked by health professionals about their own concerns related to their wife's pregnancy, or about their social circumstances. Perinatal health professionals queried whether it was their role to meet the needs of men.

CONCLUSION

There are many challenges for families of refugee background navigating maternity services while dealing with the challenges of settlement. There is a need to move beyond a narrow conceptualization of antenatal and postnatal care to encompass a broader preventive and primary care approach to supporting refugee families through the period of pregnancy and early years of parenting. Pregnancy and postnatal care needs to be tailored to the social and psychological needs of families of refugee background, including men, and incorporate appropriate language support, in order to improve child and family health outcomes.

Evaluation of a school screening programme for young people from refugee backgrounds

AIM

To describe the development of the Optimising Health and Learning Program, guided by the only available published framework for the delivery of health services to newly arrived refugee children and report on the evaluation of the programme.

METHODS

We conducted process and impact evaluation using a mixed methods approach. The sample was 294 refugee young people enrolled in two Intensive English Centres in New South Wales. We collected quantitative data (demographic and clinical information) as well as qualitative data via focus groups, key informant interviews, surveys and programme documentation. Qualitative data were subjected to thematic analysis; programme documents underwent document review.

RESULTS

There were high levels of programme participation (90%), and the yield from routine health screening was high (80% of participants screened positive for two or more health conditions). All identified programme development strategies were implemented; programme partners and participants reported satisfaction with the programme. Sixteen programme partners were identified with a high level of intersectoral collaboration reported. Significant in-kind contributions and seed funding enabled the uptake of the programme to increase from one to five Intensive English Centres over a 4-year period.

CONCLUSION

Process and impact evaluation identified that the programme was well implemented and met its stated objectives of increasing the detection of health conditions likely to impact on student health and learning; linkage of newly arrived students and their families with primary health care; and coordination of care across primary health and specialist services.

In or out? Barriers and facilitators to refugee-background young people accessing mental health services

Refugee young people have been identified as a group with high risk for mental health problems, due to their experience of trauma, forced migration, and stressors associated with settlement. A high prevalence of mental health problems is reported in this group, however some research suggests refugee young people have low rates of mental health service access. There is little information available on barriers and facilitators to mental service delivery for this group. Using data from 15 focus groups and five key informant interviews with a total of 115 service providers from 12 agencies in Melbourne, Australia, this paper explores barriers and facilitators to engaging young people from refugee backgrounds with mental health services. Eight key themes emerged: cultural concepts of mental health, illness, and treatment; service accessibility; trust; working with interpreters; engaging family and community; the style and approach of mental health providers; advocacy; and continuity of care.

Prioritizing vulnerable children: strategies to address inequity

BACKGROUND

While current strategies to address the needs of vulnerable child populations in Australia aim to reduce inequities, they are isolated, group specific and disparate.

AIM

The aim of this study was to address health inequities by generating tools that are useful in clinical service settings to assist with the identification, prioritization and monitoring of all vulnerable populations.

METHODOLOGY

Current local and national initiatives to address inequities were reviewed. Shared strategies in delivering health services to vulnerable populations were highlighted, and existing tools used for identification and prioritization were adapted.

FINDINGS

Analysis of at-risk populations resulted in the formulation of four key questions to identify vulnerable children at presentation to services and strategies for prioritizing children within services. An existing refugee child health service delivery framework was adapted as a proposal for use in the development and evaluation of services for all vulnerable child populations.

CONCLUSION

A systemic approach across all vulnerable populations, supplemented by group-specific measures, is likely to add value to health service delivery as well as be more efficient and sustainable than multiple group-specific interventions. Given the limited outcome evidence available, there is also a need to collect data on vulnerable children and to track the effectiveness of interventions designed to address their health needs.

Caries burden and efficacy of a referral pathway in a cohort of preschool refugee children

BACKGROUND

This study aimed to assess the early caries experience and the efficacy of a community based dental referral pathway in preschool refugees in Western Australia.

METHODS

Preschool refugee children referred to the Western Australian paediatric hospital Refugee Health Clinic were prospectively screened for caries by a paediatric dentist before being referred to community dental clinics. Dental forms and medical records were audited to assess decayed, missing and filled teeth (dmft), medical data and dental services engagement. Poisson regression analysis determined the contribution of count variables to the final model.

RESULTS

Among the 105 screened children (54% male, median age 3.2 years, 41% Burmese), community dental clinic engagement was low (46%, n=48). Of the 62% with caries (n=65/105, mean dmft 5.2, SD 4.1), 45% were recommended for specialist dental services and 48% were treated. After adjustment for age, gender and total number of teeth, caries incidence was significantly associated with BMI-for-age Z score (p=0.02).

CONCLUSIONS

Preschool refugee caries burden was high. The community dental referral pathway was ineffective compared to co-located intersectorial dental screening. Specialist dental service needs are high in this cohort and require a targeted approach.

Educational, developmental and psychological outcomes of resettled refugee children in Western Australia: a review of School of Special Educational Needs: Medical and Mental Health input

AIM

There are limited data regarding the educational backgrounds and associated psychological and developmental outcomes of refugee children resettling in Western Australia (WA). The WA paediatric Refugee Health Service (RHS) revised its first consult questionnaire (August 2011) to increase educational and psychosocial documentation, concurrent with engagement of a School of Special Educational Needs: Medical and Mental Health (SSEN: MMH) liaison teacher. This study aims to utilise these data to increase understanding of this cohort's educational, developmental and psychological needs and to describe SSEN: MMH's role within the RHS.

METHODS

Retrospective audit and analyses were performed on all initial standardised questionnaires for school-aged refugee children (4-18 years) and SSEN: MMH referrals between August 2011 and December 2012.

RESULTS

Demographic data from 332 refugees are described (mean age 9.58 ± standard deviation 3.43 years). Detailed educational information was available for 205 children. Prior education was limited (median 2 years), 64.9% experienced likely schooling interruption and 55.8% received education in their primary language. Language development concerns were significantly associated with previous education in a second language (odds ratio (OR) 4.55, P < 0.05). Other severe developmental and schooling issues were uncommon at presentation, with few correlations to prior education. In contrast, several migration factors, including family separation and mandatory detention, were significantly associated with psychological comorbidities such as post-traumatic stress disorder (OR 5.60, P < 0.001 and OR 14.57, P < 0.001, respectively). SSEN: MMH reviewed 59 complex cases. Referral was significantly associated with multiple educational, developmental and psychological concerns.

CONCLUSIONS

Refugee children have varied migration, trauma and educational backgrounds, impacting on health and psychological outcomes. In-depth multidisciplinary history including prior education and psychosocial issues is recommended. Partnering with education services appears to play an effective, multifaceted role in aiding resettlement; however, longitudinal studies are required.

Caring for refugees in general practice: perspectives from the coalface

This qualitative research project explored the experiences of primary health care providers working with newly arrived refugees in Brisbane. Data from 36 participants (20 general practitioners, five practice nurses and 11 administrative staff) involved in five focus groups and four semi-structured interviews were analysed. The results indicated that despite difficulties, providers are committed and enthusiastic about working with refugees. The flexibility of the general practice setting enables innovative approaches. The establishment of a specialised refugee health service in Brisbane has improved providers’ capacity to deliver refugee health care. However, most practices continue to feel isolated as they search for solutions, and the need for greater supports and a more coordinated approach to care were emphasised. The themes of communication, knowledge and practice and health care systems encapsulated the factors that influence health care providers’ ability to care for refugees and provide a framework for improving available supports. Australian primary health care is currently undergoing great change, which provides an opportunity to make significant gains in the provision of care for refugees and other minority groups within our community. As health care reforms are implemented it is essential that they are responsive to the expressed needs of health care providers working in these areas.

Health needs of refugee children younger than 5 years arriving in New Zealand

BACKGROUND

New Zealand accepts 750 refugees annually who enter via the Mangere Refugee Resettlement Centre.

AIMS

To evaluate the health needs of refugee children less than 5 years of age.

METHODS

Retrospective audit on the outcomes of health screening and referrals in children less than 5 years of age at the Mangere Refugee Resettlement Centre between 2007 and 2011.

RESULTS

Of the 343 children, the most common infectious diseases were latent tuberculosis (15%) and parasitic infections (15%). In those older than 1 year old who had rubella and measles serology information, immunity was found in 50% and 59%, respectively. Hepatitis B immunity was found in 68%. Complete vaccination certificates were available for 66% on arrival to New Zealand. Vaccinations were administered to 73% while at the Mangere Refugee Resettlement Centre. Iron deficiency and vitamin D deficiency were the main noninfectious diseases found and were present in 33% and 12%, respectively. The total requiring referral for further medical assessment or support was 58% with 19% requiring referral to more than one service.

CONCLUSIONS

Screening identified health needs in otherwise asymptomatic newly arriving refugee children. A proportion of children required access to multiple specialized medical services and may benefit from a comprehensive pediatric service.

Tertiary paediatric refugee health clinic in Western Australia: analysis of the first 1026 children

AIM

Children account for approximately half of the humanitarian refugees currently resettled in Australia. A multidisciplinary refugee health clinic (RHC) was established at the tertiary paediatric hospital in Western Australia to address burgeoning referrals of refugee children following voluntary post-resettlement health assessment. The aim of this study is to describe the epidemiology of common conditions in resettled paediatric refugees attending a tertiary multidisciplinary RHC.

METHODS

Standardised clinical and demographic data were routinely collected during first visit clinical assessment at the RHC. Descriptive analyses of the first 1026 children are presented.

RESULTS

One thousand twenty-six refugee children from 475 families and over 30 different ethnicities were described. Nine hundred twenty-seven (90.4%) children were referred following post-resettlement health assessment. Median age was 7.8 years. Common reasons for referral were: vitamin D deficiency (400, 39%), iron deficiency (226, 22%), positive Helicobacter pylori serology (206, 21%), poor appetite (175, 17.1%), and schistosomiasis (170, 16.6%). Comorbidities identified by the RHC included tinea capitis and corporis (297, 28.9%), and dental disease (228, 22.2%). Two-thirds of children (680, 66.3%) had at least one abnormal finding on clinical examination that identified pathologies that were not evident from the history. Three hundred eighty children (37%) were referred to sub-specialty services.

CONCLUSIONS

A multidisciplinary paediatric RHC facilitated and strengthened the management of refugee children with multiple and complex health needs. Evidenced-based culturally appropriate methods to identify developmental delay, psychological morbidity and quantify social needs of this vulnerable population remain uncertain. These findings are relevant to the continuing evolution of paediatric refugee health care in Australia and other high income countries.

Urban inequities; urban rights: a conceptual analysis and review of impacts on children, and policies to address them

This paper explores current conceptual understanding of urban social, environmental, and health inequality and inequity, and looks at the impact of these processes on urban children and young people in the 21st century. This conceptual analysis was commissioned for a discussion paper for UNICEF's flagship publication: State of the World's Children 2012: Children in an Urban World. The aim of the paper is to examine evidence on the meaning of urban inequality and inequity for urban children and young people. It further looks at the controversial policies of targeting "vulnerable" young people, and policies to achieve the urban MDGs. Finally, the paper looks briefly at the potential of concepts such as environment justice and rights to change our understanding of urban inequality and inequity.

Accessing maternal and child health services in Melbourne, Australia: reflections from refugee families and service providers

BACKGROUND

Often new arrivals from refugee backgrounds have experienced poor health and limited access to healthcare services. The maternal and child health (MCH) service in Victoria, Australia, is a joint local and state government operated, cost-free service available to all mothers of children aged 0-6 years. Although well-child healthcare visits are useful in identifying health issues early, there has been limited investigation in the use of these services for families from refugee backgrounds. This study aims to explore experiences of using MCH services, from the perspective of families from refugee backgrounds and service providers.

METHODS

We used a qualitative study design informed by the socioecological model of health and a cultural competence approach. Two geographical areas of Melbourne were selected to invite participants. Seven focus groups were conducted with 87 mothers from Karen, Iraqi, Assyrian Chaldean, Lebanese, South Sudanese and Bhutanese backgrounds, who had lived an average of 4.7 years in Australia (range one month-18 years). Participants had a total of 249 children, of these 150 were born in Australia. Four focus groups and five interviews were conducted with MCH nurses, other healthcare providers and bicultural workers.

RESULTS

Four themes were identified: facilitating access to MCH services; promoting continued engagement with the MCH service; language challenges; and what is working well and could be done better. Several processes were identified that facilitated initial access to the MCH service but there were implications for continued use of the service. The MCH service was not formally notified of new parents arriving with young children. Pre-arranged group appointments by MCH nurses for parents who attended playgroups worked well to increase ongoing service engagement. Barriers for parents in using MCH services included access to transportation, lack of confidence in speaking English and making phone bookings. Service users and providers reported that continuity of nurse and interpreter is preferred for increasing client-provider trust and ongoing engagement.

CONCLUSIONS

Although participants who had children born in Melbourne had good initial access to, and experience of, using MCH services, significant barriers remain. A systems-oriented, culturally competent approach to service provision would improve the service utilisation experience for parents and providers, including formalising links and notifications between settlement services and MCH services.

The health of newly arrived refugees to the Top End of Australia: results of a clinical audit at the Darwin Refugee Health Service

Accurate data on the health of refugees in primary care is vital to inform clinical practice, monitor disease prevalence, influence policy and promote coordination. We undertook a retrospective clinical audit of newly arrived refugees attending the Darwin refugee primary health service in its first 12 months of operation. Data were collected from the clinic files of refugee patients who attended for their initial health assessment from 1 July 2009 to 30 June 2010 and were analysed descriptively. Among 187 refugees who attended in 2009–2010, ~60% were from Asia and 42% were female. The most common diagnoses confirmed by testing were vitamin D deficiency (23%), hepatitis B carrier status (22%), tuberculosis infection (18%), schistosomiasis (17%) and anaemia (17%). The most common documented health conditions recorded by the GPs were vitamin D deficiency or insufficiency (66%), followed by schistosomiasis (24%) and dental disease (23%). This clinical audit adds to a limited evidence base suggesting a high prevalence of infectious disease, nutrient deficiency and dental disease among refugees arriving to Australia. GPs involved in the care of refugees must be aware of the epidemiology of disease in this group, as some diseases are rare among the general Australian population. Our results also highlight the ongoing need for advocacy to address service constraints such as limited public dental access for this population.

Invisible populations: parallels between the health of people with intellectual disability and people of a refugee background

When considering the delivery of primary health care in the community, some populations remain virtually invisible. While people with intellectual disability might seem to share few characteristics with refugees and humanitarian entrants, there are a number of difficulties that both groups share when accessing and receiving primary health care. Commonalities include communication barriers, difficulties accessing past medical records and the complexity of health needs that confront the practitioner providing health care. These issues and additional systemic barriers that prevent the delivery of optimal health care to both groups are explored. Integrated multidisciplinary care is often required for the delivery of best practice care; however, such care can be difficult for each group to access. In May 2010, the specific Medicare Health Assessment Item numbers for both of these groups were incorporated into a group of more generic Item numbers. This has resulted in a lost opportunity to enhance the evidence surrounding health care delivery to these vulnerable populations. This paper recognises the importance of health policy in leading affirmative action to ensure these populations become visible in the implementation of the National Primary Health Care Strategy.