Transcript SA Health PowerPoint Template

Health
and
Cross-cultural issues
Dr. Jill Benson
Senior Medical Officer
Migrant Health Service
and
Director,
Health in Human Diversity Unit
Discipline of GP,
University of Adelaide
What is a refugee?
> “Everyone has the right to seek and enjoy in other countries asylum
from persecution”
Article 14, Universal Declaration of Human Rights 1948 (signed by member
countries, including Australia and NZ)
> Under international law, refugees are persons who "owing to well-founded
fear of being persecuted for reasons of race, religion, nationality,
membership of a particular social group or political opinion, is outside
the country of his (sic) nationality and is unable or, owing to such fear,
is unwilling to avail himself of the protection of that country ... " (1951
Convention relating to the Status of Refugees)
> Generally, refugees are people who have been forced to flee their homes,
their lands, have lost family and friends, have few possessions and have
been the subject of human rights violations.
Refugee profile
> Approximately 13000 refugees/year to Australia, about
1300 to South Australia
> 30% from Africa
• Sudan, Congo, Burundi, Liberia
> 30% from Middle East
• Afghanistan, Iran, Iraq
> 30% from elsewhere
• Burma, Bhutan, China
> Up to 50% aged under 18
> Approx. equal numbers of men and women
Voluntary vs involuntary migrant
> Voluntary (choice)
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Prepare
Say goodbye
Learn language
Bring household items etc with them
Have career recognised
Look forward to a new life
> Involuntary (refugee)
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No time for preparation
Bring nothing
Lose contact with family and friends
Don’t know language
Lose career
Often still look back to what they have left behind
Refugee profile
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Higher levels of poverty
Families often headed by female
Greater cultural differences
Larger families with lower levels of education
• Often no education at all or only religious education
> Older children responsible for younger ones
> Long periods (often >10 years) in flight and/or refugee
camps
> Limited or disrupted access to health care or education
> ‘Unaccompanied minors’ highest risk as they lack the
support of families
> Forced child labour, kidnapping, child soldiers
Flight and Camp
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Stateless, no country
No home or privacy
No contact with family
Limited health-care, food or sanitation
Witnessing starvation, rape, murder, death, selfabuse
Mandatory detention in ‘safe’ country
Average stay in Kakuma camp ~ 17 years
Many children born and raised in refugee
camps
• ~ 8 million worldwide
Most have no hope of ever leaving camp
Survival
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‘Survival’ is a priority, not necessarily health or education
Coping with challenges of resettlement
Dealing with loss and dislocation
Housing and food
Language
Transport
Loneliness
Clothing
Perceptions of illness
Caring for family
Mistrust of authority
Fear of being ‘sent back’
Aspirations for a better life
World-view
> ‘Western’ individualistic world-view
• Individualism
• Consumerism
• Body and mind are separate
• Secular and conflictual
• Usually assumes people are responsible for their own misfortune
> Collectivist world-view (Indigenous cultures & the developing world)
• Spiritual
• Ecological
• Consensual and communal
• Spirituality pervades every aspect of the lives of people from most
collectivist cultures and cannot be differentiated from either their
physical or mental well-being
Infections vs Non-communicable Diseases
in Africa
> Chronic disease contributes over 70% of disease
burden in Australia and will increase to 80% by 2020
> In most of Africa the risk of dying at a young age from
an infectious disease is much greater than the risk of
dying of a chronic disease (NCD)
> Mortality from malaria in Africa is 3 million/year
> Gastroenteritis kills 2 ½ million and pneumonia 3 ½
million African children per year
> About 2 million children die from measles each year in
Africa
> HIV affects 23 million people in Africa with 1.6 million
dying each year of HIV/AIDS
> TB prevalence in Africa is >300/100,000 (3 million
people) cf Aus 5.8/100,000
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• About ½ million deaths each year from TB in Africa
Nutrition in Africa
> 14 million people in Africa suffer from malnutrition and
starvation
> Ingestion of unsafe water, inadequate availability of
water for hygiene, and lack of access to sanitation
contribute to 1.5 million child deaths per year
> Stunting or chronic undernutrition affects 35-40% of
children
> May cause abnormal liver function tests on initial
screening
> May be protein, vitamin B12 or other deficiencies.
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Pre-departure
> HIV > 15 years or high risk
> CXR >11 years or high risk
> Some have had treatment for malaria and parasites
and given MMR as part of voluntary ‘Fitness to fly’
> Some have ‘Health Undertakings’ eg TB
> However compliance, inconsistent paperwork,
delay in leaving etc mean that investigation and
treatment sometimes cannot be relied upon.
Parasites and Infections
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Schistosomiasis
Strongyloides
Hookworm
Pork tapeworm (taenia solium)
Giardia
Entamoeba histolytica
Malaria
Cutaneous leishmaniasis
Yaws
TB
Hepatitis B, C and D
Other Health Issues
> Chronic diseases
• Hypertension, diabetes, asthma
• Nutritional deficiencies – Vitamin D, A, B12, folate,
and Iron
> Injuries from pre-migration torture and trauma
> Dental problems
> Rheumatic heart disease
> Childhood development problems
> Low immunisation rates
> Serious mental health problems eg PTSD
Tuberculosis
> 90% of those with TB in Australia are born
overseas
> Active TB (infectious) rare
> Latent (dormant) TB common
Needs to be treated in children
> Can be reactivated if illness or pregnant
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> Most risk in first 2 years after arrival
> Non-pulmonary (not in the lungs) TB more
common, especially in children
• Can be in lymph nodes or bone
> Chest Clinic does Mantoux on children
through schools
Mantoux test
The test needs to be measured 48-72 hours after the injection
Immunisation
> Many refugees come from countries without
good immunisation programs
> This leaves them susceptible to diseases like
measles, rubella and tetanus
> Free vaccines are provided by local councils
– NARI Clinics, GPs and community health
centres
Malaria
> About 70% are from areas where malaria is endemic
> A ‘fitness to fly’ assessment includes a rapid diagnostic test
• If positive, given a 3 day course of treatment
> We can’t catch malaria here as we don’t have the right sort of
mosquitoes
> Refugees from Africa might have life-threatening malaria even
though they’ve been tested
> Children are most at risk
> Any newly arrived refugee with ‘flu-like’ symptoms of fever,
headache, muscle pain and vomiting might actually have
severe malaria and should be taken to hospital immediately
Hepatitis
> Hepatitis A is not serious and quite common in children
overseas
> Hepatitis B is usually contracted from a child’s mother
at birth or from having an unclean injection
• 70% of those with chronic hepatitis B in Australia born
overseas
• Approx 20% of refugees from some countries are hepatitis B
positive
• 90% of those infected at or around the time of birth will have
chronic infection with 25% risk of cirrhosis or liver cancer
• Vaccine available
> Hepatitis C is usually contracted from having an
unclean injection
• Can be treated but no vaccination
Attitude to food after arrival in Australia
> The food in refugee camps is often scarce and of
poor quality, so food may be overeaten in Australia
> Food was about survival and not about taste or
preference and now there is a huge range
> Multi-generational deficiencies of vitamins and iron
passed from mother to child
> Dietary guidelines and a ‘balanced diet’ are
completely unknown
> Thin means poor, diseased, not loved, despair,
> Fat means rich, powerful, doing well, well cared for,
blessed by God
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The Importance of knowing
correct age
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Taught at a suitable educational level
Correct vaccinations
Correct medication and dose
Developmental milestones eg urinary incontinence
Dental care
Determining potential emotional resources for dealing
with stressful life events
> Get married, join the army, drive, receive Centrelink
payments or vote
> Local authorities fulfil their obligations in providing support
and services to vulnerable groups, such as
unaccompanied minors aged less than 18 years
Why don’t we know the correct age?
> The significance of birthdates tends to be cultural and
many may know the year of birth without having noted the
day and month.
> Banning of calendars (eg in Afghanistan),
> Chaotic circumstances surrounding the time of birth (eg
during flight),
> Child may have spent considerable time separated from
the parents
> Child is the child of only one parent (eg one wife may
come with the children of other wives),
> Child may be adopted from another family,
> Visa authorities made an inappropriate estimate of the
child’s age
> Many other systemic or administrative errors or mishaps.
How can we assess a child’s age?
> Even if a child has good health, adequate nutrition and a
stable environment, behavioural, social and physical
milestones vary within a wide range of normality
> If there is illness, undernutrition, extreme stress and
disrupted socialization, any tools used to assess age are
likely to be even less reliable
> Use narrative accounts, physical assessment of puberty
and growth, and cognitive, behavioural and
emotional assessments
> X-rays should be used as a last resort
Mental health problems in refugee patients
> Post traumatic stress disorder, depression and/or
anxiety disorder are present in up to 100% of
refugee patients in some studies
• eg children who have been in detention all had
depression, PTSD or personality disorder
> Most come from cultures with no concepts of
mental health issues
> Religion is more likely to be important in the
cause and management
Issues in past that affect mental health
> Imprisonment, kidnapping, abduction, hostage,
forced labour
> Loss of family members, home and possessions
> Betrayal by family, friends or work colleagues
> Torture, rape and/or threats of these
> Witnessing torture, rape or murder
> Poverty
> Political events
> Hunger
Mental Health Issues
> Pre-migration
• Grief from loss of family, culture, food, stability
• Guilt, loss of a sense of hope and meaning in
family
• Child becoming care-giver
> Post-migration/resettlement
• Cultural adjustment
• Family dynamics
• Changing gender roles
• Stresses of resettlement
• Schooling
‘Continuous Traumatic Stress Disorder’
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Detention
Family reunion
Racial prejudice
Bureaucratic technicalities
Education, esp girls
Foreign culture and language
Poverty
Disintegration of family life
Isolation
Intergenerational issues
• eg arranged marriages, chaperoning
Pre-existing factors for resilience
> Childhood history (especially relationship with
mother)
> Genetic predisposition
> Religion (rules)
> Spirituality (relationship with God)
> Personality
> Finances
> Education
> Health
> Sense of humour
> Locus of control
Useful Therapies
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Family support
Community support
Learning English
Play, drama, drawing or music therapy
Stability and safety of housing and family
Education and support at school
Religious observance, music, ritual
PTSD treatment with distraction, exercise, etc
Honouring those who have died
Restoration and attachment to other human beings
Development of ‘third culture’
Cultural Awareness
> Symptoms of mental health problems may only be conceived
in physical or behavioural terms eg
• Aggressive or withdrawn behaviour
• ‘Acting out’ in school or social circumstances
• Physical symptoms such as bed-wetting, pain, eating
problems
• Parents do not have a concept of ‘mental health’
> Using questions such as those in the Cultural Awareness Tool
can assist in accessing cultural problems and exploring the
aetiology, expectations and possible solutions without being
fully aware of the patient’s cultural background or
compromising beliefs
Cultural Awareness Tool (1)
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What do you think caused your problem?
Why do you think it started when it did?
What do you think illness does to you?
What are the chief problems it has caused for
you?
> How severe is your illness?
> What do you most fear about it?
Cultural Awareness Tool (2)
> What kind of treatment/help do you think you
should receive?
> Within your own culture how would your
illness be treated?
> How is your community helping you?
> What have you been doing so far?
> What are the most important results you
hope to get from treatment?
Spiritual issues
> Discussing the cultural and spiritual causes and implications
is extremely important
> Don’t be afraid of asking about a child’s spiritual and cultural
beliefs
> A good relationship may cancel out gender, culture and
religious barriers
> Often we confuse culture with religion or politics and treat it
as taboo
Cultural issues
> Culture is just one aspect of a young person’s life
> Important in adequate management eg fasting, fatalism,
contraception
> Most cultural practices are not harmful but important to
ask as some might be eg
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Not giving certain foods if a child is sick eg protein
‘Cupping’, scratching or rubbing with kerosene
Female and male circumcision
Children should not be fasting in Ramadan but some do
Fear of becoming addicted to medication
Massaging broken limbs
Recovery
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Good social supports
Sense of belonging
Secure environment
Healthcare
Welfare
Education
Housing
Safety
Gender issues
Assistance with learning about transport,
shopping, playing
> Freedom to practice religion
> Music
Self-reflection
> Only a small percentage of motives, beliefs and reactions
are conscious
> The ‘ethnocentricism’ of the health professional or educator
needs to be conscious to properly recognise the cultural
beliefs and expectations of an individual
> In each culture there are different:
• approaches to knowledge
• communication styles
• attitudes toward conflict
• approaches to completing tasks
• notions of time
• decision-making styles
• attitudes toward disclosure
Self-education
> Learn as much as possible about cultural practices
• Countries of origin and transit
• Gender expectations
• Food – past and present
• Relationships
• Body language
• Religion
• Fasting
• Cultural practices
• Spiritual resources
Teachers who care
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Mandatory reporting
Legal obligations
School rules and requirements
Limited resources
‘The rest of the class’
Burnout
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Helplessness
Guilt about enjoying life
Anger
Disappointment with colleagues
Overwhelming emotions
Vulnerability
Intolerant of conflict
Burnout, compassion fatigue and vicarious
trauma
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Awareness, balance and connection
Endorphins
Sense of humour
Relaxation
Exercise
Nutrition
Sharing emotions with close friends
Debriefing with colleagues
Inservice and other training
Appropriate expectations of self, family and community
Hobbies
Team work
Safe working environment
Compassion satisfaction
‘If you have come to help me, go
home, but if this is about your
struggle for survival as well as
mine, we can work together to
make a difference’
Lila Watson, Aboriginal elder