Paprckova.pptx - Slide 1


Published on

  • Be the first to comment

  • Be the first to like this

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide
  • Variable eg Thai-Burmese border- better conditions and access to PHC facilities
  • Variable eg Thai-Burmese border- better conditions and access to PHC facilities
  • Have different models of care, different staff, resources
  • 2005: Of 1557 refugee children <14 yrs settled in NSW, 330 (21%) attended specific refugee health services
    KEY: Insufficient capacity
  • To bridge some of the gaps and barriers.
  • Model developed by the Sydney Children’s and Wollongong hospitals, Multicultural Health, and the Illawarra Division of General Practice
  • This is the list of screening tests that GPs are encouraged to order, with the results copied to:
    Community Paediatrican SCH
    Infectious Diseases specialists, TWH
    These results are recorded in a database of all new arrivals, held by the AHS, to support access to care and to track health status.
  • Only 1 child had no problems identified on screening; 2 had 7 problems
  • 67% under-immunised for Measles, Rubella or Hepatitis B.
  • Ongoing sustainability is an issue, requiring advocacy for continued funding of the Refugee Health Nurse and Fellow positions. There was recently a Refugee portfolio created within the MHS.
    The use of community GPs is unusual (compared to GPs as part of a centralised Refugee Service) but this study proves it can work in our context
    Wagga – Geraldine Duncan and John Preddy, Paed Fellow. Single GP. Paed R/v all children and retrospective R/V of children arriving in 2006 and 2007.
  • For the period March 2007 – February 2008:
    28% were referred to the Sydney Children’s Hospital Refugee Health Clinic and/or Private Paediatricians
  • KEY: consistent with what we expect from the literature
    Incomplete screening: Hep A: 2/9, Syphillis: 1/117, HIV: 0/25
  • Paprckova.pptx - Slide 1

    1. 1. J Paprckova1,2, K Zwi1,2, K Williams1,2, L Woodland3, J Lane3,4 1 Department of Community Child Health, Sydney Children’s Hospital 2 School of Women & Children's Health, University of New South Wales 3 Multicultural Health Service, SE Sydney and Illawarra Area Health 4 University of Wollongong Assessment of the health and well being of refugee children on arrival and at 6 - 12 months of their settlement
    2. 2. High Risk Groups Children of drug dependence parents COPMI Children of parents in jail Children of parents with DD Children known to DoCS Children in OOHC Children with DD Children with chronic medical conditions Poverty Homeless Children in jail Aboriginal Refugee and Asylum Seeker CALD/NESB SCH Department of Community Child Health
    3. 3. Overview  SCH Department of Community Child Health  Refugees in the world  Refugees in Australia  SESIAH Model of care  Progress at 18 and 30 months  New longitudinal study of refugee children
    4. 4. Who is a Refugee?  UN Definition: "Owing to a well founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside of the country of his nationality and is unable, or owing to such a fear is unwilling to avail himself of the protection of that country…“ Article 1A, 1951 Convention on the Status of Refugees
    5. 5. How do they get here?  People are displaced from their country (or internally) 31 million classified by UNHCR as ‘people of concern’ - including 11 million refugees worldwide  They may end up at a refugee camp  They are determined to be “refugee” by the UN  Australia advises UNHCR re: wish to accept a certain No of refugees  The refugees are interviewed and receive a health screen  If they pass, then they get on the list for those who are granted a visa
    6. 6. Refugee experience  Conflict, forced exile, deprivation, unhealthy environmental conditions  Limited healthcare in country of origin and in refugee camps  Minimal health intervention prior to embarkation – especially children
    7. 7. Rwandan refugee camp, East Zaire
    8. 8. Refugee Camp  No country - stateless  No home  No privacy  No contact with family  No / minimal education  Difficult conditions in a refugee camp  Mandatory detention in ‘safe’ country  Extremely unsafe  Poor sanitation  Infectious diseases  Poor diet, hunger  Limited health care  Witnessing death, rape, murder, self-abuse, torture
    9. 9. Burmese refugee camp
    10. 10. Humanitarian program  Australia accepts around 13,500 humanitarian entrants / year  50% children and young people  NSW gets 40%; 85% settle around Sydney  Change in nature of refugee intake 2005: 70% African refugees Now: 1/3 from Africa, Middle East, SE Asia • Middle East: Iraqi refugees • Asia: long term Burmese and Bhutanese refugees
    11. 11. Refugee Distribution by area in NSW 44% 38% 4% 3% 3% 2% 2%0%0% 4% Sydney South West Sydney West South Eastern Sydney Illaw ara Hunter New England Greater Southern North Coast Northern Sydney Central Coast Sydney (unspecified) Greater Western Other/Unrecorded 2004 - 2009
    12. 12. Visa  Visa 200 – Humanitarian entrant Refugees, usually family groups - travel paid by government. Mandatory link to Settlement service and case worker (min. 6 months)  Visa 204 – Women at risk program Like 200, but are classified as Women and Children at risk  Visa 202 – Sponsored by family already in Australia Proposer responsible. Not linked to a case worker.  “Asylum seekers” Arrived either on a visitors visa, or with no visa and awaiting determination of their status
    13. 13. Refugees in Australia  Permanent residents - Medicare but not channelled to screening routinely  Australian Government support after arrival - Settlement services: assist with initial housing, Centrelink etc - English language (520 hours) - Mental health assessment
    14. 14. Prior to arrival  Minimal screening prior to arrival - General medical check  CXR as TB screen for those over 11 years  HIV testing for those over 15 years & unaccompanied minors  Hep B screening only on unaccompanied minors or pregnant women  Syphilis screening for those over 15 years, living in refugee camp  Urinalysis for those over 5 years  No previous requirement for immunisation  Changes in 2007: - MMR immunisation for those under 30 years - Malaria screening and treatment as required - Albendazole anti-helminthic treatment
    15. 15. Health problems  Growth & Development issues  Under-immunisation  Vitamin D deficiency  Iron deficiency, Anaemia  Poor dental health  Infectious diseases - Tuberculosis - Schistosomiasis - Malaria - Hepatitis B - Intestinal parasites  Undetected chronic disease  Hemoglobinopathies - Sickle Cell, Thalassemia  Psychological disorders - PTSD, anxiety, depression - detention, child soldiers, sex slaves  Physical consequences of war, torture - shrapnel injures - limb deformities - musculoskeletal pain - hearing loss
    16. 16. 37 44 20 19 18 15 13 10 8 5 2 Hep B Acute Infection – 3 Hep B Previous Infection – 4 Hep B Not Immune – 2 Strongyloides infection – 2 Schistosomiasis infection – 5 Vitamin D insufficient in all 11, 3 with borderline hypocalcaemia Newborn was at risk of Vit D deficiency at birth Microcytic anaemia – 1 Low ferritin - 1 Burundian Family
    17. 17. What is available in NSW?  Health care for newly arrived refugees is provided predominantly by GPs  Refugee Health Clinics - NSW Refugee Health Service: GP clinics, family focused, community based - HARK, Children’s Hospital at Westmead: tertiary based, child focused - Hunter Clinic, Newcastle: Family focused, multi-discipl., community based - GP clinics in Coffs Harbour and Wagga Wagga - SESIH GP Hospital Collaborative Care mode: Refugee Child Health Clinic
    18. 18. Refugee Children in NSW Summary of Health Screening in 2005 (n=330) NSW Refugee Health Service % Newcastle Refugee Clinic % HARK Clinic (CHW) % FBC (anaemic) 21 28 25 Schistosomiasis Pos 22 36 24 Hep B non-immune 55 70 81 Malaria 15 23 9 Measles/Rubella non- immune 19 None tested None tested Low Vitamin D levels 10 None tested 30 Mantoux >10mm None tested None tested 25 Mantoux +ve and CXR positive for TB None tested None tested 5 Raman et al. Australian and NZ Journal of Public Health,2009 Survey in 2005: 21% Refugee Children in NSW are being screened
    19. 19. Recommendations  RACP Policy Statement 2007: - Comprehensive health assessments for every refugee - Provision of publicly funded health care to all refugees which is of high quality, accessible, culturally respectful & affordable  Australian Society for Infectious Diseases / ASID Guidelines 2008: - Screening and management guidelines of Infectious Diseases for newly arrived refugees
    20. 20. Illawarra area 2007….  Innovative model of care  GP-Hospital Collaborative Care Model  Provide screening program to capture all new arrivals  Community based - refugee friendly GP’s as centre of care  Partnerships: settlement services, primary & tertiary health care services  Developed by Sydney Children’s Hospital (SCH) The Wollongong Hospital (TWH) Multicultural Health Service (MHS) Collaborative Care Model
    21. 21. Child/Family Settlement Services Linked GPs • Conduct routine comprehensive health assessment on arrival as per guidelines provided by Wollongong Hospital & Sydney Children’s Hospital • Refer to Refugee Child Health Clinic and/or Adult services as required • Provide ongoing family-centered care GP-Hospital Collaborative Care Model for refugee children and their families Sydney Children’s Hospital Refugee Child Health Clinic Wollongong Hospital Chest Clinic Multicultural Health Service • Liaise with GPs • Provide tertiary referral service • Maintain database/track health status • Proactive in follow-up and support through Refugee Health Nurse Methods
    22. 22. Screening tests  FBC + Ferritin  EUC, LFT  Vit-D, Ca, P04  Malaria T/T, Ag  HepBsAg, cAb, sAb  HepCAb  Quantiferon gold*  Chest clinic: CXR, Mantoux  Urine M/C/S  HIV (pre & post discussion)  Measles  Rubella*  Varicella  Schistosomiasis  Strongyloides  Syphilis  Gonorrhoea, Chlamydia PCR  & ßHCG Females >15 years All recommended by ASID except* Cost: $323.51 SESIH guidelines
    23. 23. What has happened after 18 months… For the period March 2007 – August 2008  100% of 81 children arriving on Visa 200 & 204 were seen by GPs  100% had recommended screening blood tests  28% were referred to the Sydney Children’s Hospital Refugee Health Clinic and / or Private Paediatricians  5% were hospitalised
    24. 24. Results  100% under-immunised  37% low Vitamin D (25-OH-Vit D<50nmol/L)  25% Schistosomiasis  11% anaemic  8% latent Tuberculosis  7% active Hepatis B infection (and 56% non-immune)  6% Strongyloides  5% Malaria  10% Entamoeba & other parasites  Mean number of health problems per child = 3  Range of health problems per child = 0–7 Conditions detected
    25. 25. Other gut infestations Stongyloides positive Schistosomiasis positive Abnormal TB screening Malaria Previous Hepatitis B Active and Chronic Hepatitis B MMR required Hepatitis B Immunisation required Vitamin D insufficient / deficient Iron deficient Haemoglobinopathies 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% Health problems detected
    26. 26. Progress...  Further evaluation over time (a larger cohort) was needed to allow analysis of differences in disease burden between groups within the cohort.  Can this Model work elsewhere or for larger populations?
    27. 27.  Information on refugees settling in SESIAHS on class 200 and 204 (refugee) visas provided by the Department of Immigration &Citizenship  Settlement services link families with designated GPs: - 138 (100%) screened - 12 children of refugee background on sponsored visas also screened  Of 150 children screened in the first 30 months (to September 2009): - 85 of African origin - 59 of South East Asian origin - 5 of Middle Eastern origin After 30 months…
    28. 28. Health problems detected African (n=85) SE Asian (n=59) Under-immunity to hepatitis B 57% 36% Active Hepatitis B 5% 2% Serum Ferritin <20 36% 20% Anaemia 18% 9% Positive TB specific antigen 15% 14% Malaria 8% 2% Schistosomiasis 26% 3% Strongyloides 6% 0% Rubella not immune 15% 20% Measles not immune 15% 7% Required MMR vaccine 27% 25% 25-OH Vitamin D <50 nmol/L 24% 16% Hepatitis C 0% 0% High rates of treatable and largely asymptomatic conditions in a complete cohort of newly arrived refugee children reinforces the need for a universal national screening program in Australia.
    29. 29. Can we improve ?  Screening of mental and developmental health?  What about long term?  A longitudinal study of refugee children has commenced to assess the long term physical and mental health, as well as the developmental progress.
    30. 30. Assessment of the health and well being of refugee children on arrival and at 6 - 12 months of their settlement J Paprckova1,2, K Zwi1,2, K Williams1,2, L Woodland3, J Lane3,4 1 Department of Community Child Health, Sydney Children’s Hospital 2 School of Women & Children's Health, University of New South Wales 3 Multicultural Health Service, SE Sydney and Illawarra Area Health 4 University of Wollongong
    31. 31. Significance  Existing research suggests that, while many refugee children display remarkable resilience and adaptability, mental health problems are often persistent, especially PTSD.  Little is known, about the contribution that physical ill health make to the psychological outcomes in this population.  The assessment at 6-12 months and broadens the comprehensiveness of the evaluation to include standardised development and mental health measures.
    32. 32. Significance  Extends the follow-up period to 1 year, as opposed to the initial screening only.  This will provide a more complete view of the child’s health status and better understanding of the holistic health needs of refugee children.  Study will add valuable information to the existing evidence base in this group of children.  Opportunity to identify any requirements to develop appropriate services especially, in the mental health area.
    33. 33. Objectives  Describe the health status of refugee children on arrival to Australia and assess their physical health, psychological well-being and development at 6 to12 months after their arrival.  Document their existing health conditions, evaluate their health care requirements and access to the services in our area.  Explore which pre- and post- arrival factors contribute to favourable health outcomes.  Address the health needs identified with recommendations for development of appropriate services, and further enhancement of existing programs.
    34. 34. Study population  Approximately 60 children (0-16 years)  Arriving in Australia from June 2009  Settling within the catchment area of SESIH  Recruited through the existing SESIH Refugee Health Program
    35. 35. Methods  Prospectively following a cohort of newly arrived refugee children for 12 months.  Describing health status, development and psychological wellbeing of refugee children on arrival and at 6 -12 months after the arrival.  Prevalence of identified conditions will be compared with Australian prevalence data and with the evidence reported in the international literature.
    36. 36. Methods  Explore factors contributing to the physical health & psychological well-being outcomes, analyse this data, and describe any particular patterns that emerge.  Potentially modifiable factors will be identified from those factors found to contribute to physical and / or psychological health outcomes.  Use this information to develop recommendations to improve refugee health services in the area.
    37. 37. Physical health Pre arrival health assessments  Health Manifests via DIAC  Past Medical History
    38. 38. Physical health Baseline assessment on recruitment  Performed by GP  Entered onto a database as per current routine screening program  Pathology screening as described earlier  Other investigations & routine physical examinations undertaken by GPs, Paediatricians and / or other specialists
    39. 39. Physical health Reassessment at 6-12 months  Weight  Height  Head circumference  Calculated BMI  Mid arm muscle circumference  Blood pressure
    40. 40. Psychological wellbeing Strengths & Difficulties Questionnaire (SDQ):  Emotional & behavioural problems  Children and young people (4-16 years)  Administered by Refugee Health Nurse
    41. 41. Development Australian Developmental Screening test (ADST):  Children 0-5 years of age  Administered by Refugee Health Nurse and Registrar  5 domains of development - Personal & Social - Language - Cognitive - Fine Motor - Gross Motor
    42. 42. Pre-arrival factors Comprehensive range of socio-demographic information  Name, DOB, gender, language  Country of birth, country of origin (parent/guardian’s country of birth)  Transit countries, time in refugee camps and/or detention centres  Family composition, Family history of health conditions  Information obtained from - Health Manifests - General Practitioners - Refugee Health Nurse
    43. 43. Post - arrival factors Semi-structured interview (SSI):  Interview with parents at 6 - 12 months  Administered by Refugee Health Nurse  Access to health services  Socioeconomic resources  Community support  Exposure to racism / discrimination
    44. 44. Post - arrival factors Social Readjustment Rating Scale (SRRS):  Parent report at 6 - 12 months  Administered by Refugee Health Nurse  Life events experienced over the preceding 12 month period  Changes in family composition  Employment of parent/s  Stability of residence and school placements
    45. 45. Screening tools  Instrument we chose are readily available to mainstream clinicians  No specific training required  Recommendations that we will develop can be used in practice
    46. 46. Limitations  Although the instruments for assessment of development and psychological wellbeing of children are internationally accepted, they haven’t been used in this population before.  Completing these questionnaires through the interpreter affects might affect the understanding and accuracy of the answers.  We have organised a specific training for the health interpreters that we are collaborating with during these assessments.
    47. 47. Limitations  Cultural, differences and stigmatism may have an effect on admitting and acknowledging any mental health problems.  Refugee families are likely to be a challenging group to follow up as they are known to be a population with high mobility.
    48. 48. Anticipated outcomes  A significant proportion of physical health problems resolve over the initial settlement period  Psychological health problems can be documented 6-12 months post arrival.  25 children enrolled in the study so far  Analysis aspect will be presented later
    49. 49. Acknowledgements  Multicultural Health Unit  The Financial Markets Foundation for Children  SCH Foundation  GESCHN  SCH Management Group: Jonny Taitz, Virginia Binns, Les White  SCH Departments - Infectious Diseases, Cardiology, Gastroenterology, Endocrine, Haematology, Genetics; Pharmacy  TWH: Craig Boutlis, Allan James  Wollongong Community Paediatricians  Allied Health Teams Wollongong  Chest Clinic, Wollongong & SCH  Immunisation Clinic SCH  SEALS: Roger Wilson  Public Health Unit SESIH  GP Division: Linda Blackmore  DIMIA Case Management Team
    50. 50. Remember, every encounter with a refugee is an opportunity to heal the past and bring hope or the future…