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.

Promoting the inclusion of Afghan women and men in research: reflections from research and community partners involved in implementing a 'proof of concept' project.

INTRODUCTION: With mounting evidence that poor maternal and child health outcomes are related to the social determinants of health, researchers need to engage with vulnerable and isolated communities to gather the evidence that is essential to determine appropriate solutions. Conventional research methods may not ensure the degree and quality of participation that is necessary for meaningful study findings. Participatory methods provide reciprocal opportunities for often excluded communities to both take part in, and guide the conduct of research. METHOD/DESIGN: The Having a baby in a new country research project was undertaken to provide evidence about how women and men of refugee background experience health services at the time of having a baby. This two year, multifaceted proof of concept study comprised: 1) an organisational partnership to oversee the project; 2) a community engagement framework including: female and male Afghan community researchers, community and sector stakeholder advisory groups and community consultation and engagement. DISCUSSION: Inclusive research strategies that address power imbalances in research, and diversity of and within communities, are necessary to obtain the evidence required to address health inequalities in vulnerable populations. Such an approach involves mindfully adapting research processes to ensure that studies have regard for the advice of community members about the issues that affect them. Researchers have much to gain by committing time and resources to engaging communities in reciprocal ways in research processes.

How do Australian maternity and early childhood health services identify and respond to the settlement experience and social context of refugee background families?

BACKGROUND: Refugees have poor mental, social and physical health related to experiences of trauma and stresses associated with settlement, however little is known about how refugee families experience maternity and early childhood services. The aim of this study was to explore the responsiveness of health services to the social and mental health of Afghan women and men at the time of having a baby. METHOD: Participatory methods including community engagement and consultation with the Afghan community and service providers in Melbourne, Australia. Bicultural researchers conducted interviews with Afghan women and men who had recently had a baby. Interviews and focus groups were also conducted with health professionals working in the region. RESULTS: Thirty interviews were conducted with Afghan women and men who had recently had a baby. Thirty-four health professionals participated in an interview or focus group.Afghan women and men reported significant social hardship during the period before and after having a baby in Australia, but were rarely asked about their social health by maternity and early childhood services.Most health professionals recognised that knowledge and understanding of their client's migration history and social circumstances was relevant to the provision of high quality care. However, inquiring about refugee background, and responding to non-clinical needs of refugee families was challenging for many health professionals. Factors that made it more difficult for health professionals to engage with Afghan families in pregnancy included limited understanding of the context of migration, dependency of many Afghan women on their husband for interpreting, short appointments, and the high likelihood of seeing different health professionals at each antenatal visit. Community-based maternal and child health nurses had more scope to work with interpreters, and build relationships with families, providing a stronger foundation for identifying and responding to complex social circumstances. CONCLUSION: There are significant challenges in providing comprehensive, high quality primary health care for Afghan families accessing Australian maternity and early childhood services. The limited capacity of public maternity services to identify families of refugee background and provide tailored service responses are contributing to inequitable maternal and child health outcomes for families of refugee background.

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.

Afghan families and health professionals' access to health information during and after pregnancy.

BACKGROUND: Having a baby in a new country can be challenging, especially if unable to communicate in a preferred language. The aim of this paper is to explore the provision of health information for Afghan women and men during pregnancy, childbirth and the first year after birth in Melbourne, Australia. METHODS: Community engagement underpinned the study design. Qualitative study with bicultural researchers conducting semi-structured interviews. Interviews and focus groups were also conducted with health professionals. RESULTS: Sixteen Afghan women and 14 Afghan men with a baby aged 4-12 months participated. Thirty four health professionals also participated. Verbal information provided by a health professional with an interpreter was the most common way in which information was exchanged, and was generally viewed favourably by Afghan women and men. Families had limited access to an interpreter during labour and some families reported difficulty accessing an interpreter fluent in their dialect. Availability of translated information was inconsistent and health professionals occasionally used pictures to support explanations. Women and men were unsure of the role of health professionals in providing information about issues other than pregnancy and infant wellbeing. CONCLUSION: Both individual and health system issues hinder and enable the availability and use of information. Consistent, understandable and 'actionable' information is required to meet the needs of diverse families. Health professionals need to be supported with adequate alternatives to written information and access to appropriate interpreters. Inconsistent provision of information is likely to contribute to low health literacy and poor maternal and child health outcomes.

The physical and mental health problems of refugee and migrant fathers: findings from an Australian population-based study of children and their families.

OBJECTIVES: The aim of this study was to report on the physical and mental health of migrant and refugee fathers participating in a population-based study of Australian children and their families. DESIGN: Cross-sectional survey data drawn from a population-based longitudinal study when children were aged 4-5 years. SETTING: Population-based study of Australian children and their families. PARTICIPANTS: 8137 fathers participated in the study when their children were aged 4-5 years. There were 131 (1.6%) fathers of likely refugee background, 872 (10.7%) fathers who migrated from English-speaking countries, 1005 (12.4%) fathers who migrated from non-English-speaking countries and 6129 (75.3%) Australian-born fathers. PRIMARY OUTCOME MEASURES: Fathers' psychological distress was assessed using the self-report Kessler-6. Information pertaining to physical health conditions, global or overall health, alcohol and tobacco use, and body mass index status was obtained. RESULTS: Compared with Australian-born fathers, fathers of likely refugee background (adjusted OR(aOR) 3.17, 95% CI 2.13 to 4.74) and fathers from non-English-speaking countries (aOR 1.79, 95%CI 1.51 to 2.13) had higher odds of psychological distress. Refugee fathers were more likely to report fair to poor overall health (aOR 1.95, 95% CI 1.06 to 3.60) and being underweight (aOR 3.49, 95% CI 1.57 to 7.74) compared with Australian-born fathers. Refugee fathers and those from non-English-speaking countries were less likely to report light (aOR 0.25, 95% CI 0.15 to 0.43, and aOR 0.30, 95% CI 0.24 to 0.37, respectively) and moderate to harmful alcohol use (aOR 0.04, 95% CI 0.10 to 0.17, and aOR 0.14, 95% CI 0.10 to 0.19, respectively) than Australian-born fathers. Finally, fathers from non-English-speaking and English-speaking countries were less likely to be overweight (aOR 0.62, 95% CI 0.51 to 0.75, and aOR 0.84, 95% CI 0.68 to 1.03, respectively) and obese (aOR 0.43, 95% CI 0.32 to 0.58, and aOR 0.77, 95% CI 0.61 to 0.98, respectively) than Australian-born fathers. CONCLUSION: Fathers of refugee background experience poorer mental health and poorer general health than Australian-born fathers. Fathers who have migrated from non-English-speaking countries also report greater psychological distress than Australian-born fathers. This underscores the need for primary healthcare services to tailor efforts to reduce disparities in health outcomes for refugee populations that may be vulnerable due to circumstances and sequelae of forced migration and to recognise the additional psychological stresses that may accompany fatherhood following migration from non-English-speaking countries. It is important to note that refugee and migrant fathers report less alcohol use and are less likely to be overweight and obese than Australian-born fathers.

Compromised communication: a qualitative study exploring Afghan families and health professionals' experience of interpreting support in Australian maternity care.

INTRODUCTION: Difficulties associated with communication are thought to contribute to adverse perinatal outcomes experienced by refugee background women living in developed countries. This study explored Afghan women and men's experience of language support during pregnancy, labour and birth, and health professionals' experiences of communicating with clients of refugee background with low English proficiency. METHODS: Interviews were conducted with (1) Afghan women and men in the first year after having a baby in Australia, by multilingual, bicultural researchers and (2) midwives and medical practitioners providing care to families of refugee background. Analysis was conducted thematically. RESULTS: Sixteen Afghan women, 14 Afghan men, 10 midwives, five medical practitioners and 19 community-based health professionals (refugee health nurses, bicultural workers, counsellors) providing maternity or early postnatal care participated. Midwife and medical informants concurred that accredited interpreters are generally booked for the first pregnancy visit, but not routinely used for other appointments. Very few Afghan participants reported access to on-site interpreters. Men commonly interpreted for their wives. There was minimal professional interpreting support for imaging and pathology screening appointments or during labour and birth. Health professionals noted challenges in negotiating interpreting services when men were insistent on providing language support for their wives and difficulties in managing interpreter-mediated visits within standard appointment times. Failure to engage interpreters was apparent even when accredited interpreters were available and at no cost to the client or provider. CONCLUSIONS: Improving identification of language needs at point of entry into healthcare, developing innovative ways to engage interpreters as integral members of multidisciplinary healthcare teams and building health professionals' capacity to respond to language needs are critical to reducing social inequalities in maternal and child health outcomes for refugee and other migrant populations.