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.

Rites of passage: improving refugee access to general practice services.

BACKGROUND: Refugees in Australia experience barriers in accessing healthcare services. The aim of this study was to analyse the factors influencing Afghan refugees' access to general practice. METHODS: A qualitative study on a single general practice in south-east Melbourne in 2013 was conducted. Data were collected using individual, semi-structured interviews and field observations. Data were analysed thematically and informed by the Penchansky and Thomas concept of access. RESULTS: The general practice utilised multiple strategies to improve access for refugees. Nevertheless, persistent barriers included language and cultural differences at reception, difficulties with transport to the practice, long wait times and the cost of care. DISCUSSION: This case study highlights the benefits of providing affordable, co-located, culturally responsive services with integrated interpreter and settlement agency support. Increasing the use of interpreters and translated materials at reception, and improving the coordination of patient transport assistance could enhance refugees' access to general practice.

Importance of community engagement in primary health care: the case of Afghan refugees.

Refugees can experience problems accessing and utilising Australian primary health care services, resulting in suboptimal health outcomes. Little is known about the impact of their pre-migration health care experiences. This paper demonstrates how the Afghan pre-migration experiences of primary health care can affect engagement with Australian primary care services. It considers the implications for Australian primary health care policy, planning and delivery. This paper is based on the international experiences, insights and expert opinions of the authors, and is underpinned by literature on Afghan health-seeking behaviour. Importantly, Afghanistan and Australia have different primary health care strategies. In Afghanistan, health care is predominantly provided through a community-based outreach approach, namely through community health workers residing in the local community. In contrast, the Australian health care system requires client attendance at formal health service facilities. This difference contributes to service access and utilisation problems. Community engagement is essential to bridge the gap between the Afghan community and Australian primary health care services. This can be achieved through the health sector working to strengthen partnerships between Afghan individuals, communities and health services. Enhanced community engagement has the potential to improve the delivery of primary health care to the Afghan community in Australia.

A cross-sectional survey of the mental health needs of refugees and asylum seekers attending a refugee health clinic: a study protocol for using research to inform local service delivery.

BACKGROUND: Refugees and asylum seekers have high rates of risk factors for mental disorders. In recent years, Australia has experienced a rapid increase in asylum seeker arrivals, creating new challenges for services in areas with high settlement numbers. This paper describes the design, including analytic framework, of a project set in a refugee health service in the state of Victoria, Australia, as part of their response to meeting the mental health needs of their burgeoning local population of refugees and asylum seekers. In order to assist service planning, the primary aim of this study is to determine: 1) an overall estimate of the prevalence of psychiatric disorders; 2) the specific prevalence of post-traumatic stress disorder 3) the perceived need and unmet need for mental health treatment. The secondary aim of the study is to establish matched risk ratios based on an Australian-born matched comparison group from the 2007 National Survey of Mental Health and Well-Being. METHODS/DESIGN: A cross-sectional survey is used to estimate the prevalence of psychiatric disorders in refugees and asylum seekers attending a local refugee health service. Measures include the Kessler Psychological Distress Scale-10, the Post-Traumatic Stress Disorder-8, the General-practice User's Perceived-need Inventory together with service utilisation questions from the National Survey of Mental Health and Well-Being. Data collected from refugees and asylum seekers (n = 130) is matched to existing data from Australian-born residents drawn from the 2007 National Survey of Mental Health and Well-Being (n = 520) to produce estimates of the risk ratio. DISCUSSION: The paper describes a prototype for what is possible within regular services seeking to plan for and deliver high quality mental health care to refugees and asylum seekers. A novel project output will be the development and dissemination of an epidemiological methodology to reliably compare mental health status in a relatively small target sample with a matched comparator group.

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.

A narrative synthesis of the impact of primary health care delivery models for refugees in resettlement countries on access, quality and coordination.

INTRODUCTION: Refugees have many complex health care needs which should be addressed by the primary health care services, both on their arrival in resettlement countries and in their transition to long-term care. The aim of this narrative synthesis is to identify the components of primary health care service delivery models for such populations which have been effective in improving access, quality and coordination of care. METHODS: A systematic review of the literature, including published systematic reviews, was undertaken. Studies between 1990 and 2011 were identified by searching Medline, CINAHL, EMBASE, Cochrane Library, Scopus, Australian Public Affairs Information Service - Health, Health and Society Database, Multicultural Australian and Immigration Studies and Google Scholar. A limited snowballing search of the reference lists of all included studies was also undertaken. A stakeholder advisory committee and international advisers provided papers from grey literature. Only English language studies of evaluated primary health care models of care for refugees in developed countries of resettlement were included. RESULTS: Twenty-five studies met the inclusion criteria for this review of which 15 were Australian and 10 overseas models. These could be categorised into six themes: service context, clinical model, workforce capacity, cost to clients, health and non-health services. Access was improved by multidisciplinary staff, use of interpreters and bilingual staff, no-cost or low-cost services, outreach services, free transport to and from appointments, longer clinic opening hours, patient advocacy, and use of gender-concordant providers. These services were affordable, appropriate and acceptable to the target groups. Coordination between the different health care services and services responding to the social needs of clients was improved through case management by specialist workers. Quality of care was improved by training in cultural sensitivity and appropriate use of interpreters. CONCLUSION: The elements of models most frequently associated with improved access, coordination and quality of care were case management, use of specialist refugee health workers, interpreters and bilingual staff. These findings have implications for workforce planning and training.

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.

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.