Chronic Health Conditions in the African community in AustraliaClinical Management, Treatment and Referral Options Dr Jill Benson Senior Medical Officer Migrant Health Service, Adelaide
Refugee profile • Approximately 13000 refugees/year to Australia • 30% from Africa • Sudan, Congo, Burundi, Liberia • 50% from Middle East • Afghanistan,Iran, Iraq • 20% from elsewhere • Burma, Bhutan, China • Up to 50% aged under 18 • Approx. equal numbers of men and women
African Refugee profile • Higher levels of poverty • Families often headed by female • Greater cultural differences • Larger families with lower levels of education and English proficiency • Older children have often been responsible for younger ones • Long periods (often >10 years) in refugee camps - extremely unsafe, infectious diseases, poor sanitation and diet • Come from areas where malaria, TB and other tropical infections endemic • Limited or disrupted access to health care
Concepts of survival vs health • ‘Survival’ is a priority, not necessarily health • Coping with challenges of resettlement • Dealing with grief, loss and dislocation • Unfamiliar with role of the health profession • Fear of being ‘sent back’ if chronically ill • No concept of preventive health care • Expectation that health will deteriorate with age • Housing and food • Health literacy • Caring for family • Education • Aspirations for a better life
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 • 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.
Increased risk of chronic disease in Australia • Genetic predisposition • Length of stay in Australia • Generation • Acculturation • Cultural beliefs and values • Parity • Stress • Poor housing • Physical inactivity • High alcohol consumption • Language barriers • Discrimination
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 but this is not a priority • 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
Common Chronic diseases • Diabetes • Hypertension • Asthma • Rheumatic Heart Disease • Coronary heart disease • Cerebrovascular disease • Hepatitis B • Mental Health problems • Pain
Abnormal initial screening tests • Important to do a full screen as there are other unusual causes of chronic disease • Schistosomiasis or Strongyloides • Nutritional and vitamin deficiencies eg Vit D, B12 • Anaemia – may be multigenerational • Hookworm and other worms that can affect Hb, protein etc • Liver problems caused by parasites, malaria, malnutrition • Kidney problems caused by dehydration • Infection load (ears, teeth, bowel, lungs) causing high ESR • Chronic lung disease from cooking fires • Injuries • Important to make sure we’re treating the patient and not just the blood tests
Difficulties with adherence to investigations, appointments, self-management and medications • Socio-political issues • The health professional • The patient • The health-professional-patient interaction • The organisation • In each culture there are different: • approaches to knowledge and health • communication styles • attitudes toward conflict • approaches to completing tasks • notions of time • decision-making styles • attitudes toward disclosure
Socio-political issues • Religious and traditional issues • Can affect attitude to management– God’s will • Fear of addiction to medication • Stigma • Denial of certain illnesses because of stigma eg TB, Hep B • View that diseases are contagious eg mental illness • Poverty and transport issues • Not enough money to pay for test or medication • Discrimination • Interpreters, staff attitudes • Health system literacy • Gender issues • Access to healthcare for women • Women often look after health of family rather than their own
The Health professional • Time • Communication style • Cultural awareness • Language • Expectations • Sticking to the ‘evidence’ • Hopelessness • Ethnocentricism • Only a small percentage of motives, beliefs and reactions are conscious for both health professional and patient • The ‘ethnocentricism’ of the health professional needs to be conscious to properly recognise the cultural beliefs and expectations of the patient • Learning about cultural practices • Countries of origin and transit, Gender expectations, Food – past and present, Relationships, Body language, Religion, Fasting, Attitudes to medication, Cultural health practices, Spiritual resources
The patient • Language • Importance of an appropriate interpreter • Literacy and Education • Draw pictures and other visual cues for medication etc • Difficulties with numbers, time • Health literacy • Importance of explanations and diagrams • Expectations – Conscious and unconscious • Expect a short-term treatment that will cure the problems • Unusual to have personal responsibility for health • Prevention of chronic illness a very foreign concept • Health is expected to deteriorate with age • Priorities • Education and care of family come before chronic illness • Grief • Resettlement
The health-professional-patient interaction • Mismatch of style • Authoritarian • Empathic • Informative • Collaborative • Use of Cultural Awareness Tool • Religious and gender issues • Differences in world-view • Ego-centric vs socio-centric • Patient-centred therapies • Narrative therapy • Inco-operating traditional therapy
Working with different views of illness • The health professional works exclusively within the biomedical model • The patient and health professional function exclusively within each of their own beliefs • The health professional works within the patient’s framework • The patient and health professional negotiate between their concepts of the cause of the problem/illness/disease and the most appropriate management to reach mutually desirable goals
Cultural Awareness Tool • 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? • 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 resultsyou hope to get from treatment?
The organisation • Time • Takes at least twice as long and usually even longer to see a refugee patient • Finances • Decreased remuneration as doing the same work in twice the time • Administrative support • Need to have cultural awareness training • Booking of interpreters • Multi-disciplinary team • Best way to support patients with complex issues, multiple problems or big families • Home visits from RDNS or nurse re insulin, using glucometer • Visits to supermarket • Support for health professionals who are ‘burning out’ or stressed
Diabetes • CALD Australians have significantly higher rates of diabetes, diabetes-related hospitalisations and deaths • Men born in North Africa have 3.6 times more diabetes • Increased reliance on convenience foods and not on healthy food prepared in the home • The ‘thrifty’ genotype • If undernourishment in pregnancy increased risk of insulin resistance in the children • Some ethnicities seem to have insulin resistance and some insufficient production of insulin • Pre-migration often very active with lots of walking to get to school or the shops, get wood or water • No TV or computer games • Often rapid weight gain within 5 years of arrival
Asthma and lung disease • In one study, traditional healers in Dar es Salaam, Tanzania were convinced that asthma is caused by “ingestion of amniotic fluid during birth” (83%), by “God” (75%), or “one inherits [asthma] from parents” (73%) • Traditional asthma remedies are usually tried without major success although some may contain pharmacologically active substances • May never have even tried any asthma medication • Women may have spent long periods of time tending fires indoors and have a restrictive component to their lung disease • Important to screen for TB
Hypertension in the African population • Different ethnicities metabolise medication differently • Africans suffer an earlier onset, greater severity and more end-organ damage • Twofold higher rate of stroke and 50% higher mortality from heart disease • ACE inhibitors less effective for blood pressure because of lower renin activity • May be best to use calcium channel blockers +/- diuretics for hypertension
Cardiovascular and cerebrovascular disease • Migrants are more affected than those born in Australia • Increased risk factors – smoking, diabetes, hypertension, diet • Language and other barriers mean the presentation is often late • Angina and TIAs are initially clinical diagnoses and so need accurate language • Safety to go out and walk • Difficulties with changing views of food • Difficulties with the idea of preventive health care and chronic medication
Stages of change • Precontemplation: The patient has no intention of changing their behaviour in the foreseeable future. The patient is perhaps unaware that there is a problem. • Contemplation: The patient is aware that a problem exists and is thinking about changing their behaviour but has no firm commitment to take action. • Preparation: The patient intends to change and develops a plan and a time-frame for its implementation. • Action: The patient begins to modify their behaviour to overcome the problem. This requires considerable commitment and energy. • Maintenance and relapse prevention: The patient works to prevent relapse. This stage may last for many months or years.
Precontemplation • Culturally specific identification of what constitutes health, chronic disease, and inevitability • Consideration of cultural norms, and the way things were ‘back home’ and influence on current health decisions and drivers for change • Consider all the experience and long-term influences on individuals’ current health status, and their capacity to change • Build family, environment, local community readiness to change at the same time as the individual is making changes • Identification of the problem requiring change from the patient’s perspective • Consideration of gender differences and new opportunities • Focus on health and, good experiences rather than disease
Contemplation • Value cultural experiences and traditional stories • Promote peer learning with community health workers or in groups • Focus on health and good experiences rather than disease • Build shared knowledge with family or community • Create opportunities for getting together and tapping into existing structures or groups • non-health-related groups work best for engaging people • Consider homogeneity of the group - disease, nationality, gender, purpose • Ensure appropriate content, delivery style, and language • Ensure health care setting is culturally appropriate and easily accessible • Celebrate/reward effective self management behaviour
Planning • Written and visual material culturally appropriate • Provide take home information for later reference • Focus on current strengths and skills • Generate written summaries of consultations using easily understandable or translated language • Support determination of goals and outcomes both short and long term • Use an approach which allows flexibility and change to goals as required • Provide ongoing support and long term management opportunities, 1:1 or group and access to facilities, peers, health workers etc • Pathways to existing services or facilities
Action • Support individuals to follow their own path with support • Involve communities and families with individuals’ changes to ensure sustainability within context of family, community, culture • Focus on health and good experiences • Offer one to one care in the context of family and community care • Provide pathway to support services and facilities
Maintenance • Provide a pathway to health service and community supports • Celebrate being part of a cultural group • Celebrate good health • Reinforce health management strategies as part of daily routines • Provide a pathway to support services and facilities • Provide ongoing group meetings/support networks if possible
Conclusion • Dealing with chronic health problems in the African community involves a wider range of potential illnesses, as well as an increased risk of some of the more familiar illnesses • Culturally appropriate education and management style are of the utmost importance • Recognition that there are many factors that may influence adherence to management plans • The health professional needs to be aware of the patient’s readiness for change • A multidisciplinary team and a culturally aware workplace is probably the best place to deal with more complex chronic health problems.
References • Grimmer-Somers K, Guerin M, Luker J, Jones D, Zucco. Chronic disease management for vulnerable and disadvantaged communities: Clinical Issues and Practical Suggestions (unpublished) • Renzaho A. (2007) Ischaemic heart disease and Australian Immigrants: the influence of birthplace and language skills on treatment and use of health services. Health Information Management Journal 36:2 pp 26-36 • Renzaho A. (2008) Re-Visioning cultural competence in community health services in Victoria. Australian Health Review 32:2 pp 223-235 • AIHW. (2003) A picture of diabetes in overseas-born Australians. AIHW Bulletin #9 • Renzaho A. (2002) Fat, rich and beautiful: changing socio-cultural paradigms associated with obesity risk, nutritional status and refugee children from sub-Saharan Africa. Health and Place 10 pp 105-113 • Renzaho A, Gibbons C, Swinburn B, Jolley D, Burns C. (2005) Obesity and undernutrition in sub-saharan African immigrant and refugee children in Victoria, Australia. AsiaPacJClinNutr 15:4 pp482-490 • Park I, Taylor A. (2007) Race and Ethnicity in Trials of Antihypertensive Therapy to prevent Cardiovascular outcomes: A Systematic Review. Annals of Family Medicine 5:5 pp 444-452 • Benson J. (2005) Concordance. Australian Family Physician 34:10 pp 831-834