Dr Jill Benson Senior Medical Officer Migrant Health Service, Adelaide

1. Chronic Health Conditions in the African community in AustraliaClinical Management, Treatment and Referral Options Dr Jill Benson Senior Medical Officer Migrant Health Service, Adelaide

2. 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

4. 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

5. 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

6. 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

7. 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.

8. 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

9. 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

10. Common Chronic diseases • Diabetes • Hypertension • Asthma • Rheumatic Heart Disease • Coronary heart disease • Cerebrovascular disease • Hepatitis B • Mental Health problems • Pain

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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?

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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.

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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.

31. 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