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2010 - African Australians: human rights and social inclusion issues project

A compendium detailing the outcomes of the community and stakeholder consultations and interviews and public submissions

7 Health

7.1 Overview

This section highlights the outcomes of the consultations in relation to health and health related issues for African Australians.

The right of everyone to the highest attainable standard of physical and mental health is an inclusive right, extending beyond healthcare to the
determinants of health, freedom from violence and discrimination, and access to health-related information and education.

It contains both freedoms and entitlements:

Freedoms include the right to control one's health, including the right to be informed and free from non-consensual treatment and experimentation.

Entitlements include the right to a system of health care that guarantees equity in access.

As part of the discussion on health issues, a series of focused consultations with relevant organisations were held, including a number of disability
and mental health services:

• two focus groups with staff and managers at the Victorian Foundation House for Survivors of Torture
• one focus group with staff and managers at the NSW Service for the Treatment and Rehabilitation of Torture and Trauma Survivors (STARTTS)
• one focus group with staff at Action on Disabilities in Ethnic Communities (ADEC)
• Survivors of Torture and Trauma Assistance and Rehabilitation Service (STTARS) (South Australia) were also involved in organising a focus group
  for the Project with members of the African women's support group.

Interviews were conducted with individual staff and managers at:

• Multicultural Disability Advocacy Association of NSW (MDAA)
• City of Melbourne.

It should be noted that questions relating to communities' experience of mental health services were met with concerns by the Forum of Australian
Services for Survivors of Torture and Trauma (FASSTT) who subsequently submitted formal correspondence to the Australian Human Rights Commission.
Despite concerns raised, the FASSTT reiterated their support for the project and their commitment to being involved in the research.

7.2 What are the main areas of concern for African Australians in regard to health, well-being and health care

(a) In their first year after arrival in Australia

(i) Community

Responses varied depending on one's entry to Australia, for example, under the refugee and humanitarian program or via another migration program. There
were, however, a number of common areas of concern in regard to health, wellbeing and health care. These were largely associated with the settlement
process and included:

• experiences of culture shock
• breakdown of family ties and community cohesiveness
• language barriers
• changes in food and diet resulting in health problems
• difficulties in accessing sources of traditional foods or finding halal foods
• poor appetite
• dental/oral health needs
• nutrition-related illnesses
• social isolation as a result of moving away from extended family networks
• ongoing medical problems as a result of FGM
• loss of employment or "under-employment" and its impact on wellbeing
• lack of access to culturally appropriate health services
• inter-generational conflicts
• breakdown of traditional cultural lifestyles and values
• discrimination and racism.

Language barriers were frequently cited as a critical issue particularly in terms of ensuring effective communication with health professionals:

"When people don't speak English then they either don't get help for their health problems or they go to the doctors and try to understand as much as
possible. It's not good when the doctor or other health professionals don't use an interpreter."
(Community Participant, WA)

Sensitivity surrounding health issues, in addition to understanding medical terminology, can make understanding or communication difficult even with
the use of interpreters.

The experience of culture shock and its impact was frequently cited by community respondents as having profound impact on their health and wellbeing:

"It is very hard to just find yourself completely without all the things you felt comfortable about. All the things that felt like your home, your
family, your culture, it's all cut off from you. And then you haven't even got time to think about it because you are out there trying to find housing,
employment...."
(Community respondent, NSW)

Other factors involved in poor health include overcrowded living conditions and a lack of access to immunisation, health care facilities and education
for those who spend lengthy periods in the refugee camps.

Many community respondents referred to issues related to oral health, and their apprehensions about visiting a dentist, as some had never had dental
care with the majority never exposed to common preventive measures.

Stress and tensions relating to intergenerational issues were repeatedly raised by community respondents. Children and adolescents frequently become
language brokers as their English skills often advance more rapidly than those of adults. Community respondents were concerned at the speed with which
their roles as parents changed, and the experience of being displaced further by their children.

A number of respondents also stressed the point that six months of IHSS services was insufficient, and that withdrawal of service often meant that many
did not continue to attend appointments relating to the maintenance of their health.

Finally, experiences of discrimination, racism and in some instances outright hostility were also cited. Repeated exposure to either actual or
perceived acts of discrimination was reported as having an ongoing negative impact on personal wellbeing and on interpersonal relations both with
family and with the broader Australian community. Coping strategies varied considerably:

"I think the hardest thing about being discriminated is when you are really not sure that you are being discriminated against. I go through this talk
in my head that says I should stand up against it, but then I start to feel unsure - maybe it's me and then I just get angry that I even have to go
through this."
(Community respondent, SA)

(ii) Stakeholders

Stakeholders identified similar issues to those identified by community respondents. The following key areas of concern were highlighted, with
particular reference to newly arrived refugee and humanitarian entrants:

• Specific health conditions that are epidemiologically different such as higher rates of infectious diseases (such as malaria and tuberculosis),
  and nutritional deficiencies such as vitamin D and Vitamin A,
  "Some women who have been in refugee camps for a long time may not have had the opportunity to learn from mothers or aunties things like how to cook
  for their families and so on. This means then that they struggle with things like nutrition for their babies and children, so we find there are
  nutritional problems that come up"
  (Stakeholder, WA)

Some clients were reportedly suffering from a wide range of chronic illnesses including hypertension, heart disease and diabetes, and several
stakeholders expressed the view that these often remained untreated.

Psychological problems such as depression, anxiety and post‐traumatic stress disorders due to prolonged exposure to war or violence were
repeatedly identified by stakeholders as a key issue:

"The way that people respond to torture and trauma is complex, and often linked to transition. Some people struggle, but most get through it. There is
a percentage of the community where they have not had the supports, and so therefore are more affected."
(Stakeholder, NSW)

Stakeholders expressed the view that health issues were often made worse by the fact that most newly arrived community members tend not to be familiar
with the health and community services system and as such were less likely to follow up on health concerns.

A small number of stakeholders expressed the view that health screening conducted overseas were inadequate and that conditions such as anaemia, Vitamin
D deficiencies, and various infectious diseases were not being properly detected.

(iii) Public submissions

Information regarding health issues for African Australians were offered by almost half (44%) of the submissions.

According to the submissions, the main areas of concern for African Australians in regard to health, wellbeing and health care are:

• lack of knowledge of good hygiene practices
• lack of knowledge regarding sexual health
• lack of knowledge about nutrition
• overeating due to the availability of food
• cultural beliefs in the value of sugar, cocoa cola and palm oil
• some children have arrived with the effects of rickets due to a lack of calcium in their diet and inadequate exposure to sunlight
• vitamin D deficiencies
• resistance to healthy dietary changes
• lack of knowledge about the importance of exercise
• some adult inactivity is resulting in obesity and diabetes, and worsened by depression
• lack of interpreters are problematic in some areas
• the practice of African Australians politely agreeing that they understand doctors when they do not
• some African Australians become overwhelmed and confused about using the medical system when service provision is not systematic and
  appropriately clear.

(b) In the longer term

(i) Community

A number of community respondents were of the view that many of the health related issues identified during the first year of settlement, when not
properly identified or addressed, continued to intensify and become more acute. Inability to successfully navigate the health system was also
identified as having a significant impact on access to services.

Additional issues included:

• ongoing social isolation - continued grief in relation to the loss of extended family support systems
• drug and alcohol abuse, particularly by disengaged young people
• under age pregnancies/multiple and/or unplanned pregnancies
• changes in families and roles contributing to family breakdowns and family conflict
• loss of cultural identity
• family violence issues
• intergenerational conflict.

A number of issues specific to women were also raised, including accessing antenatal and postnatal care and the issue of postnatal depression:

"Some women may not have had contact with a doctor when they are pregnant because of different cultural practices and beliefs about pregnancy and
childbirth, or because they still lack the confidence to get this service. This can happen even after three or four years of arriving in Australia."
(Community participant, SA)

Refer also to the following sections of this document for additional information about specific issues for women.

(ii) Stakeholders

Similar to the views expressed by community respondents, stakeholders stressed the need for early intervention in order to prevent long-term health
problems.

Several respondents said that psychological issues do not cease when refugees reach their country of settlement. In fact for many, psychological
distress may intensify as they deal with the stressors of the early resettlement period.

"Mental health is very much neglected during this time unless it is an extreme problem. Immediately upon arrival, most African Australian refugees are
highly motivated to get housed, obtain employment, ensure that their children are schooled, and so on. Only after these things have been put in place,
do people then find that mental health issues are emerging. This could take three, five, even ten years to identify and address. Sometimes it may never
be properly identified."
(Stakeholder, Vic)

Stakeholders expressed the view that cultural reluctance to discuss issues of a personal nature often meant that people did not seek treatment, and so
the problems exacerbated leading to other problems such as drug and alcohol abuse, family breakdown and family violence.

Stakeholders also identified issues for children and adolescents who may have been subjected to pre arrival trauma, particularly if those experiences
have not been properly identified:

"We see some of the younger children in particular experience real problems at school, and teachers or other professionals not identifying what the
real issue is, and they either end up withdrawing or launching into bouts of rage which leads them to the principal's office."
(Stakeholder, NSW)

Other issues for children that were identified by stakeholders included delayed growth and development because of nutritional deficiencies.

The issue of suicide and self-harm was raised by some stakeholders, with a small number making reference to recent examples of suicides within African
Australian communities.

In Tasmania, a partnership has been formed between the Mental Health Team of the University Department of Rural Health based in Launceston, and the
Phoenix Centre, the specialist service for survivors of torture and trauma, based within the Migrant Resource Centre (Southern Tasmania). The primary
goal of the project is to increase the capacity for prevention, intervention and post intervention management of suicide-related crises in refugee and
other vulnerable migrant communities and associated support services in Tasmania.

(c) Does the Australian health care system adequately meet the needs of African Australians, especially newly-arrived refugees? Please provide some
examples.

(i) Community

Responses to this question varied from state to state, and both positive and negative experiences were cited.

Most community respondents from Tasmania were extremely positive about their experiences of the health system, citing specific programs that were
perceived to have improved both access to services and the quality of service provision.

Particular mention was made of the Bi-Cultural Community Health Program. This program was seen to assist those who are newly arrived
in Tasmania, especially refugees, to make informed decisions and independently access appropriate health services.

Other community respondents from different states and territories, however, were more likely to express the view that the health care system was
falling short of meeting the needs of African Australians, especially newly-arrived refugees. Specific gaps identified included:

• Medicare processes not well understood by community members
• lack of appropriately qualified interpreters, particularly within hospital and GP settings
• high medical costs - sometimes also the result of confusion in relation to programs such as the Pharmaceutical Benefits Scheme (PBS)
• inappropriate or stereotyped responses by health professionals; lack of cultural sensitivity.

Most respondents were of the view that African Australians should be offered the same level and type of health care as the general population,
including a balance between health promotion, disease prevention and treatment services.

Most explicitly stated that they valued doctors who listened to them, and almost all mentioned this quality when describing a good experience with a
doctor or the health system more generally.

Both state and federal governments in Australia are implementing a number of strategies to aim at addressing the health care needs of recently arrived
refugee communities. Positive programs provided by community respondents included:

Refugee Health Nurse Program

- is intended to optimise the long-term health of refugee community members through promoting accessible and culturally appropriate health care
services that are responsive to changing patterns of refugee settlement.

Please see:
www.refugeehealthnetwork.org.au/referral/Refugee-Health-Nurse-Program

Good Food for New Arrivals

- a nutrition awareness program designed to facilitate and improve access to sound and relevant information by newly-arrived humanitarian and refugee
families with young children (Association for Services to Torture and Trauma Survivors Inc. (ASeTTS) WA).

Please see:
http://goodfood.asetts.org.au/

The Refugee school health project (Vic)

- a key entry point for newly-arrived children under 12 and their families to health and welfare services.

Refugee Maternity Service at the Mater Mothers' Hospital

- was developed in response to an unmet community need and is based on a women and family centred care model that supports appropriate health care,
psycho-social support and resources for women of a refugee background birthing at Mater Mothers' Hospital.

Please see: http://brochures.mater.org.au/Home/Brochures/Mater-Mothers--Hosptials/Refugee-Maternity-Service

FaRReP Program

(and other state equivalents) - the project focuses on the prevention of FGM and increasing the access of affected women to information and services to
improve their sexual and reproductive health. FaRReP works to build trust with women and communities to promote the wellbeing and human rights of women
and girls.

Please see: www.health.vic.gov.au/vwhp/farrep.htm

It is important to note however, that social and family networks, including faith networks, were identified as being the most positive in terms of
improving immediate and long-term health of African Australians:

"What your community can give you in terms of support and breaking down isolation, strangers cannot. There really is no replacing these sources of
support."
(Community leader, SA)

(ii) Stakeholders

Stakeholder responses also varied significantly depending on the extent to which particular specialist health programs had been implemented in the
state or territory.

Several stakeholders identified a number of clinical service gaps which are particular to newly-arrived refugees:

• lack of acute community based mental health services able to identify, engage and manage refugee issues
• cessation of support for clients by settlement service providers after six months leading to inadequate follow up management for health
  conditions - hinders ongoing access to health care
• shortfall of specialised medical assistance in some areas/regions across Australia - inadequate number of appropriately skilled GPs
• complexity around the Medicare enrolment processes leading to lack of access to Medicare funded services and Pharmaceutical Benefits Schemes
• inadequate access to specialised screening and treatment services
• lack of suitably up-skilled bilingual/bicultural workers in primary health care support roles.

A small number of stakeholders raised the issue of child and adolescent health, suggesting that there has been little attention given to the
development of a systemic approach to child and adolescent health issues, although there continue to be services developed in response to identified
need.

Several respondents suggested that negative experiences of health care overseas can be a factor which may also affect access to care in Australia.

Examples of positive health care initiatives or responses included:

• timely on-arrival health assistance to new arrival refugees through prompt initial needs assessment and referral to appropriate primary health
  services by settlement service providers
• school lunches are a new concept for many new arrivals. Parents and children may require access to information and support to help them adjust
  to the cultural transition of providing lunch at school.

Overall, programs that maintain a holistic approach, recognising that nutrition and health cannot be separated from other goals and needs were
identified as being more successful in meeting the needs of African Australians.

(iii) Public submissions

A number of submissions stated that the Australian health care system in their local area does adequately meet the needs of African Australians,
including newly-arrived refugees. Examples include:

"In Queensland… most families are linked to a local GP who is experienced with newly arrived refugees. This has benefits as they have a
commitment to good information and are more aware of health problems that are endemic in Africa. Many we have worked alongside."

Most submissions, however, stated that the health concerns of African Australian communities were not adequately addressed.

"The general practical model of health service in Australia is not ideal in terms of meeting the needs of newly arrived African Australians."
(s16)

Major restrictions to equitable access to health care for migrant and refugee women identified were language and cultural barriers.

(d) As an African Australian, do you generally find Australian health services good quality and are staff professional and polite?

(i) Community

Responses to this question varied considerably, with examples of both negative and positive experiences provided.

Negative experiences included:

• discrimination and stereotyped responses
• lack of interpreter - reliance of non-medical family members resulting in wrong diagnosis
• lack of awareness of health professionals, particularly in relation to pre-arrival experiences of refugee and humanitarian entrants
• inadequate cultural skills and knowledge of professionals
• problems with translation and miscommunication

Several community respondents stressed the need for health professionals to spend more time finding out about clients' family and community
relationships, carefully explaining diagnoses and treatments, and listening to, incorporating, and facilitating community views on health issues and
traditional treatments.

African Australian women, particularly those who identified as being Muslim, reported experiencing widespread discrimination and disadvantage in
relation to accessing appropriate health care, particularly pre natal and peri natal health care.

Positive experiences included:

• health professions accessing appropriate interpreters
• health professionals taking the time to explain the health issues
• the use of bi-cultural health workers who had an understanding of the cultural issues
• health practitioners showing respect for traditional methods of healing
• provision of gender specific health practitioners.

(e) Please comment on any gender-specific or youth-specific health issues for African Australians.

(i) Community

Women

Community respondents raised a number of specific health concerns in relation to African Australian women. These included:

• sexual health issues amongst newly-arrived young women, particularly unplanned pregnancies
• lack of traditional and family support networks, particularly apparent during pregnancy and child birth experiences
• refugee women may have suffered from poor nutrition during early pregnancy which may give rise to health problems
• prior exposure to particular infectious diseases, such as malaria, hepatitis or TB, that can complicate childbirth
• under representation of women in programs, such as the chronic conditions self-management strategy
• inadequate translation services for women who could not speak English
• in the absence of the extended family to help with care giving, women with infants have little opportunity to move beyond the domestic sphere
  and are isolated from the wider community
• provision of specialist services and multidisciplinary care for women with complex mental health or social problems, including substance misuse
  and domestic violence, generally experienced as inadequate.

Issues related to FGM (female genital mutilation) were specifically identified by many of the women only focus groups that were conducted across each
of the states and territories. Issues included:

• mismanagement of care during pregnancy and labour
• lack of appropriate levels of clinical knowledge and skills by midwives.

Attention needs to be paid to ensure continuity of care, maximising verbal communications and challenging stereotypical views of women from affected
communities.

Many African Australian women said that they prefer to see health professionals of the same gender, particularly for matters surrounding sexual and
reproductive health.

Several consultation sessions were conducted with older African Australian women. Many within those sessions said that they were largely unaware of the
range of services that might be available to them and that English language proficiency increased their vulnerability to poorer health outcomes.

One project that sought to specifically address issues for older African Australian women was the Inspired Arts Project. The women are from the Horn of Africa Senior Women's Program and many have arrived in Australia under a Women at Risk program.

Youth specific health issues

Respondents identified the follow issues as impacting on the health and wellbeing of newly-arrived children and young people from African Australian
backgrounds:

• loss of family members
• dislocation
• little or no experience of school, or very disrupted schooling
• racism and discrimination
• drug and alcohol abuse
• lack of nutritional knowledge
• sexual health issues: lack of information, early pregnancy, sexually transmitted diseases
• dealing with conflicting norms and expectations from their own culture and that of the new culture
• low confidence and low self-esteem
• torture and trauma recovery
• difficulties in establishing trust and friendships
• suicide.

A number of young people said that there was an urgent need for health programs that specifically target young African Australians and that recognise
and celebrate their resilience. For example, the refugee health clinic at the Royal Children's Hospital plays a key role in assessment
and care of newly-arriving refugee children and young people.

There are a number of other programs in each of the states and territories that have an interest in young people's health and wellbeing which have a
particular focus on refugee young people, including some school nurses and school focussed youth services. There are also funded youth worker positions
under the DIAC settlement grants program.

Young people spoke strongly of the desire for better futures and opportunities to make their communities and families proud, but felt that they had to
contend with discriminatory and stereotyped attitudes on a regular basis.

There were a number of examples of projects aimed at improving the health and wellbeing of young newly-arrived African Australians. These included:

The Sudanese 'Lost Boys' Association of Australia

(SLBAA) is a not-for-profit organisation which provides recreational programs and support networks for Sudanese youth living in Australia. One of the
programs the group runs is the leadership training and mentoring program which develops leadership and communication skills for newly-arrived Sudanese
young people from across Victoria.

Please see: www.lostboys.org.au

Ayen's Cooking School

This is a project of Supporting Survivors of Torture and Trauma in South Australia which aims to improve the nutrition, health and wellbeing of young
male Sudanese refugees living in Adelaide by teaching them how to prepare and cook food. The cooking and nutrition classes provide an opportunity for
social interaction with the local Sudanese community, help participants rediscover their cultural identity and assist in the adjustment and settlement
process.

The needs of newly-arrived African Australian young people are different to the needs of second or third-generation young people and this was
particularly emphasised by young African Australians born in Australia.

Sport, recreational, and artistic programs were seen to be the most effective in terms of addressing some of the specific health issues that may emerge
from discrimination and racism.

(f) What are the issues for African Australians with disabilities in relation to the Australian health care system?

(i) Community

Community respondents raised a number of issues related to African Australians with disabilities, including:

• limited understanding of the health needs of people with disabilities amongst health providers
• stigma within communities can prevent carers from accessing appropriate support services
• cultural issues in relation to disability
• issues around child care, particularly for single women with disabilities, or women who have children with disabilities
• social isolation, difficulties accessing education and anxieties about the future are some of the other challenges confronted by young people
  with disabilities.
  "There isn't a lot of work done in African communities because they think that you shouldn't discuss disabilities in the public realm. There is a view
  that it should be a responsibility that is carried by the family rather than government."
  (African Disability Support Worker)

There are also a range of cultural issues in relation to disability that need to be addressed, such as the fact that in some languages there is no
overall word for 'disability'.

"The concept of disabilities isn't something that you would respond to in any formal way. It would be a traditional approach, and the community would
just absorb it into the community. Health and illness is something that comes from God and there is nothing you would do about it."
(Community Participant)

Community respondents were of the view that African Australians were not likely to be aware of the range of services and supports available and lack
the knowledge necessary to access appropriate services in relation to disability.

(ii) Stakeholders

There were a number of specific consultation sessions that were conducted with agencies/organisations that had a specific focus on working with people
with disabilities. Participating organisations included:

• Action on Disabilities in Ethnic Communities (ADEC) (Victoria)
• Multicultural Disability Advocacy Association of NSW (MDAA).

Specific feedback was also received from Melbourne City Council, who had recently undertaken research in relation to the experiences of African
Australians with disabilities and their carers.

Each of these stakeholders provided considerable insight into the range of issues impacting on people with disabilities from African Australian
backgrounds.

Broadly, the issues identified included:

• African Australians with a disability face many disadvantages and neglect including family and personal humiliation resulting from
  discrimination
• cultural factors such as stigma and different attitudes towards disability within some African Australian communities
• service access and availability continues to be a major issue
• many families supporting people with disability may make the difficult decision to leave behind a family member in order to build a life in
  Australia
• the current migration health assessment may give rise to unjustifiable indirect discrimination against refugees and migrants with disability
• there is general unfamiliarity with respite services and the distrust of paid caters who might be insensitive to Muslim practices.

Organisations such as multicultural advocacy providers and multicultural resource centres played an important role in connecting people and providing a
vehicle and opportunity for people to have a voice. ADEC staff spoke about the Somali Education project with the Somali community in the Northern
Region in 2008/09. The project identified a number of specific issues for African Australians with disabilities including:

• the Somali community responds quite well to information and advice provided by their local Sheiks and Imams
• educating sheikhs and Imams could also help to reach the community members whom are unable to attend education sessions due to time restraints
• there is evidence that Somali refugees settled in Western countries have low rates of access to mental health services.

The researchers in the Somali project discovered that different ways of categorising mental health problems are used by this group, in comparison to
Australian mainstream health providers. Difficulties prior and subsequent to their forced migration from Somalia were perceived to be major causes of
distress.

It was found that many of the participants felt that health services were inappropriate for some mental health problems, as these situations were
viewed more as social or spiritual problems than illnesses.

7.3 Mental health and wellbeing

(a) If you used a torture, trauma and rehabilitation service, did it help to meet your needs? Do you have any suggestions for improvement to the
service?

Note: As noted in the introductory part of this section, concerns were raised by the Forum of Australian Services for Survivors of Torture and Trauma
(FASSTT) in relation to this question. Despite concerns raised, FASSTT reiterated their support for the project and their commitment to being involved
in the research.

(i) Community

Torture and trauma services provide specialist psycho-social recovery and support services for people who have experienced torture and trauma in their
countries of origin or while fleeing those countries.

Advice received from DIAC highlighted that torture and trauma services are more likely to be of use from six to 18 months rather than during the
initial six months when entrants are experiencing culture shock, adjusting to acculturation, learning English, and being assisted in a multitude of
practical tasks during the settlement process.

Responses in relation to the above question of satisfaction with torture trauma services tended to be generic, with only a small number of community
respondents making specific references to their own personal experiences of torture trauma and rehabilitation services. Generic responses primarily
related to cultural issues associated with categorising stress related experiences as constituting 'mental health'.

Feedback regularly received throughout the consultations highlighted people's concerns that current approaches are too heavily weighted toward mental
health considerations, which tend to individualise and pathologise complex processes.

Comments in relation to barriers to accessing services were also frequently made. These included:

• communication difficulties
• cultural differences and cultural misunderstandings around mental health concepts and experiences
• services' lack of sensitivity and cultural understanding
• The mental health needs of older people in the African communities has been largely neglected
• In some communities a lack of understanding and the stigma attached to mental illness may prevent individuals or families from seeking help.

Several respondents suggested that information about the torture trauma services needed to be disseminated more widely in culturally appropriate and
responsive ways as there was a lot of misunderstanding about their role and the services that they provide.

Of the very few respondents who shared their personal experiences of services, these were both positive and negative. Positive experiences included:

• having cultural and religious considerations taken into account
• alternative health services provided
• opportunity to talk to others in own language
• normalising of the experiences.

Negative experiences included:

• feeling that you are having to tell your story a few times was stressful
• having to attend sessions that don't feel comfortable.

Although cultural factors provide many complexities for resettlement they also provide strength and resilience to communities. Feedback received from
respondents in most states and territories said that mental health services are not appropriately resourced to provide continuity of care and
culturally sensitive assessment and interventions.

(ii) Stakeholders

Focus groups were conducted with staff and managers at:

• Victorian Foundation for Survivors of Torture (Foundation House)
• The NSW Service for the Treatment and Rehabilitation of Torture and Trauma Survivors (STARTTS).

These groups provide a range of services including:

• medical and primary health services
• health promotion
• counselling and advocacy
• community capacity building.

Considerable feedback was provided in relation to the above question from service providers and other related agencies.

Much discussion revolved around the concepts of torture and trauma and approaches used in specialist services.

Respondents strongly rejected the view that that providing a service to respond to trauma amounted to pathologising clients:

"It is normal to have strong emotional or physical reactions following a traumatic event."

A strengths-based approach was promoted by respondents as the most effective way of providing effective quality services to the client groups:

"What we do now, is work with human potential. We educate services about the potential that people can bring."

This included a range of group activities for torture and trauma survivors who aim to assist and increase both the individual and community capacity to
improve overall mental health, by identifying and building on internal strengths, resources and skills:

"We try to find solutions to community issues and strengthen community groups and structures as part of a community development and community capacity
approach."

Community development is a critical strategy in sustaining the support given to survivors of torture and trauma. Community Development Programs also
aims to work with other service providers to respond to a wide range of community needs by providing culturally appropriate support and services.

Another key focal point for discussion with stakeholders was the importance attached to building the cultural capabilities of mainstream mental
health services:

"We have a critical role in contributing to service development and the planning and development of programs that will enhance service delivery by
mental health service staff to people from African Australian backgrounds."

Several stakeholders also highlighted the fact that torture trauma services and their staff reflected the communities that they worked with:

"If you look around STARTS there are people working from many of the communities - having someone who understands how the communities work. Community
leaders can work with the worker."

(iii) Public submissions

Issues relating to African Australians' mental health and wellbeing were addressed by over a third (38%) of the submissions.

The submissions revealed a number of pertinent issues relating to the mental health and well-being of African Australians. They include:

• African cultures usually do not recognise mental health as a medical issue requiring attention:
• "…there is not a concept of mental health or the therapeutic intervention of counseling in traditional African communities. Therefore symptoms of
  mental illness are not recognised as this and when the individual becomes sick the community response is to generally be one of hostility and to
  isolate them as a threat."
  (s60)
• The inability of the mental health system in Australia to adequately service African Australian communities:
• "Consultations conducted in 2005 on behalf of the Across-Government Working Party on Settlement Issues for African Humanitarian Entrants found that
  African humanitarian entrants were not receiving adequate treatment to overcome the impact of torture and/or trauma experiences. Specialist mental
  health services were overloaded and did not provide for the scale of demand for long-term treatment. In addition, there was no provision of services to
  provide torture and trauma counseling for children aged five to twelve years."
  (s55)
• A lack of appropriate mental health service provision is likely to result in compounding mental and physical health issues, social isolation,
  increased rates of alcohol and drug abuse, and increased incidences of crime and anti-social behaviour.

(b) How do the effects of family separation impact upon the mental health and wellbeing of African Australian families?

(i) Community

Most community respondents agreed that the effects of family separation upon the mental health and wellbeing of African Australian families were
significant and overwhelming:

"Mental health issues of one family member affect the whole family."
(Participant, community focus group, Vic)

Several respondents were of the view that many newly-arrived members were overwhelmingly preoccupied with locating lost family members, desperately
trying to find out whether they were dead or alive and therefore unable to make any long-term plans.

Another issue raised was the impact of fear for family remaining in the country of origin and under potential threat on the mental health of refugees.

(ii) Stakeholders

Service providers and others who work as counsellors with refugees reiterated the importance of adequate access to family reunion, primarily with one's
spouse and children, as an essential component in the recovery from trauma, for mental and emotional wellbeing and successful settlement.

Stakeholders also stressed the deleterious effects of family separation on the health and wellbeing of African Australians. Having family present can
ameliorate the psychosocial effects of traumatic events and gives newly arrived communities the emotional resources to begin to rebuild their lives in
Australia.

Those most affected by family separation are the most vulnerable - women, children and the elderly. For instance, in the absence of the extended family
to help with care giving, women with infants have little opportunity to move beyond the domestic sphere and are isolated from the wider community.

(c) How do you feel your mental health and wellbeing has changed since coming to Australia?

(i) Community

Some community participants highlighted that their mental health and wellbeing had deteriorated significantly as a result of a number of key factors
including:

• family breakdown, including intergenerational conflict
• inappropriate interventions by service providers, particularly in relation to children
• racism and discrimination.

Other related issues included:

• unemployment and underemployment
• access to affordable and appropriate housing options.

Some women, who are also Muslim and African, felt that their mental health and wellbeing had deteriorated and that many did not feel that things would
improve again.

Concerns relating to suicide in communities were also raised by some community respondents.

(ii) Stakeholders

Several stakeholders were keen to reflect on the implications of past approaches to responding to the mental health needs of refugee and humanitarian
entrants:

"Refugees who arrived 20-30 years ago, their mental health needs were often not addressed and as a result these people now have exacerbated mental
health issues..."

Several stakeholders were still of the view that many mainstream mental health services are still lacking cultural competency in working with CALD
clients, particularly African Australians, and there continues to be a lack of use of interpreters.

Several stakeholders also raised the importance of meeting important settlement needs such as employment, education, access to health care and
appropriate housing, as essential to ensuring improved health and wellbeing overall.

(d) How can the stigma attached to mental health be addressed in African Australian communities?

(i) Community

The issue of stigma associated with mental health was discussed in a number of community focus groups, particularly in Victoria and NSW. Community
respondents raised the following issues:

• stigma can have very serious negative impacts on people, families and whole communities and adds to the burden of living with a mental illness
• in some cultures certain health issues, such as mental health, are not discussed
• the structure of one-on-one counselling is also not familiar to some cultures.

Suggestions in relation to addressing stigma included:

• developing more creative ways of increasing community awareness in relation to the impact that settling in a new country has on mental health
• utilising cultural values and belief frameworks that empower communities to address the issues in ways that are most appropriate for them
• respected community leaders, especially spiritual and religious leaders in most communities, were identified as a crucial resource when dealing
  with mental health issues
• increasing opportunities for participation in services and activities by assisting with transport.

One strategy that was suggested involved the increased use of local media in particular ethnic community radio and newspapers as a way of promoting
messages about mental health.

Peer mentoring programs for young people were cited as particularly effective in challenging stigma. The example was given of the Multicultural Centre for Mental Health and Well-Being in Queensland which is currently conducting a peer mentoring program for young,
newly-arrived African refugees living in Brisbane.

In collaboration with the local African community, the Centre will train older established African youths to act as mentors for young newly-arrived
African refugees, many of whom have limited family support. On arrival, these younger refugees will have immediate access to support from their older
peer mentors to help them adapt to life in Australia.

(ii) Stakeholders

Stakeholders highlighted the stigma associated with mental health amongst many African Australian communities, and stressed the need for more
comprehensive public information and education for African Australians, particularly in relation to:

• mental health risk factors
• how to prevent mental illness and promote mental health
• how to seek assistance.

Stakeholders stressed the need to develop effective communication strategies to demystify mental health, including the translation of information in
all relevant language groups. The translated information needs to take into account the different understandings of mental health in different
cultures.

Better engagement with elders, community and spiritual leaders to gain their respect and trust and to receive their input regarding how people in their
communities view mental health and mental illness was also highlighted.

Stakeholder respondents also reiterated the need for early intervention and prevention programs that target newly arrived young refugees, who are at
risk of developing mental health and behavioural problems, and may be at risk of coming into contact with the juvenile justice system.

(e) Can you provide best practice examples of how to treat sustained mental health issues for African Australians?

(i) Community

Several focus groups highlighted the need to recognise the resilience of many refugees, even afterserious trauma.

A repeated success factor in relation to responding effectively to mental health issues was ensuring that the approaches were 'family inclusive'. An
example was provided where three communities (Liberian, Sudanese and Somali) were supported to develop and implement their own ideas about how best to
meet the needs of their families and their communities.

The project was considered to be highly successful in terms of community building, with each group using the opportunity to strengthen and expand their
own network:

"The real success was that it involved community members themselves and it didn't ignore the fact that our communities are really suffering."

The Families in Cultural Transition was also cited by community respondents as a good practice example of responding in sustained ways
to mental health issues. The (FICT) program is a 10 week series of workshops designed to help newly arrived refugees learn about Australia and settle
successfully in their new country.

As well as finding out about Australian culture and systems, participants talk about how their torture and trauma experiences may affect them and their
families. They also learn about organisations that can help.

(ii) Stakeholders

Stakeholders referred to the following projects as examples of responding in a sustained way to the mental health needs of African Australian
communities:

Stepping Out of the Shadows: Promoting Acceptance and Inclusion in Multicultural Communities in QLD

- this project between Multicultural Mental Health Australia and Action on Disabilities in Ethnic Communities - is aimed at reducing stigma that exists
around mental illness and increasing mental health awareness in multicultural communities in Queensland. There are currently 12 communities that have
Bicultural Mental Health Promoters who are working directly with them to raise awareness of stigma around mental illness, and running free group
education programs with interactive activities in a range of community languages.

Please see: www.adec.org.au/Steppingoutoftheshadows.htm

The Victorian Foundation for Survivors of Torture (Foundation House)

- provides a range of counselling and other services for refugee survivors of torture and trauma, including the refugee mental health clinics at
Brunswick and Dandenong.

Please see: www.foundationhouse.org.au

Complex Case Support (DIAC)

- supports refugee and humanitarian entrants where pre-migration experiences, severe physical and mental health conditions, or crisis events after
arrival in Australia present significant barriers to successful settlement. The intention of the program is to provide flexible, tailored, local
responses to meet the individual needs of people who have particularly high levels of need which cannot be met through existing settlement services. A
panel of more than 30 organisations has been set up to deliver CCS services, and referrals must be made through DIAC who will allocate cases to panel
providers depending on the identified need.

Please see: www.immi.gov.au/living-in-australia/delivering-assistance/government-programs/settlement-programs/ccs.htm

(iii) Public submissions

Suggestions for improving torture, trauma and rehabilitation services given in the submissions include:

• research and develop best practice methods for providing culturally appropriate and effective trauma counselling for African humanitarian
  entrants
• extend access to counselling services for new arrivals to a minimum of two years
• establish an orientation program where refugees are introduced to service providers
• partner counselling services with other key settlement service providers, such as education and general health, to provide a more coordinated
  and holistic service
• develop partnerships between schools and torture and trauma counselling services
• make STARTTS more face-to-face and utilise interpreters
• make sure interpreters are completely neutral; do not use relatives or friends
• train medical practitioners, allied health workers and pharmacists in using STARTTS
• inform all new arrivals about doctor confidentiality, and use translated brochures and DVDs to promote understanding about doctor
  confidentiality, privacy information, informed consent and how to make treatment decisions.

7.4 Access to health services

(a) What are examples of successful ways to explain the Australian health care system to newly-arrived Africans?

(i) Community

Community respondents made reference to a range of ways in which information related to the health care system was successfully provided to newly
arrived African Australians. Broadly these included:

• support and strengthen the ability of individuals, families and refugee communities to improve their health and wellbeing outcomes
• information sessions provided in the language of the audience
• participation and involvement from communities themselves to help them better adjust to their new lives
• fostering connections with cultural, social and religious groups of their own ethnic background
• using a variety of methods of support that extend beyond just counselling models
• training and utilisation of bicultural community trainers
• ensuring the availability of female carers within the antenatal period
• gender specific interpreters in the delivery of health services
• bridging courses for overseas trained and qualified health professionals.

(ii) Stakeholders

Stakeholder respondents made reference to a number of strategies and programs aimed at improving awareness amongst African Australians of the health
care system.

Examples included:

• Refugee Health Nurse Program
• The Refugee School Health Project
• Refugee Maternity at Mater Mothers' Hospital.

Most stakeholder respondents also stressed the importance of building capacity and expertise of mainstream and specialist services and health care
practitioners in refugee health care.

Since July 2007, the Refugee Youth Active and Connected with Everyone (RYACE) program has been building individual and community
resilience for refugee youth from Melbourne's northern and western suburbs. Spectrum Migrant Resource Centre runs the program's activities, which
include: basketball, art classes, water safety training, healthy eating talks, one-on-one counselling.

Please see: www.livingisforeveryone.com.au/Refugee-Youth-Active-and-Connected-with-Everyone-RYACE.html

(iii) Public submissions

Issues relating to African Australians access to health services were addressed by close to half (43%) of the submissions.

Main areas of concern for African Australians in regard to accessing health services in Australia highlighted in the submissions include:

• language difficulties and lack of available interpreters
• lack of interpreting services available (s69)
• restricted access to Medicare and private health insurance due to citizenship status and low income
• lack of timely access to specialist services when needed due to lack of private health cover and low income
• females are less likely to access health services due to cultural principles
• the cultural stigma associated with accessing mental health services exacerbate problems
• some African Australians do not understand the importance of maintaining a regular GP which results in incomplete medical histories and poor
  continuity of care.

(b) Even though African Australians may know how to access certain health services, they do not always utilise all the services that they are
offered and entitled to. What can be done to change this?

(i) Community

Most community respondents challenged the notion that cultural barriers were greater than lack of awareness of services; with most insisting that the
biggest barrier to accessing services for most of the community is a lack of information.

Community participants did say that the lack of cultural appropriateness of a service would deter them from utilising or accessing that service.

Community respondents attending an ethno specific session made reference to what they perceived to be an important element in traditional Oromo
thinking:

"There is a belief that a person who has mental health issues is believed to possess an ayana, which is a special divine agent that can descend upon
people, but also means a person's character and personality. In the traditional Oromo society, the Kallu is the religious leader who, can investigate
the causes of the disorder and advise what to do."

Other barriers identified included factionalism in communities which sometimes meant that interpreters from within those communities would not be
called to provide interpreter services. Religious differences might also impact on patterns of service utilization.

(ii) Stakeholders

Stakeholders also identified cultural issues as having a significant impact on utilisation of particular health services amongst African Australians:

"When Africans migrate to live in Australia they bring with them their understanding of health, their customs and beliefs. These may be in direct
conflict with the approaches taken by western health providers."
(Stakeholder, SA)

Several stakeholders suggested that a significant proportion of African Australian women only access care when their condition becomes acute, with a
generally low participation rate in preventative health care measures.

Culturally appropriate education materials empowering healthy lifestyles, encouraging preventive care and explaining the intricacies of health system
utilisation would be of benefit.

Providing refugees with a package of information in their own language through settlement support services on arrival in Australia could address this
need. This might be a very efficient and effective way of conveying information which otherwise may not be automatically provided by GPs or other
primary health care providers who may not have the resources available at the time of consultation.

(iii) Public submissions

Some examples of services that are addressing the general and mental health needs of African Australians include:

• The Drug and Alcohol Office in WA is offering interpreting services to callers to the Alcohol and Drug Information Service
• The Victorian Refugee Health Network Model
• The Logan Refugee Clinic in Queensland
• Transcultural Mental Health NSW provides cultural sensitivity and awareness training for medical workers
• Migrant Health Clinics
• Princess Margaret Children's Hospital
• Community based refugee health nurses
• The Western Australia Migrant Health Unit
• The Multicultural Services Centre in North Perth has established a community based specialised mental health service
• The North Metropolitan Child and Adolescent Mental Health Service cater to the specific needs of CALD families
• The South Metropolitan Area Health Service (Mental Health)
• ASeTTS in WA provides specialist services to promote wellbeing of torture and trauma survivors
• The WA Perinatal Mental Health Unit at King Edward Hospital consulted with refugee women and produced resources in Iraqi, Sudanese and Ethiopian
  languages explaining mental health issues associated with the perinatal period.

(c) How can interpreting and translation services be improved to provide better access and assistance to African Australians in the health sector?

(i) Community

Community respondents agreed that limited English language proficiency was a common barrier to accessing health information and services:

"People in our communities worry that they may not properly understand what the doctor tells them, or that they can't adequately explain the nature of
their health complaint, and so anxiety wins out, and they end up not going to see a health care professional at all."
(Community leader, Qld)

As such, the use of health interpreters as required was identified as critical to ensuring safe and effective health care and treatment.

A number of gaps in relation to interpreting and translating services were identified, these included:

• hospital staff that do not access TIS interpreters for people with language difficulties
• family members (including children) are still being used as interpreters by health workers
• limited availability of interpreters, particularly in some of the more recent African languages
• lack of adequate funding for interpreters
• confidentiality is sometimes breached.

(ii) Stakeholders

Stakeholder consultations provided anecdotal information on the inconsistent use by the broader health system of professional interpreter and
translating services for people who cannot speak English, including refugees.

In addition, stakeholders reported difficulties in accessing qualified interpreters onsite during consultations with newly-arrived African Australians.

Stakeholders highlighted a number of good practice examples. These included:

The Doctors Priority Line

The Doctors Priority Line is a free telephone interpreting service which helps medical practitioners to communicate with their non-English speaking
patients.

Please see: www.immi.gov.au/living-in-australia/help-with-english/help_with_translating/free-services.htm

Free interpreting services to pharmacies

Under this federal government initiative, the Department of Immigration and Citizenship provides free telephone interpreting to pharmacies through the
Translating and Interpreting Service (TIS National) to help them communicate with culturally and linguistically diverse Australians about PBS
medications.

Please see: www.immi.gov.au/living-in-australia/help-with-english/help_with_translating/free-services.htm

7.5 Culture and health

(a) What are some important issues/facts about being from African backgrounds that would be helpful for Australian health service providers to
know?

(i) Community

Community respondents suggested that the following issues/facts about the backgrounds of African Australians would be helpful in terms of improving
cultural responsiveness by health providers:

• supernatural/spiritual healing and natural remedies are highly valued
• strong belief in the ancestral spirit and animal spirits (especially birds)
• rituals are performed regularly
• during health crisis oracles are sought out to identify the offended spirit and determine the proper remedy
• belief in the 'evil eye', malevolent person possessing supernatural powers
• sickness or disease are often explained by superstition: individuals may be unwilling to share personal information (such as how many children
  they have) due to superstitutious belief that the information might be used by the 'evil eye' to cause harm
• they may object to a blood transfusion because Sudanese think blood is life and someone not have the authority to transfer life to another
  person
• chronic diseases are considered punishment from either god or the ancestor whose spirit is not satisfied with the family
• mental health problems are attributed to witchcraft from within the extended family
• medical treatment is resorted to when spiritual healing does not bring the desired outcome
• women are not normally examined by a male practitioner
• people tend to seek treatment only when they are very sick (the concept of appointment to be seen by a doctor is 'strange')
• when a patient is admitted to the hospital, it is a social obligation for friends and family members to visit
• birth control may be seen as contrary to the cultural value of bearing children
• people expect a fast cure and may stop treatment if there is no quick benefit
• the shame in the girl's family is shared by all family members.

(ii) Stakeholders

Stakeholder respondents reiterated the view that there is a lack of awareness of the health needs and cultural issues of African Australians by most
health agencies and health practitioners.

Many of the above issues were also cited by stakeholders. Some further additional issues highlighted the following:

Many Africans incorporate traditional practices with western medicine:

"This means that they will do both things, that is they will find the traditional healer if there is one in the community and then they will go to the
western GP as well. The problem will be ensuring that the two approaches are aligned."

They will consult the spirits of ancestors while taking antibiotics, they will take traditional medicines along with conventional medicines, they will
practice letting blood while taking malaria treatment. This was a very important fact for health care providers to know.

In addition, more time is required by GPs in negotiating the management of health issues due to differences in beliefs about the causes and treatment
of illness, and due to the need to educate refugees in how to use the health system (for example, where to seek emergency assistance should their
illness deteriorate, how to call an ambulance, how to book follow-up appointments of adequate consultation duration, how to request the use of an
interpreter at a consultation, and how to fill original and repeat prescriptions from pharmacies).

Several stakeholders cautioned about the danger of health care providers assuming that once they had attended a cultural information session on a
particular ethnic group, that they would no longer need to update their knowledge of the community.

Finally, the issue of collaborative and integrated health responses was reiterated. Collaborative partnerships in developing services and programs
which are culturally responsive to African Australians are important, particularly for those who are newly arrived were highlighted.

(iii) Public submissions

Issues relating to culture and health were addressed by a third (35%) of the submissions.

The submissions revealed a number of important issues that Australian health service providers should consider when treating people from African
backgrounds, including:

• limited access to basic vaccinations in Africa, such as childhood vaccinations
• unhealthy food preference, for example, sweetened drinks and over use of oil
• the limited (quantity, quality and range) traditional diet may not contain all nutritional needs but are initially preferred to the wide range
  of food available in Australia
• susceptibility to nutrient deficiencies and outcomes for example, rickets
• sickle cell is more common in people from African backgrounds
• psychological effects of trauma
• many African Australians are unfamiliar with our health care structure, such as the range of services available, where and how to access
  different services, and the terminology used
• some African Australians are more likely to seek assistance from leaders from their own community than from strangers, so community leaders
  should be kept informed of important health updates, particularly relating to mental health services
• topics relating to mental and sexual health are considered taboo by many African cultures
• some females may have undergone 'female genital mutilation' prior to arriving in Australia which will impact their health care requirements.

(b) What training and support should be put in place to assist health professionals to provide culturally-appropriate services to African
Australians?

(i) Community

Clearly, differences in culture, value systems, education, backgrounds, arrival in Australia - whether as migrants or refugees, and their settlement
experience all impact on how many African Australians might approach health care providers and how they make decisions regarding their health care.

Community respondents suggested a number of training and support programs that could be put in place to better inform health care providers of these
cultural issues and their impact. However, a primary prerequisite according to most community respondents was the need to ensure community
participation in the development, implementation and evaluation of effective, responsive and appropriate health care.

Other approaches identified included:

• the implementation of appropriate cultural competency 'training'
• establishing a culturally diverse workforce by employing bilingual staff or staff who have an understanding of other cultures
• developing partnerships with multicultural and ethno-specific agencies
• access to appropriate language services
• building relationships based on mutual trust

(ii) Stakeholders

Stakeholders generally agreed that further work is needed to build the capacity of mainstream services to appropriately manage health issues relating
to newly-arrived African Australians, particularly refugees. This includes upskilling of GPs, refugee health nurses and other nursing and allied health
staff to support delivery of specialist services for refugees.

A range of training programs and providers can be located. Following are just a few that were highlighted during the consultations:

Foundation House has a series of training modules for health and community services for working with refugees. This includes quarterly training days for
refugee/community health nurses.

Please see: www.survivorsvic.org.au/home/index.htm

Centre for Culture, Ethnicity and Health - provides training for A range of service providers, in particular community health and disability services on cultural competence and working with
interpreters.

Please see: www.ceh.org.au

Victorian Transcultural Psychiatry Unit - provides training and secondary consultation for mental health services.

Please see: www.vtpu.org.au

(c) What can governments, NGOs, communities and health services change to improve the interaction between an African Australian and the health care
system?

(i) Community

Community participants who responded to this question identified the following actions that could improve the interaction between African Australians
and the health care system:

• primary health care systems should focus on wellness and person-centred care, and should address inequalities in primary health care access
• involving members of African Australian communities in advisory committees/health boards and so on as equal project partners.

Several community respondents warned of the common example whereby mainstream services engaged African Australians in the project until they received
funding:

"In collaboration with the community develop program with clear goals, started from the community by the community but after they got the funding it
became an agency project, they employ non-African worker. They still collect clients to take photos and attract funds for their agencies."
(Participant, community focus group, NSW)

The value of various government funded place-based partnership initiatives which bring together multiple sectors and provide a vehicle for tackling
health inequalities by addressing the broader determinants of health in a deliberate and coordinated way was identified by a number of respondents.

Several community respondents made reference to health networks that had been established to ensure the delivery of more holistic health care.

One example cited was the Victorian Refugee Health Network which provides a forum for health services and practitioners to work
collaboratively to address the needs of newly arrived migrants and refugees. The Network brings together a wide range of representatives from the
health, settlement and community sectors who actively participate in the projects and initiatives of the Network. This work builds on the many
activities and programs around the state, past and current, to support refugee health and wellbeing.

Please see: www.refugeehealthnetwork.org.au/Home/Home.htm

The Refugees and Primary Health (RaPH) project is a partnership between key refugee health services, primary and tertiary care
providers, divisions of general practice, settlement support services and refugee communities. It is funded by Queensland Health through Connecting
Health in Communities (CHIC). The project is managed by the Mater UQ Centre for Primary Health Care Innovation and works closely with the Refugee
Health Queensland Service. The project is focused on developing information and referral pathways to support primary health care professionals working
with refugee communities and has compiled a list of key partners and web resources. Refugee communities as partners include: Queensland African
Communities Council (QACC), Queensland Sudanese Community Council.

Please see: www.materonline.org.au/Home/Services/Refugee-health/Refugee-and-Primary-Health-Project.aspx

An Australian Nursing Federation (ANF) special interest group Nurses for Refugees and Asylum Seekers (NRAS) has been established in
Victoria and held their first meeting in late 2007. This group seeks to provide a forum for nurses who are interested in the plight of refugees and
asylum seekers, including those who may work with them or volunteer to assist them. It is beneficial for nurses who work in a variety of clinical
settings and who may have intermittent contact with refugees and asylum seekers, for example, schools, emergency departments, local councils, and
community health centres as well as general health settings.

Please see: www.anfvic.asn.au/sigs/topics/9064.html

Occupational Opportunities for Refugees and Asylum Seekers (OOFRAS) is a network of occupational therapists working together to develop a field of practice that responds to the occupational needs of refugees and asylum
seekers. It is a non-profit, volunteer-run organisation coordinated and supported by occupational therapists for occupational therapists. It is based
in Brisbane, but has members from around Australia and is linked with networks internationally.

Local committees, working groups and networks on refugee health have been established in a number of areas of high refugee settlement, in metropolitan
and rural areas. Some groups meet regularly and others on an as-needs basis. A number of areas have also conducted refugee health forums.

Please see: www.oofras.com/index.php?page=blog&blog_section=list_posts&blog_category_id=32

(ii) Stakeholders

Stakeholders identified a number of gaps that would need to be addressed in order to improve the health outcomes overall for African Australians. These
included:

• lack of integration and communication between settlement services and health services in some areas
• identified need to build these relationships to develop a better understanding of roles and responsibilities and to work together to build the
  health literacy of new arrival refugees
• identifying and training GPs to work with refugees in newer settlement areas.

Other suggestions related to the implementation of better support and referral pathways:

• build capacity of the hospital based service to respond in a culturally competent manner (i.e. workforce development during orientation and
  training on how to access interpreters)
• frameworks and measures to implement cultural competence should be aimed at providing health environments focused on the cultural safety of the
  client
• government should ensure that newly arrived refugee women receive comprehensive health assessments, thereby ensuring preventive health measures
  (such as immunisations) are undertaken, and that referrals are made to appropriate services to prevent the progression of chronic conditions
• without effective coordination and referral between service providers and across service silos, it is easy for gaps to arise where the needs of
  some individuals are not being met.

(iii) Public submissions

Suggestions made in the submissions for Governments, NGOs, communities and health services to improve the interaction between an
African Australian and the health care system include:

• ensure health professionals use accredited health interpreters when necessary
• make sure African Australians are adequately informed of their rights and understand the health system
• providing health professions with specialised training and support to assist then in providing more culturally appropriate services to African
  Australians
• employ more bilingual disability workers.

7.6 Discrimination and health

(a) Can you provide examples of how African Australians are treated differently in the health sector?

(i) Community

There were many examples provided by community respondents of what was perceived to be differential treatment by the health sector. Many of the
experiences cited relate particularly to maternity issues and pre and post natal care and support.

One of the most common issues raised was the failure of the health care provider to provide accredited interpreter services. This can give rise to a
range of complexities and miscommunication about procedures that are actually taking place. Examples ranged from having the wrong dental work happen to
leaving a doctor's appointment with severe anxiety about the status of their health or that of their children.

Some respondents also explained how despite some English fluency, direct translations of particular words or health concepts may be completely at
variance with the cultural background of the patient or client:

"In the Somali language the word for pain is the same as the word used for illness."

There were many examples given where children were inappropriately used as interpreters in a range of health care settings.

Other examples cited included situations where interpreters had been arranged without any discussion or consent of the client, resulting in either the
wrong dialect or feelings of having their privacy breached.

Community respondents also shared numerous anecdotal experiences relating to discriminatory treatment by some health care providers. Examples shared
included:

• Incongruent beliefs and expectations between the patient and health professional leading to misunderstandings and confusion
• derogatory statements made about the number of children that the client had given birth to
• assumptions that all African women were circumcised
• several respondents from a range of different states spoke generally of not having input into major health decisions, including not being asked
  or listened to about what their wishes are regarding family planning
• some of the women's focus groups raised issues related to FGM and referred to examples of women who are 'infibulated' reportedly being made to
  feel ashamed during various health related procedures
• some community respondents discussed experiences, particularly during pre natal care, where medical professionals did not consult them about
  their birthing plans, even when an interpreter had been made available
• some respondents reflected on experiences of being in hospital and being made to feel embarrassed about members of the community attending in
  large numbers with offers of food and support
• examples of challenging reactions by hospital staff and other medical practitioners to women bringing midwives or traditional birth attendants
  with them during birth were also occasionally shared during the women's focus group discussions:
  "The doula came with [her] in the hospital as in my country it is not the men who come in, but all of the extended network of women. So here, we think
  this might be alright but sometimes this is not allowed."
• the lack of multilingual information relating to major health issues was also cited by several community respondents.

Overall, community respondents stated that indications of friendliness and respect on the part of the health practitioner or provider went a long way
to ensuring better rapport and communication with African Australians.

(ii) Stakeholders

While stakeholders said that some African Australians were receiving differential treatment in a variety of health care settings for some this did not
necessarily amount to intentional discrimination and racism, but may be the result of cultural assumptions, stereotyping or miscommunication on the
part of the health provider/practitioner:

"So much of the health needs that are emerging with the new communities are just not that well known or familiar to so many of the health practitioners
out there, particularly the GPs and other health specialists. This area has traditionally always had a very homogenous Anglo Saxon community and so the
issues presenting are completely new. It's more likely to be cultural ignorance than discrimination."

Several stakeholders were able to provide good practice examples of improved accessibility and inclusion, these include:

• The Refugee Health Assessment Template and other resources, developed under the auspices of General Practice Victoria and endorsed by the Royal Australian College of General
  Practitioners (RACGP)
• The Launceston Project is an example of a project that has been designed with attention to the interaction of culture and trauma, and the long-term cycles of settlement
  for refugees.

(iii) Public submissions

Issues relating to discrimination and health were addressed by around a tenth (13%) of the submissions.

Some examples of discrimination provided in the submissions include:

• some African Australians enduring unacceptably long waiting lists to see specialists
• the use of African Australian patients with unusual diseases as teaching examples in hospitals without being informed or asked for their consent
• medical services not providing adequate access to interpreters
• some medical and health service providers not treating African Australians as individuals.

(b) What is the impact of this discrimination?

(i) Community

Many examples were provided by community respondents clearly demonstrating how health outcomes deteriorate when health professionals do not provide
care that is culturally appropriate or the patient is not properly engaged and consulted. Other impacts included:

• loss of trust leading to avoidance in the future even when health needs might be quite dire
• safety is compromised through the failure to understand cultural issues, including things like previous experiences of trauma, including sexual
  assault
• feelings of being treated with disrespect and disdain
• medical mismanagement may lead to negative health outcomes
• feelings of alienation from the broader Australian society.

The range and number of cases cited during the consultations highlights perceived inadequacies in the health system, despite in some instances, the
existence of comprehensive multicultural and access and equity policies.

For example, despite numerous efforts to improve access to interpreter services, people repeatedly said that many health services, including large
health institutions, continue to neglect to use them during medical consultations and medical procedures.

(ii) Stakeholders

Overall, most stakeholders emphasised the need for cultural awareness training, and also identified structural and organisational blocks that need to
be addressed, including hospital policies such as visiting rules etc.

7.7 The effect of religion, age, gender, sexuality and disability

(a) Are the experiences of African Australians, in regard to health, different based on religion, age, gender, sexuality or disability?

While new arrivals can experience the same challenges as other Australians in accessing health care services, including the limited availability of and
access to health professionals, community respondents highlighted how this is compounded by the physical and psychological health issues that may be
particular to the experiences of being a refugee or from the experiences of migration itself. These issues were seen to have significant and
deleterious effects on women, young people and people with disabilities generally.

For women, social isolation was identified by community respondents as being one of the greatest challenges facing them, particularly those who may be
here without extended family or come from smaller minority African communities.

Social isolation of the women had reportedly impacted negatively on things such as maternal wellbeing, parenting capacity and the availability of
avenues for generating social networks. This also then impacted on children's wellbeing and development.

Muslim women also identified as having very specific and all too frequently negative or problematic experiences when interfacing with the health system
at large.

It is important to highlight, however, that many within the diverse Muslim African communities also spoke of their religion and faith as a source of
personal strength.

Many women who have undergone FGM in their countries of origin highlighted different experiences with health professionals:

"Health care providers are in positions of power and should not be make judgments about women who have undergone this procedure. There are many reasons
for why women in our communities have undergone these things, including things like social acceptance and marriageability, so these things need to be
understood"

It is important to note that several community respondents also highlighted a number of excellent examples of culturally responsive and respectful
programs and practices in a number of different states and territories:

"While highly successful programs relating to support for women from communities where female circumcision and FGM are practiced, some newly-arrived
women are not aware of their existence…"

(i) Public submissions

Information relating to the effects of religion, age, sexuality and disability in reference to African Australian's health issues were addressed by one
fifth (20%) of the submissions.

Submissions cited that disability services often do not meet needs of African Australians living with disabilities. Reasons for this
include:

• refugees with a disability are usually unaware that support services are available to them
• refugees with a disability often will not admit they are disabled because they fear they will be returned to their country of origin
• service providers wrongly assume that strong community support structures mean individuals don't require additional service
• disability funding structures limit the providers' ability to offer services to emerging communities
• Sexuality is a difficult issue to address within African communities as homosexuality is a taboo topic, and practising homosexuality is a criminal offence in
  some African countries.
• Gender issues impact some females' ability to access health services, including:
  • Females usually find it culturally inappropriate to be serviced by a male practitioner
  • Many health topics are considered taboo for females
  • Females may not receive money or permission from their husbands or other male relatives to access particular health services
  • Females are less likely than males to have received formal educational experiences prior to settlement, exacerbating language difficulties and
    resulting in them requiring more assistance in understanding information about health issues and services
  • Women with children who do not have suitable childcare options available may not seek medical assistance because they do not wish their children to
    witness the appointments.

7.8 Government and health

(a) What actions can governments take (or what targets can government set) to ensure African Australians are more healthy, can better overcome any
physical or mental health issues from their refugee or migration experience, and can thrive upon arrival in Australia:

A number of overarching features were identified through this project as required in building an effective and sustainable model of care for refugee
populations. These include:

• refugee health service models are integrated within the broader health system
• services are easily accessible to key settlement areas
• local context drives the application of regional service provision
• services are affordable or free of charge for refugee families
• adequate levels of administrative support are available to coordinate service delivery
• availability of qualified interpreters
• primary care involvement (including GPs and refugee health nurses) is essential
• clear pathways between specialist and primary care services are established
• clearly documented communication protocols between providers facilitate streamlined transition through the care continuum for refugees
• care coordination for refugees with more complex health issues
• service provision minimises duplication and number of follow up appointments
• consistency of screening/assessment processes
• service models facilitate simultaneous care to both adults and children (i.e. family centred)
• clear pathways facilitating transition to culturally competent mainstream services are developed (for example, mental health and maternity
  care).

(i) Public submissions

Issues relating to government and the health of African Australians were addressed by one fifth (19%) of the submissions.

A number of recommendations are provided in the submissions for the government to ensure African Australians are more healthy, can better overcome any
physical or mental health issues from their refugee or migration experience, and can thrive upon arrival in Australia. They include:

• conduct standardised health and immunisation assessments on arrival
• employ more tropical disease specialists (familiar with diseases from Africa)
• conduct more HIV awareness programs
• provide cultural competency training for medical personnel, including training that encourages the appropriate use of interpreters (not family
  or friends and being gender sensitive)
• ensure cultural competency training on health issues for Africans generally, and refugees specifically, take into account the need to treat each
  patient as an individual
• provide community leaders with training on how to access the health system so they may better advise and assist their local communities
• conduct community education sessions on the health system and relevant issues, including addressing the stigma associated with mental health and
  the need for women to address women's health concerns
• form partnerships with schools to provide better access to torture and trauma counselling for young people
• inform health professionals about the types of health problems faced by refugees that they may need to screen for
• advise new African Australians about nutrition
• provide translated information on the dangers associated with alcohol and drugs
• ensure pharmacies have a system in place to confirm that medication labels and instructions are understood (including the use of interpreters
  and translated information when needed)
• encourage local communities to increase their sense of wellbeing by actively celebrating their cultures and networking with other local
  communities to share cross-cultural celebrations that foster mutual respect and support
• ensure all new arrivals are advised of medical tests required for entry into Australia.