Patient follow-up is a major barrier to continuity and quality of care for new arrivals. The change in housing assistance from 13 weeks to four weeks has severely affected the ability of doctors to locate and follow-up with patients.231 For instance, medical examinations and test results often come back after the patient has moved out of public housing and, if they do not return to the health care facility for a follow-up appointment, then the facility is unable to trace them. Furthermore, the patient may have difficulty getting to the health facility if they have moved to a different part of the city. They may not understand the public transport system or may not be able to afford the fare.
Transportation, and the ability to reach services, is a significant barrier to accessing health care232. Health services, in general, must address issues of follow-up. In this situation a case worker would be able to serve as a point of contact between patient and provider. Primary care doctors have advocated for refugee health nurses and case workers.233 In addition, it has been suggested that refugee patients should be able to take their medical records with them so that, if they do need to change doctors, opportunities for care are not missed and tests or immunisations are not repeated234.
There is a need to develop a food and nutrition education program for newly-arrived refugees. Their diet has often changed significantly because of differences in access to food and food security, changes in food supply, patterns of purchase, changes in familial responsibility for food preparation, and changes in social networks – all of which can influence food habits and physical activity.
Coming into a Western culture, the diets of refugee communities tend to towards a pattern of higher fat and lower fibre intake, coupled with lower physical activity.235 Any approach to promoting healthy and balanced diets with refugee families must take into account small details, such as when a person goes to a major supermarket and whether they recognise all the products they see, especially pre-packaged foods.
Food, as a key component of culture and shared experience, can also serve as an important means for refugee communities to learn about and interact with Australian culture.236
21.1A case study example
Migrants from developing countries have been shown to quickly develop higher rates of obesity than others in the host nation. Renzaho et al. has examined the link between acculturation and obesity risks among African migrant children in Australia.237 Dividing the children into four categories – traditional (African), assimilated (Australian), integrated (both) and marginalised (neither) – they were assessed on their Body Mass Index (BMI); leisure and physical activity; sedentary behaviour; and food quality and energy.
The study found that children in the ‘traditional’ group had more positive outcomes in terms of physical health and activity than the other three categories. These children had lower BMI, spent less time in sedentary activities and had a less energy-dense diet. However, ‘integrated’ children engaged in nearly one hour more of physical activity per day, which could be attributable to greater participation in school-based sports activity and a sign of integration into mainstream school culture. The ‘less traditional’ that African migrant children became; the more likely they were to develop eating and sedentary habits that lead to obesity.
Not surprisingly, the same holds true for adults. As refugees become more acculturated to the local diet, they are more prone to diseases of affluence, including stroke and heart disease.238
22Trauma and mental health
Post-conflict trauma is a characteristic of African refugee communities, with a significant number having experienced torture, rape, family separation or loss and community breakdown. Around 70% of humanitarian entrants have faced physical or psychological violations and 25% have experienced torture or trauma, both of which can have long-term and trans-generational repercussions.239
Refugees consistently display higher levels of mental stress, post-traumatic stress disorder (PTSD), anxiety, depression, grief and psychosomatic issues, which stem from pre-migration, conflict-related trauma and post-migration stressors.240 The conditions are often continual and cumulative, with physical and psychological distress increasing based on the length and intensity of the trauma.
Personal safety, interpersonal relationships, a sense of justice, identity and greater vulnerability to life stressors are all compounded by moving to a new environment and a different culture in Australia. Unfortunately, when traumatised refugees display a negative – but normal – reaction to the stress of settlement, it can make their communities appear ‘unstable’, reinforcing a poor perception of them by the broader society. This can make their settlement experience more difficult, which simply adds to their feelings of stress. Issues that intensify feelings of anxiety and depression all make the process of integration more challenging.241
Refugees face the same relocation stressors as voluntary migrants. However, these are exacerbated by the burden of having to come to terms with the reasons they were forced to flee their home country.242 The mental strain of dealing with what they have experienced can have a profound impact on their prospects for successful social inclusion.
22.1The experience of PTSD
One of the barriers to accessing mental health services in response to issues arising from PTSD is a lack of agreement among refugees that they are, in fact, experiencing PTSD. While memories of experiences of conflict in their home country are stressful and can cause anxiety, the individuals clearly understand its origin.
Former soldiers (who are also refugees) will often express that they knowingly entered a conflict and accept the psychological consequences that come from this as ‘par for the course’. They are willing to cope with the trauma because, for them, the potential for victory was more compelling. The resulting stress they feel, and the PTSD they experience, are the “burden [they] carry as part of [their] choices to fight in the war.”243
It is an interesting and powerful statement: that what they experienced as former soldiers, and the repercussions they have endured, was worth it or, at least, necessary. In this way of thinking, the trauma these former soldiers grapple with is therefore not a ‘problem’ to be addressed in the way that a Western mental health specialist might perceive it.
However, what this viewpoint does not address is the experience of a great many people – probably the majority – who were not willing fighters but, regardless, were swept up in the terrors of conflict in their home countries.