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In the latest edition of Australia's Health1 the health of Australia's children appears fairly robust, however, further examination of these statistics is more alarming. Not all children are doing so well. For example, the perinatal death rate and child mortality for Indigenous children is still at least double that of other Australian children. Children in rural areas have higher rates of injury morbidity and mortality2. Poorer children are more obese3, have more mental health problems4 and have poorer literacy and numeracy results at school5. Unfortunately, we lack specific data about a number of diverse groups in Australia that are often at risk, particularly refugee and immigrant children.

These data reflect the considerable inequality in health and developmental outcomes for children in Australia. Paediatricians have the opportunity to play a key role in looking after the health of all Australian children, however, there are a number of significant clinical and advocacy challenges in undertaking this role, many of which have been highlighted by Davidson et al. in their papers focusing on refugee children6,7. These issues are relevant not only to refugee children, but to many children in Australia. In fact, what is striking from these papers is not that there is something very different about the issues for refugee children, but that the issues are so very similar to those that face many children and challenge health care providers around Australia everyday.

See related articles, p 562, 569.

Whilst refugee children have a special set of circumstances, they highlight the issues for all health care providers, but particularly paediatricians. These include:

  • • 
    Advocacy and the role of the paediatricians in advocating for both individual children and groups of children
  • • 
    Cultural awareness and competence and the challenges of working in diverse settings and communities
  • • 
    Equity and equality and the rights of all children in Australia to equitable access to high quality services and resources.

If each of these issues is considered, it becomes quite clear that paediatricians play a critical role in looking after the health of Australia's children. Paediatricians have long been involved in advocacy on behalf of children. Many paediatricians undertake individual advocacy, ‘the process of challenging an organisation on behalf of an individual, a process in which an individual or group attempts to obtain more responsive, adequate and effective services for a child or a family’8, on a daily basis. This includes writing letters, telephoning schools and health or community services departments on behalf of their patients. Alternatively advocacy may also be necessary for groups of children, noted as class advocacy, that is ‘working on behalf of groups to effect changes in policies, practices and laws that affect all people in a specific class or group’9. Paediatricians are in an excellent position to undertake some form of advocacy during their everyday business. However O’Brien et al. note that ‘paediatricians are often too polite, too passive and too unaware of how to move the system10.’ In fact despite their potentially powerful advocacy role, most paediatricians have had little if any training in the art and science of advocacy.

Training has also been limited for many health care providers in the area of cultural competence or awareness despite the increasing diversity of the Australian population. Cultural competence in health care has recently been defined as ‘the ability of systems to provide care to patients with diverse values, beliefs and behaviours, including tailoring delivery to meet patients’ social, cultural and linguistic needs11.’ Most paediatricians have had no training in cultural competence, yet as Davidson et al. have noted, there is an absolute need to better understand and communicate appropriately and sensitively with children and families from diverse cultures in order to provide high quality health care7. This diversity should include Indigenous children.

Similarly, whilst the plight of refugees on temporary protection visas clearly highlights an equity issue, there are a number of equity and equality issues within the Australian context, particularly within the Indigenous community. For example Indigenous children are over represented in the juvenile justice and child protection system and under represented in high school completion rates12. Rural children have limited access to bulk billing GP’s13 and fluoridated water14. Whilst children on temporary protection visas struggle to access any health care, children from socially disadvantaged families continue to live in areas with poorer schools, lower life expectancy and higher rates of illness15, exacerbating already established inequalities and disadvantage. Systems have struggled to respond to issues of inequality, many of which require broad-reaching social and environmental responses that focus on addressing issues of inequity. Whilst it is acknowledged that the biggest differences to inequalities in child health will not be made through the health system, nevertheless the challenge remains to address local need through local innovation and resources.

There are many important lessons to be learned from the work undertaken in child refugee clinics around Australia, including the multiple roles that paediatricians must play. Not only is there the obvious need to understand and evaluate the clinical context of the individual child, there is also the need to understand the cultural and community context of the child and the family, as well as advocate for the child and their family within a complex and sometimes frustrating system. It is vitally important that there is a multidisciplinary and collaborative approach to many issues for children that will need to include jurisdictions, sectors and governments. At the same time this is a unique and opportune moment in the policy history of this country where children are clearly on the policy agenda. The challenge for paediatricians is to ensure they are well trained in order to enhance the effectiveness of their role and ensure their capacity to make a difference.

References

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  2. References
  • 1
    Australian Institute of Health and Welfare. Australia's Health. AIHW: Canberra, 2004.
  • 2
    Australian Institute of Health and Welfare. Health in Rural and Remote Australia. Canberra: AIHW, 1998.
  • 3
    Booth M, Chey T, Wake M, Norton K, Hesketh K, Dollman J. Change in prevalence of overweight and obesity among young Australians, 1969−97. Am. J. Clin. Nutr. 2002; 77: 2936.
  • 4
    Sawyer M, Arney F, Baghurst P et al. Child and Adolescent Component of the National Survey of Mental Health and Well-Being. Australia: Commonwealth of Australia, 2000.
  • 5
    Australian Council for Educational Research. Literacy Standards in Australia Camberwell: ACER, 1997.
  • 6
    Davidson N, Skull S, Chaney G et al. Comprehensive health assessment for newly arrived refugee children in Australia. J. Paediatr. Child Health 2004; 40: 5628.
  • 7
    Davidson N, Skull S, Chaney G et al. An issue of access: Delivering equitable health care for newly arrived refugee children in Australia. J. Paediatr. Child Health 2004; 40: 56975.
  • 8
    Margolis L, Cole G, Kotch J. Children's right, social justice and advocacy in maternal and child health. In: KotchJ, ed. Maternal and Child Health: Problems and Policy in Public Health. Gaithersburg: Aspen Publishers, 1997.
  • 9
    Hepworth D, Larsen J. Direct Social Work Practice: Theory and Skills. Pacific Grove, CA: Brooks/Cole, 1993.
  • 10
    O'Brien S, Parker S, Greenberg J, Zuckerman B. Putting children first: The pediatrician as advocate. Contemporary Pediatrics 1997; 14: 10318.
  • 11
    Betancourt J, Green A, Carrillo J. Cultural competence in health care: Emerging frameworks and practical approaches. New York: The Commonwealth Fund, 2002.
  • 12
    Steering Committee for the Review of Government Service Provision. Overcoming indigenous disadvantage. Key Indicators 2003. Canberra: Productivity Commission, 2003.
  • 13
    Young A, Dobson A. The decline in bulk billing and increase in out-of-pocket costs for general practice consultations in rural areas of Australia, 1995−2001. Med. J. Aust. 2003; 178: 1226.
  • 14
    Department of Human Services Victoria. Fluoridation: a Guide to Fluoride Levels in Water Supplied to Victorian Towns and Cities. Melbourne: Department of Human Services Victoria, 2002.
  • 15
    NSW Department of Health. NSW health and equity statement: In all fairness. North Sydney: NSW Department of Health, 2004.