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Keywords:

  • children;
  • model of care;
  • post-resettlement health assessment;
  • refugee

Abstract

  1. Top of page
  2. Abstract
  3. What is already known on this topic
  4. What this paper adds
  5. Methods
  6. Results
  7. Discussion
  8. Conclusions
  9. Acknowledgements
  10. References

Aim:  Children account for approximately half of the humanitarian refugees currently resettled in Australia. A multidisciplinary refugee health clinic (RHC) was established at the tertiary paediatric hospital in Western Australia to address burgeoning referrals of refugee children following voluntary post-resettlement health assessment. The aim of this study is to describe the epidemiology of common conditions in resettled paediatric refugees attending a tertiary multidisciplinary RHC.

Methods:  Standardised clinical and demographic data were routinely collected during first visit clinical assessment at the RHC. Descriptive analyses of the first 1026 children are presented.

Results:  One thousand twenty-six refugee children from 475 families and over 30 different ethnicities were described. Nine hundred twenty-seven (90.4%) children were referred following post-resettlement health assessment. Median age was 7.8 years. Common reasons for referral were: vitamin D deficiency (400, 39%), iron deficiency (226, 22%), positive Helicobacter pylori serology (206, 21%), poor appetite (175, 17.1%), and schistosomiasis (170, 16.6%). Comorbidities identified by the RHC included tinea capitis and corporis (297, 28.9%), and dental disease (228, 22.2%). Two-thirds of children (680, 66.3%) had at least one abnormal finding on clinical examination that identified pathologies that were not evident from the history. Three hundred eighty children (37%) were referred to sub-specialty services.

Conclusions:  A multidisciplinary paediatric RHC facilitated and strengthened the management of refugee children with multiple and complex health needs. Evidenced–based culturally appropriate methods to identify developmental delay, psychological morbidity and quantify social needs of this vulnerable population remain uncertain. These findings are relevant to the continuing evolution of paediatric refugee health care in Australia and other high income countries.

Children represent over half of the humanitarian refugee intake to Australia.1 This vulnerable population has complex medical, psychological and social health needs, many of which may be unfamiliar to practitioners.2,3 The Australian Government and the Royal Australasian College of Physicians4 support voluntarycomprehensive health assessment following resettlement to identify acute and chronic health issues that are particularly prevalent in refugees.2,5–8

In response to the increasing emergency presentation and referral of refugee children to the tertiary paediatric hospital (Princess Margaret Hospital for Children (PMH)) in Western Australia (WA), a dedicated multidisciplinary paediatric refugee health clinic (RHC) was established in 2006. The RHC aimed to co-ordinate and manage the initial complex care needs (medical, social and psychological) of refugee children in a holistic manner. The multidisciplinary team includes general and specialist paediatricians, a general practitioner, an infectious diseases/refugee health fellow, social worker, dietician, community refugee health nurse/immunisation provider and refugee liaison nurse. Detailed demographic and clinical data were routinely recorded during detailed clinical assessment of all children on their initial visit to the RHC. Onsite or telephone interpreters were utilised. We present data on the first 1026 children assessed by the RHC over 33 months and discuss the implications for the provision of paediatric refugee health care in Australia.

What is already known on this topic

  1. Top of page
  2. Abstract
  3. What is already known on this topic
  4. What this paper adds
  5. Methods
  6. Results
  7. Discussion
  8. Conclusions
  9. Acknowledgements
  10. References
  • 1
    Children account for approximately half of the humanitarian refugees currently resettled in Australia.
  • 2
    The Australian Government and the Royal Australasian College of Physicians support voluntary comprehensive health assessment following resettlement to identify acute and chronic health issues that are particularly prevalent in refugees.
  • 3
    This vulnerable population has complex medical, psychological and social health needs, many of which may be unfamiliar to practitioners.

What this paper adds

  1. Top of page
  2. Abstract
  3. What is already known on this topic
  4. What this paper adds
  5. Methods
  6. Results
  7. Discussion
  8. Conclusions
  9. Acknowledgements
  10. References
  • 1
    This is the largest Australian study to date to document prospectively the characteristics of resettled refugee children and youth.
  • 2
    The prospective study identified common morbidities, revealed additional morbidities refractory to identification through initial health screening and symptom inquiry and delineated gaps in care for this vulnerable patient group.
  • 3
    Prospective documentation of health data is now available to support evidenced-based health policy for this emergent patient group of refugee children and youth.

Methods

  1. Top of page
  2. Abstract
  3. What is already known on this topic
  4. What this paper adds
  5. Methods
  6. Results
  7. Discussion
  8. Conclusions
  9. Acknowledgements
  10. References

Study design

Standardised data collection forms were developed to record systematically demographic and health data of all children at first presentation to the RHC. The family data included self-reported ethnicity, place of birth, genogram (including missing/deceased members), length of time and countries of transit, resettlement details, data on the post-resettlement health assessment and referral source. Individual data included the laboratory results obtained at the post-resettlement health assessment, antenatal, perinatal and early development history, nutritional history (including specific risk factors for iron and vitamin D deficiency), previous education, past medical history (including exposure to tuberculosis (TB)), current medications, immunisation and allergies. Systemic and psychological symptoms as well as physical examination findings were recorded with additional qualitative and descriptive notations as necessary.

Data from each child were de-identified, coded and entered into a secure database. Every family and child was assigned a study number. Quantified data were analysed using SPSS version 16.0 (SPSS Inc., Chicago, IL, USA) and were performed after the dataset was completed for the first 1026 children. The study was approved by the Ethics Committee of PMH, WA (ref 1255/EP).

Results

  1. Top of page
  2. Abstract
  3. What is already known on this topic
  4. What this paper adds
  5. Methods
  6. Results
  7. Discussion
  8. Conclusions
  9. Acknowledgements
  10. References

Demographic data

One thousand twenty-six children from 475 families presented to the RHC between March 2006 and December 2008. The median number of days between arrival in Australia and first review by the RHC was 215 days (range 7–908 days; standard deviation (SD) 124 days). The median number of days between initial post-resettlement health assessment and first review by the RHC was 159 (range 11–418, SD 98 days). The majority of children (927, 90.4%) were referred from the Migrant Health Unit (MHU), a specialist service that undertakes voluntary post-resettlement health assessment on over 80% of refugees resettled in WA.9 The staff of the MHU (now known as the Humanitarian Entrants Health Service (HEHS)) undertake a post-resettlement health assessment including completing a medical and immunisation history, examination and in-vitro measures examining for malaria, haemoglobinopathies, anaemia, vitamin D deficiency, liver biochemistry and immune markers indicating previous exposures to TB, blood-borne viruses, helminths and parasites. The remaining children were referred from the emergency department of PMH (33, 3.2%), other PMH departments (17, 1.7%), general practitioners (15, 1.5%), and a smaller number from community and other health service providers, including interstate.

Median age was 7.8 years (range from 2 months to 17.3 years), with 520 male children (50.7%). Approximately 110 of children were less than 24 months of age. Arbitrary dates of birth appeared to be assigned to 148 of children; for example, 118 children were reportedly born on January 1st and 30 children were born on December 31st.

Self-reported ethnicities, geographical origin and primary languages spoken are outlined in Table 1. Families of Sudanese ethnicity were the largest subgroup (335, 32.7% of total), followed by children from Burma (153, 15%) who were predominantly of Karen ethnicity. Refugee families attending the RHC had spent considerable time in at least one transit country; the mean transit time was 11 years but extended out to 39 years on occasion. Nearly two-thirds of children (647, 63.1%) were born outside their parental country of origin, spending long periods in transit, predominantly in refugee camps rather than urban townships. The majority of children had normal perinatal (785/817, 96.1%) and early developmental (797/825, 96.6%) histories. Over half of children older than 6 years of age (344/510, 67.5%) had received some education in transit countries, prior to resettlement in Australia.

Table 1.  Geographical origin, self-reported ethnicity and primary language
Geographical originSelf-reported ethnicitiesPrimary languagesTotal
  • Self-reported ethnicity may be the same as the name of their primary language.

Horn of AfricaSudanese (335); Eritrean (44); Ethiopian (23); Somalian (16); Tigrinyan (4); Mahdi (3); Nuba (2); Pojulu (1); Bari (1)Dinka (111); Arabic (66); Tigrinyan (51); Sudanese Arabic (49); English (41); Acholi (19); Bari (16); Madi (15); Somali (14); Kuku (9); Nuer (7); Zande (6); Duku (4); Swahili (3); Nuba (3); Oromo (2); Nyala (2); Juba (2); Rotana (2); Amharic (1); Nobi (1); Kakwa (1); Dari (1)429
West AfricaLiberian (91); Sierra Leonean (25); Mauritanian (19); Togolese (11); Mende (3); Pfulla (3); Ewe (2); Nigerian (1); Cote D'Ivoire (1)English (99); Pfulla (17); French (14); Kissi (10); Modingo (6); Krio (3); Ewe (3); Creole (2); Dinka (1)156
BurmaKaren (84); Burmese (42);Chin (28)Karen (84); Burmese (43); Chin (24); Mara (1); Thai (1)154
East AfricaBurundi (133); Rwandan (12); Ugandan (1); Acholi (1)Kirundi (85); Swahili (43); English (5); Tigrinyan (4); Kinyarwandan (4); Nyala (3); French (1); Acholi (1); Madi (1)147
Central AfricaCongolese (93); Central African Republic (4);Banande Tribe (2)Swahili (49); French (36); Melange (4); Franee (1); Arabic (1);99
Southern AfricaMalawian (2)Kirundi (2)2
North AfricaEgyptian (1)Arabic (1)1
Afghanistan, Iraq and SyriaAfghani (6); Iraqi (6); Iranian (2)Dari (4); Persian (2); Pushtun (1); English (1)14
Sri Lanka and IndiaSri Lankan (1)English (1)1
SerbiaSerbian (1)Serbian (1)1

One-third of children had malaria prior to arrival in Australia (299/864, 34.6%); of these, 90 children (10.4%) were hospitalised, 68 children (7.9%) received intravenous therapy, 18 children (2.1%) received a blood transfusion and seven children (0.8%) had cerebral malaria. Prolonged preferential breastfeeding and delayed introduction of solids were common; median length of breastfeeding was 15 months (range from 2 to 60 months) and introduction of solids at 6 months (range from 2 to 24 months)

Referral diagnoses

The majority of referrals to the RHC were for follow-up and management of abnormal investigations from the post-resettlement health assessment rather than symptomatic diseases/pathology. Children were typically referred with more than one identified health concern (Table 2). Management of infections, particularly gastrointestinal infections (schistosomiasis, strongyloides and positive Helicobacter pylori serology) and dermatomycoses (tinea capitis and corporis) were common. Comorbid infections and additional pathology, not always evident in the initial referral, were often identified by the RHC.

Table 2.  Common reasons for referral to the RHC of WA
Reasons for referralNumber (%)Reasons for referralNumber (%)
  1. NB. More than one referral reason for children. []† indeterminate result. PTSD, post-traumatic stress disorder; RHC, refugee health clinic; WA, Western Australia.

Vitamin D deficiency400 (39)Positive QuantiFERON Gold52 (5.0) [114]
Iron deficiency226 (22.1)Giardia64 (6.2)
Positive Helicobacter pylori serology206 (20.1)Dental62 (6.0)
PTSD183 (17.9)Abnormal liver function55 (5.3)
Poor appetite173 (16.8)Nocturnal enuresis42 (4.1)
Schistosomiasis178 (17.3)Incomplete screen41 (3.9)
Failure to thrive110 (10.7)Abdominal pain33 (3.2)
Tinea98 (9.5)Strongoloides33 (3.2)
Heart murmur88 (8.6)Lymphadeopathy26 (2.5)
Hepatitis B carrier84 (8.1)Hepatomegaly17 (1.6)
Post-arrival malaria follow-up76 (7.4)Splenomegaly7 (0.7)
Eosinophilia72 (7.0)Umbilical hernia13 (1.2)

Nutritional deficiencies were the most common reason for referral; 400 children (39%) were referred for vitamin D deficiency/insufficiency and 226 children (22.1%) were referred for iron deficiency anaemia (IDA). One hundred eighty-three children (17.9%) were referred with a haemoglobinopathy trait, of whom approximately one quarter were also iron deficient. Children homozygous for thalassaemia major or sickle cell disease were directly referred to the Paediatric Haematology Department PMH, and their data are not included.

Acute malaria (typically Plasmodium falciparum) was diagnosed post-resettlement in 76 children (7.4%), and treated initially by the PMH infectious diseases unit, with post-treatment follow-up at the RHC. Fifty-two children (5.1%) had a positive QuanitFERON-GOLD (http://www.cellestic.com) assay (QFN-G) and 114 (11.1%) indeterminant QFN-G responses. Only two children had known active TB at time of review. All children with TB or requiring further assessment (e.g. indeterminate results) were managed by the separate paediatric TB service, part of the WA TB Control Program and is co-located with HEHS. Chest radiographs and other investigations (e.g. gastric washings) were undertaken as clinically indicated by staff of the RHC and are not commented on in this review.

Psychological symptoms were infrequently reported during first review by the RHC; 35 had sleep disturbance and 25 described nightmares. Eighteen exhibited excessive crying and 16 exhibited separation anxiety and aggression. Approximately 10 children displayed one of oppositional traits, poor concentration and secondary enuresis.

History and examination

Additional comorbidities were identified by the RHC through symptom history (Table 3) and physical examination; common symptoms included toothache, headaches, early satiety, pruritis, enuresis and obstructive sleep apnoea/snoring.

Table 3.  Reported physical symptoms
Reported physical symptomsNumber (%)Reported physical symptomsNumber (%)
  1. OSA, obstructive sleep apnoea.

Abdominal pain153 (14.9)Muscle pain55 (5.3)
Anorexia156 (15.2)Fevers52 (5.0)
Poor weight gain101 (9.8)Night sweats51 (4.9)
Cough99 (9.6)Constipation37 (3.6)
Early satiety98 (9.5)Earache36 (3.5)
Rash and/or itch97 (9.4)Visual disturbance33 (3.2)
Toothache97 (9.4)Nausea24 (2.3)
Primary enuresis93 (9.0)Lethargy24 (2.3)
Hair loss88 (8.6)Diarrhoea22 (2.1)
Headaches83 (8.1)Weight loss21 (2.0)
OSA [Snoring]79 (7.7) [31]Vomiting16 (1.5)
Coryza66 (6.4)Musculoskeletal deformity10 (1.0)
Joint pain58 (5.2)Secondary enuresis3 (0.3)

Growth impairment was common irrespective of ethnicity or incorrect date of birth; the ethnic mix of this lowest quartile was Burmese (29%), Sudanese (21%) and smaller percentages of other ethnicities. Approximately a quarter of children were ≤10th centile for weight 225 (26.7%) and height 218 (26.3%), respectively, and 96 (11.4%) and 113 (13.6%) were ≤5th centile for weight and height, respectively. One-third of children had fungal skin infection; 178 (17.4%) had tinea corporis, 93 (9.1%) had tinea capitis and four had onychomycoses. Two hundred eighty-one children (27.4%) had dental caries, often severe, yet only one-third of these same children reported toothache. Eighty-six children (8.4%) had abnormal gastrointestinal examination; 37 had tenderness, 21 had hepatomegaly, 11 had splenomegaly, 13 had para-umbilical hernias and nine had genitourinary abnormalities. Otoscopy was abnormal in 65 children (6.3%); 25 had dull or scarred tympanic membranes, 16 had perforations and 13 reported diminished hearing. Visual disturbance was reported by 33 children (3.2%); 20 children recorded reduced visual acuity as assessed by Snellen or E-Chart.

Onward referrals

The RHC referred 490 (48%) of children to other tertiary and community allied health service providers. Children were commonly referred to more than one tertiary service and more than 25 different sub-speciality departments were consulted. The most common onward referrals were to otolaryngology (46, 4.5%), enuresis services (44, 4.3%), tertiary dental services (36, 3.5%), gastroenterology (33, 3.2%) and cardiology (22, 2.1%). Twenty-two children (2.1%) were referred on to specialist trauma and torture counselling services. Less than 10 children were discharged to a general practitioner after the first RHC consultation because of ongoing difficulties finding general practitioner services utilising interpreter services and offering bulk billing.

Discussion

  1. Top of page
  2. Abstract
  3. What is already known on this topic
  4. What this paper adds
  5. Methods
  6. Results
  7. Discussion
  8. Conclusions
  9. Acknowledgements
  10. References

Refugee children are an increasing population in Australia and often have complex health and psychosocial needs.2,5–8 This is the first study to document prospectively the characteristics of refugee children referred to a specialist referral clinic following resettlement in a high-income country. Prospective documentation of health data was performed to facilitate the development of an evidence base for health policy for this emergent patient group.

Referral to the RHC most commonly followed the voluntary post-resettlement health assessment performed by the MHU; over 90% of children assessed by the MHU had at least one finding that resulted in referral to the RHC (A Thambiran, pers. comm., 2008). The RHC assessment frequently identified comorbidities often not evident at time of referral. These data reinforce the need for an initial comprehensive multidisciplinary post-resettlement health assessment for refugees,6,7 including specialist services for children and adolescents, and agreed referral pathways to other specialist services.6,7 Additional diagnoses by RHC staff determined the majority of onward referrals to colleagues and sub-specialist paediatric services co-located at the same hospital as the RHC, and patient attendance was facilitated by RHC liaison nursing staff.

These data reinforce the need to determine and manage the health and psychosocial requirements of refugees.

The RHC has a number of features that facilitates holistic refugee health care. Firstly, the clinical and laboratory data were available from standardised voluntary post-resettlement health assessment, so many major issues had already been identified prior to RHC assessment. Secondly, the RHC is a multidisciplinary team, including strong allied health support. The team has a broad repertoire of skills and liaises effectively with community care providers. The third strength of the RCH is the extended time available (and necessary) to complete in-depth history and physical examinations. Where possible, all children from individual households were seen together.

Common diagnoses made at the RHC were fungal skin infections 311 (30.3%), dental caries 229 (22.3%), suspected H. pylori 263 (25.6%), cardiac murmurs 88 (8.6%), failure to thrive 85 (8.3%), and enuresis 44 (4.3%). Diagnosis of active H. pylori infection in this cohort was problematic. H. pylori serology was used for ∼18 months of the study period, until data indicated that it was not a useful investigation.10H. pylori stool antigen testing was not available outside a research setting, and endoscopy was not performed except in very selected cases. Children were therefore treated empirically on the basis of suggestive symptoms (particularly early satiety, anorexia and abdominal pain).

Dental caries were common and often severe; however, symptoms were rarely reported. Failure to report pain highlights the need for thorough clinical examination in refugee children, as their symptom history did not reliably indicate pathology. A higher prevalence of dental caries reported among refugee children resettled in the USA may have resulted from the research completed with the involvement of a dental specialist.11 Accessing affordable dental services for pre-school refugee children is difficult; engaging dental specialists at the time of first review would optimise recognition of pathology and may facilitate therapeutic engagement. The possible consequences of untreated dental disease are significant.12,13

The prevalence of IDA (22.1%) and IDA associated with a haemoglobinopathy and thalassaemia trait were similar to data from a small Dutch study14 and more recent Australian data.15 One hundred twelve children (10.9%) had a haemoglobinopathy or thalassaemia trait, but counselling for asymptomatic carriers is problematic as traits become clinically relevant only when children are of child-bearing age. This issue is compounded by the lack of lifelong, universally accessible, electronic health records.

TB screening was performed by QFN-G alone, an investigation that does not perform as well in children as adults.16 Moreover, children whose only identified diagnosis on initial assessment was a positive QFN-G were referred directly to the paediatric TB service and did not attend the RHC. A more accurate estimate of latent tuberculosis infection (LTBI) in refugee children resettled in WA16 is less than the published data of 12.9% of sub-Saharan African immigrant children to Madrid, Spain had LTBI17 and 31% of immigrant children to Montreal, Canada had LTBI.18 The Spanish and Madrid data were based upon a possibly more sensitive but less specific screening test for TB, the tuberculin skin test. In contrast, 24% of 215 refugee children from Sydney, Australia had a positive Mantoux (≥15 mm induration),15 which is a considerably higher result in a similar population than the overall result of 5.1% LTBI for this cohort.

Symptoms associated with PTSD were less frequently reported than expected from the literature.19–23 Physical phenomena of pain were more common than symptoms of mood disruption,24 which is consistent with recognised cultural dimensions of health that influence how or if families disclose traumatic events or report psychosocial morbidity.21,24 Differences were perceived, but not quantitatively measured, between parent–child reports of psychiatric symptoms. Parent–child reporting differences are recognised as one of many factors explaining the low incidence of psychiatric symptoms in this patient group.25 Furthermore, the resettlement ‘honeymoon’ period itself may influence the reporting of psychological symptoms at the initial RHC visit. Longitudinal studies of psychological well-being and assessment of the optimal tools for identifying PTSD in this population are clearly warranted.

This study has a number of limitations. Firstly, as there are no validated health assessment tools for resettled refugee children, the data selected for routine assessment at first visit were derived from the collective experience of the RHC team. Secondly, some of the data were incompletely recorded by staff and so actual prevalence rates may be higher than reported. Thirdly, the incidence of psychological or developmental anomalies was low. A parallel study examining developmental abilities with standardised testing on a sample of children from within this cohort, demonstrated a significantly higher prevalence of developmental delay than identified through history alone (Dr J Geddes, pers. comm., 2010). Fourthly, although the distribution of growth parameters may be skewed by ethnic variation (e.g. Burmese children) and/or incorrect date of births, these factors do not fully account for the large number of children with measurements ≤10th centile, suggesting that there was an additional problem such as nutritional compromise prior to arrival. Anecdotally, catch-up growth is often observed in these same children when vitamin D levels and nutrition are optimised, but measures to support these observations were not part of this study. Fifthly, although RHC staff have intercultural experience, the breadth of people from disparate regions blunted the capacity to consistently observe or understand non-verbal communication leaving staff to rely on interpreting of verbal communication. The necessary use of interpreters was an additional potential barrier when addressing sensitive issues such as gender-based violence, female genital cutting (circumcision), onset of puberty and menstrual difficulties. Finally, the chosen fields of question did not include routine documentation of social factors important to resettlement and associated with optimal psychosocial health and development outcomes.26

Conclusions

  1. Top of page
  2. Abstract
  3. What is already known on this topic
  4. What this paper adds
  5. Methods
  6. Results
  7. Discussion
  8. Conclusions
  9. Acknowledgements
  10. References

Systematic physical, psychosocial and clinical review of refugee children determines the majority of their complex and multiple health needs.3,5 Tertiary paediatric review of resettled refugee children and their families, by an interdisciplinary paediatric team, identifies additional and important health and psychosocial issues not readily indentified through in vitro screening. Symptom history could not reliably identify morbidities, and detailed physical examination was important often revealing previously unrecognised pathology. Reported symptoms of pain and reported symptoms of psychological distress were less severe and less frequent than expected from subsequent clinical findings and known histories of trauma, reinforcing the need for further clinical and psychological assessment and research.

Any cross-sectional study cannot investigate the longer term outcomes such as health service utilisation, engagement with mainstream services (particularly primary care) and broader health trajectories, although all underpin planning for refugee health services. The initial patient assessment forms used for this study have been reviewed with the aim to redress the gaps in clinical care identified in this study. These issues include exploring in more details regarding (i) physical health (obstructive sleep apnoea, menstrual irregularities, hypertension and dental mapping of caries, circumcision – both genders) (ii) educational history (acquisition of language skills and schooling) and logistics, which may impair family function (e.g. housing difficulties).

The revised RHC clinical assessment forms may be useful for health services considering a specific paediatric refugee hea1th service and potentially for national refugee health data collection. Data linkage systems will facilitate long-term mapping of health service utilisation by refugee families within Australia27 and provide evidence for resource planning and optimise resettlement outcomes.

Acknowledgements

  1. Top of page
  2. Abstract
  3. What is already known on this topic
  4. What this paper adds
  5. Methods
  6. Results
  7. Discussion
  8. Conclusions
  9. Acknowledgements
  10. References

We thank Dr Aesen Thambiran, Medical Director of the MHU (now renamed as the WA HEHS), for helpful comments on the manuscript. We thank Professor Deborah Lehman and Hannah Moore (Telethon Institute of Child Health Research, WA) for assistance with database design and Dr Louise Houliston for assistance with data collection. This work was supported by the Victorian Government's Operational Infrastructure Support Program.

References

  1. Top of page
  2. Abstract
  3. What is already known on this topic
  4. What this paper adds
  5. Methods
  6. Results
  7. Discussion
  8. Conclusions
  9. Acknowledgements
  10. References