Transcript Chronic Health Conditions in the African community in Australia

Chronic Health Conditions in the
African community in Australia
Clinical Management, Treatment and Referral
Options
Dr Jill Benson
Senior Medical Officer
Migrant Health Service, Adelaide
Refugee profile
> Approximately 13000 refugees/year to Australia
> 30% from Africa
• Sudan, Congo, Burundi, Liberia
> 50% from Middle East
• Afghanistan, Iran, Iraq
> 20% from elsewhere
• Burma, Bhutan, China
> Up to 50% aged under 18
> Approx. equal numbers of men and women
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African Refugee profile
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Higher levels of poverty
Families often headed by female
Greater cultural differences
Larger families with lower levels of education and English
proficiency
Older children have often been responsible for younger
ones
Long periods (often >10 years) in refugee camps extremely unsafe, infectious diseases, poor sanitation
and diet
Come from areas where malaria, TB and other tropical
infections endemic
Limited or disrupted access to health care
Concepts of survival vs health
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‘Survival’ is a priority, not necessarily health
Coping with challenges of resettlement
Dealing with grief, loss and dislocation
Unfamiliar with role of the health profession
Fear of being ‘sent back’ if chronically ill
No concept of preventive health care
Expectation that health will deteriorate with age
Housing and food
Health literacy
Caring for family
Education
Aspirations for a better life
Infections vs Non-communicable Diseases
in Africa
> Chronic disease contributes over 70% of disease burden in
Australia and will increase to 80% by 2020
> In most of Africa the risk of dying at a young age from an
infectious disease is much greater than the risk of dying of a
chronic disease (NCD)
> Mortality from malaria in Africa is 3 million/year
> Gastroenteritis kills 2 ½ million and pneumonia 3 ½ million
African children per year
> About 2 million children die from measles each year in Africa
> HIV affects 23 million people in Africa with 1.6 million dying
each year of HIV/AIDS
> TB prevalence in Africa is >300/100,000 (3 million people) cf
Aus 5.8/100,000
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• About ½ million deaths each year from TB in Africa
Nutrition in Africa
> 14 million people in Africa suffer from malnutrition and
starvation
> Ingestion of unsafe water, inadequate availability of
water for hygiene, and lack of access to sanitation
contribute to 1.5 million child deaths per year
> Stunting or chronic undernutrition affects 35-40% of
children
> May cause abnormal liver function tests on initial
screening
> May be protein, vitamin B12 or other deficiencies.
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Increased risk of chronic disease in Australia
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Genetic predisposition
Length of stay in Australia
Generation
Acculturation
Cultural beliefs and values
Parity
Stress
Poor housing
Physical inactivity
High alcohol consumption
Language barriers
Discrimination
Attitude to food after arrival in Australia
> The food in refugee camps is often scarce and of poor
quality, so food may be overeaten in Australia
> Food was about survival and not about taste or
preference and now there is a huge range
> Multi-generational deficiencies of vitamins and iron
passed from mother to child but this is not a priority
> Dietary guidelines and a ‘balanced diet’ are completely
unknown
> Thin means poor, diseased, not loved, despair,
> Fat means rich, powerful, doing well, well cared for,
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blessed by God
Common Chronic diseases
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Diabetes
Hypertension
Asthma
Rheumatic Heart Disease
Coronary heart disease
Cerebrovascular disease
Hepatitis B
Mental Health problems
Pain
Abnormal initial screening tests
> Important to do a full screen as there are other unusual causes
of chronic disease
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Schistosomiasis or Strongyloides
Nutritional and vitamin deficiencies eg Vit D, B12
Anaemia – may be multigenerational
Hookworm and other worms that can affect Hb, protein etc
Liver problems caused by parasites, malaria, malnutrition
Kidney problems caused by dehydration
Infection load (ears, teeth, bowel, lungs) causing high ESR
Chronic lung disease from cooking fires
Injuries
> Important to make sure we’re treating the patient and not just
the blood tests
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Difficulties with adherence to investigations,
appointments, self-management and medications
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Socio-political issues
The health professional
The patient
The health-professional-patient interaction
The organisation
In each culture there are different:
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approaches to knowledge and health
communication styles
attitudes toward conflict
approaches to completing tasks
notions of time
decision-making styles
attitudes toward disclosure
Socio-political issues
> Religious and traditional issues
• Can affect attitude to management– God’s will
• Fear of addiction to medication
> Stigma
• Denial of certain illnesses because of stigma eg TB, Hep B
• View that diseases are contagious eg mental illness
> Poverty and transport issues
• Not enough money to pay for test or medication
> Discrimination
• Interpreters, staff attitudes
• Health system literacy
> Gender issues
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• Access to healthcare for women
• Women often look after health of family rather than their own
The Health professional
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Time
Communication style
Cultural awareness
Language
Expectations
Sticking to the ‘evidence’
Hopelessness
Ethnocentricism
• Only a small percentage of motives, beliefs and reactions are
conscious for both health professional and patient
• The ‘ethnocentricism’ of the health professional needs to be conscious
to properly recognise the cultural beliefs and expectations of the patient
> Learning about cultural practices
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• Countries of origin and transit, Gender expectations, Food – past and
present, Relationships, Body language, Religion, Fasting, Attitudes to
medication, Cultural health practices, Spiritual resources
The patient
> Language
• Importance of an appropriate interpreter
> Literacy and Education
• Draw pictures and other visual cues for medication etc
• Difficulties with numbers, time
> Health literacy
• Importance of explanations and diagrams
> Expectations – Conscious and unconscious
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Expect a short-term treatment that will cure the problems
Unusual to have personal responsibility for health
Prevention of chronic illness a very foreign concept
Health is expected to deteriorate with age
> Priorities
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• Education and care of family come before chronic illness
• Grief
• Resettlement
The health-professional-patient interaction
> Mismatch of style
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Authoritarian
Empathic
Informative
Collaborative
> Use of Cultural Awareness Tool
> Religious and gender issues
> Differences in world-view
• Ego-centric vs socio-centric
> Patient-centred therapies
• Narrative therapy
• Inco-operating traditional therapy
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Working with different views of illness
> The health professional works exclusively within the
biomedical model
> The patient and health professional function
exclusively within each of their own beliefs
> The health professional works within the patient’s
framework
> The patient and health professional negotiate
between their concepts of the cause of the
problem/illness/disease and the most appropriate
management to reach mutually desirable goals
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Cultural Awareness Tool
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What do you think caused your problem?
Why do you think it started when it did?
What do you think illness does to you?
What are the chief problems it has caused for you?
How severe is your illness?
What do you most fear about it?
What kind of treatment/help do you think you should receive?
Within your own culture how would your illness be treated?
How is your community helping you?
What have you been doing so far?
What are the most important results you hope to get from
treatment?
The organisation
> Time
• Takes at least twice as long and usually even longer to see a refugee
patient
> Finances
• Decreased remuneration as doing the same work in twice the time
> Administrative support
• Need to have cultural awareness training
• Booking of interpreters
> Multi-disciplinary team
• Best way to support patients with complex issues, multiple problems or
big families
• Home visits from RDNS or nurse re insulin, using glucometer
• Visits to supermarket
>19 Support for health professionals who are ‘burning out’ or
stressed
Diabetes
> CALD Australians have significantly higher rates of diabetes,
diabetes-related hospitalisations and deaths
> Men born in North Africa have 3.6 times more diabetes
> Increased reliance on convenience foods and not on healthy
food prepared in the home
> The ‘thrifty’ genotype
> If undernourishment in pregnancy increased risk of insulin
resistance in the children
> Some ethnicities seem to have insulin resistance and some
insufficient production of insulin
> Pre-migration often very active with lots of walking to get to
school or the shops, get wood or water
• No TV or computer games
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> Often rapid weight gain within 5 years of arrival
Asthma and lung disease
> In one study, traditional healers in Dar es Salaam, Tanzania
were convinced that asthma is caused by “ingestion of amniotic
fluid during birth” (83%), by “God” (75%), or “one inherits
[asthma] from parents” (73%)
> Traditional asthma remedies are usually tried without major
success although some may contain pharmacologically active
substances
> May never have even tried any asthma medication
> Women may have spent long periods of time tending fires
indoors and have a restrictive component to their lung disease
> Important to screen for TB
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Hypertension in the African population
> Different ethnicities metabolise medication differently
> Africans suffer an earlier onset, greater severity and more endorgan damage
> Twofold higher rate of stroke and 50% higher mortality from
heart disease
> ACE inhibitors less effective for blood pressure because of
lower renin activity
> May be best to use calcium channel blockers +/- diuretics for
hypertension
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Cardiovascular and cerebrovascular disease
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Migrants are more affected than those born in Australia
Increased risk factors – smoking, diabetes, hypertension, diet
Language and other barriers mean the presentation is often late
Angina and TIAs are initially clinical diagnoses and so need
accurate language
> Safety to go out and walk
> Difficulties with changing views of food
> Difficulties with the idea of preventive health care and chronic
medication
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Stages of change
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> Precontemplation: The patient has no intention of
changing their behaviour in the foreseeable future. The
patient is perhaps unaware that there is a problem.
> Contemplation: The patient is aware that a problem
exists and is thinking about changing their behaviour
but has no firm commitment to take action.
> Preparation: The patient intends to change and
develops a plan and a time-frame for its
implementation.
> Action: The patient begins to modify their behaviour to
overcome the problem. This requires considerable
commitment and energy.
> Maintenance and relapse prevention: The patient
works to prevent relapse. This stage may last for many
months or years.
Precontemplation
> Culturally specific identification of what constitutes health,
chronic disease, and inevitability
> Consideration of cultural norms, and the way things were ‘back
home’ and influence on current health decisions and drivers for
change
> Consider all the experience and long-term influences on
individuals’ current health status, and their capacity to change
> Build family, environment, local community readiness to
change at the same time as the individual is making changes
> Identification of the problem requiring change from the patient’s
perspective
> Consideration of gender differences and new opportunities
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> Focus on health and, good experiences rather than disease
Contemplation
> Value cultural experiences and traditional stories
> Promote peer learning with community health workers or in
groups
> Focus on health and good experiences rather than disease
> Build shared knowledge with family or community
> Create opportunities for getting together and tapping into
existing structures or groups
• non-health-related groups work best for engaging people
• Consider homogeneity of the group - disease, nationality, gender,
purpose
> Ensure appropriate content, delivery style, and language
> Ensure health care setting is culturally appropriate and easily
accessible
> Celebrate/reward effective self management behaviour
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Planning
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Written and visual material culturally appropriate
Provide take home information for later reference
Focus on current strengths and skills
Generate written summaries of consultations using easily
understandable or translated language
> Support determination of goals and outcomes both short and
long term
> Use an approach which allows flexibility and change to goals
as required
> Provide ongoing support and long term management
opportunities, 1:1 or group and access to facilities, peers,
health workers etc
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Action
> Support individuals to follow their own path with support
> Involve communities and families with individuals’ changes to
ensure sustainability within context of family, community,
culture
> Focus on health and good experiences
> Offer one to one care in the context of family and community
care
> Provide pathway to support services and facilities
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Maintenance
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Provide a pathway to health service and community supports
Celebrate being part of a cultural group
Celebrate good health
Reinforce health management strategies as part of daily
routines
> Provide a pathway to support services and facilities
> Provide ongoing group meetings/support networks if possible
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Conclusion
> Dealing with chronic health problems in the African community
involves a wider range of potential illnesses, as well as an
increased risk of some of the more familiar illnesses
> Culturally appropriate education and management style are of
the utmost importance
> Recognition that there are many factors that may influence
adherence to management plans
> The health professional needs to be aware of the patient’s
readiness for change
> A multidisciplinary team and a culturally aware workplace is
probably the best place to deal with more complex chronic
health problems.
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References
> Grimmer-Somers K, Guerin M, Luker J, Jones D, Zucco. Chronic disease
management for vulnerable and disadvantaged communities: Clinical Issues
and Practical Suggestions (unpublished)
> Renzaho A. (2007) Ischaemic heart disease and Australian Immigrants: the
influence of birthplace and language skills on treatment and use of health
services. Health Information Management Journal 36:2 pp 26-36
> Renzaho A. (2008) Re-Visioning cultural competence in community health
services in Victoria. Australian Health Review 32:2 pp 223-235
> AIHW. (2003) A picture of diabetes in overseas-born Australians. AIHW
Bulletin #9
> Renzaho A. (2002) Fat, rich and beautiful: changing socio-cultural
paradigms associated with obesity risk, nutritional status and refugee
children from sub-Saharan Africa. Health and Place 10 pp 105-113
> Renzaho A, Gibbons C, Swinburn B, Jolley D, Burns C. (2005) Obesity and
undernutrition in sub-saharan African immigrant and refugee children in
Victoria, Australia. AsiaPacJClinNutr 15:4 pp482-490
> Park I, Taylor A. (2007) Race and Ethnicity in Trials of Antihypertensive
Therapy to prevent Cardiovascular outcomes: A Systematic Review. Annals
of Family Medicine 5:5 pp 444-452
> Benson J. (2005) Concordance. Australian Family Physician 34:10 pp 83131 834