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Giving a voice to the voiceless

Helping people from war-torn lands, refugee health is a dynamic mix of advocacy, care co-ordination and social support. Linda Belardi talks to one nurse in the field.

There’s nothing Ambi Kaur enjoys more than having a spirited argument with her patients. “The best part of the whole job is when your client disagrees with you. When you see the person move from being a totally helpless and totally dependent individual to someone who is quite clear about what their needs are - that means they feel empowered,” she tells Nursing Review.

As a refugee health nurse for the past six years in Victoria, Kaur (pictured right) works with some of the most marginalised and vulnerable people in society, providing “a voice to the voiceless”.

Watching her clients gain the self-confidence to argue for what’s in their best interests is, she says, the most rewarding work in her entire nursing career.

“It’s our job to ensure that the services we provide enhance the safety and improve the health outcomes of these clients so they can be valuable, contributing citizens. We all want them to participate in society and be the future of Australia and we can’t do that by isolating and discriminating them. But one of the things that we do very well is systemic discrimination,” she says.

By that, Kaur means health systems and service delivery which are inflexible and unresponsive to the unique and complex needs of this client group.

“We have a set way of doing things and we expect everyone will fall into those processes and categories instead of looking at how things can be done differently to accommodate the needs of the individual,” she says.

Supporting her clients to navigate the often complex health system and advocating for their access to the appropriate primary health and specialist services is a core part of her role in the refugee health program at Doutta Galla Community Health.

“A significant part of my work is about empowering the clients to acknowledge their rights and responsibilities, and encouraging them to take on a request for services. It’s about saying to the client you have the right to ask for a service if you think it is going to help your health outcomes,” she says.

As a refugee health nurse, advocacy is core business. “You actually talk about system change, flexibility and system responsiveness. It becomes a big part of the role because of the health literacy and English language proficiency of this client group. Over time, it is the relationships that you develop with other service providers that become much more flexible, rather than the system itself.”

From the availability of interpreting services to flexible appointments times, small changes can make an important difference, she says.

At Doutta Galla, Kaur is responsible for the health assessment and co-ordination of services for asylum seekers, refugees and new migrants who settle in and near Melbourne. Over the years she has witnessed a fluctuating demographic. “I used to see a lot people from Ethiopia and Eritrea, now I see clients from Afghanistan and Iran, and others from the Horn of Africa are arriving in Australia on special humanitarian visas.”

Her major client groups include asylum seekers living in community detention, victims of human trafficking and international students.

The health needs of refugees and asylum seekers often reflect the consequence of living in war-torn or impoverished countries without a functioning health system. “Their primary medical needs are commonly vitamin D deficiency, parasitic infections, some have latent TB which requires long-term treatment, as well as needing access to immunisations.

“In terms of their mental health, we can almost always assume that refugee clients or those seeking asylum have come from a country where they have either witnessed or experienced some form of trauma or torture,” she says.

Only after a trusting relationship has been developed will a client feel ready to disclose their experiences and then an appropriate assessment and referral can be made. At the same time, Kaur is also increasing the social supports that are made available to them to prevent long-term isolation and psychosocial health issues.

Kaur also believes strongly in setting high expectations for her clients.

“Often I tell them I anticipate within 12 months when I conduct a review of their settlement process that I will not be using an interpreter for that communication unless it is a complex discussion around health.” She also connects them with English-speaking classes and social groups to support their integration and future employment.

In addition to their physical and mental health needs, during the process of migration to a Western, free society, interpersonal and family dynamics can shift.

“We are very good as a country in empowering women but the process of migration and the difficulties for the family unit can often disempower the man, especially if they originate from patriarchal societies,” Kaur says.

“It is necessary to understand the changes that can take place in the family unit and to manage any breakdown in social relationships. Often, it’s about giving the man his masculinity back when he is feeling demasculinised because of traditional social roles and his inability to protect his family.”
Intergenerational conflict can also become an issue when the children of migrant and refugee parents begin to adopt Western cultural values and norms or challenge established family values.

Building the trust of some clients, especially young women who have been the victims of human trafficking and exploitation, requires time and sensitivity, says Kaur. Initial contact focuses primarily on screening for sexually transmitted diseases and physical health before complex psychological and trauma issues can be addressed.

Finding appropriate housing is a huge and ongoing problem, she says. In addition to a shortage of public housing, what houses are available, are not assessed properly for safety and security – taking into account the history of the accommodation. But by building on personal strengths, Kaur draws on the resilience of her clients and social supports to help them cope with the challenges of resettlement.

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