Seven focus groups were conducted with 87 parents, all female (Table ). Participants were from Karen, Iraqi, Assyrian Chaldean, Lebanese, South Sudanese and Bhutanese cultural backgrounds, who had lived an average of 4.7
years in Australia (range one month-18
years). Participants had a total of 249 children. Of these, 150 were born in Australia, with one to seven children per family.
Five interviews and four focus groups were also held with a total of 18 service providers and bilingual workers as follows: Two focus groups were conducted with three and four MCH nurses in each. Another two focus groups were held with two refugee health nurses in each. One of these focus groups also included another MCH nurse together with a worker from the ‘Healthy Mothers Healthy Babies’ program and the other focus group included an Arabic community liaison worker. The objectives of the Healthy Mothers, Healthy Babies Program are to support and provide assistance to women to access antenatal, postnatal and other health and human services throughout their pregnancy [44
]. Three interviews were conducted with community representatives/refugee mentors (who were also the bilingual playgroup facilitators). Two interviews were conducted with managers of bilingual workers (one of whom is also a bilingual community worker).
Four main themes were identified, these are: ‘Facilitating access to MCH services’; ‘Promoting continued engagement with the MCH service’; ‘Language challenges,’ and; ‘What is working well and what can be done better’. These are reported here with their subthemes.
Facilitating access to MCH services
There were four main modes identified for facilitating initial access to the MCH service. These included: the birth notification service, by settlement case workers, by refugee health nurses or by bicultural playgroup facilitators (refugee mentors).
Birth notification from hospital
Participants who had given birth in a local hospital were contacted by the MCH service via the birth notification system and received a home visit. Most mothers felt that this process worked well for them. In one focus group, the mothers reported that it was much easier for those who had children born in Australia because they are able to learn the ‘new system’. The mothers with children born outside Australia, even those with good grasp of spoken English, were still trying to catch-up and learn the way in which the healthcare services operated.
"I think it is good for her [another mother in the playgroup] because she started having children here and she has a lot of support. I am a mother of 7 kids, I’m only here, my husband went back to Sudan and I’m working and I got other thing to do…it’s a big change for us…this life for me is hard… if they can give us a special way, they can call us and say you didn’t come to check which time is good for you to come, you know?… I know anyway it’s my job to [take children to see the MCH nurse] because it’s my child and it’s important for me to care about their health but the situation I’m in, it’s hard…(South Sudanese FG)"
Settlement case workers
There was no consistent model identified for introduction to the MCH service for parents who arrived in Melbourne with young children. Some families were linked to the MCH service by their case-worker/community guide who is provided to them in the first six months of arrival by a government funded settlement service. However, at the time of the study, not all refugee-background families were eligible for this service. People of refugee background accepted into Australia as part of the humanitarian migration stream may arrive on a refugee visa making them eligible for the full range of settlement services. Others receive a special humanitarian visa provided to those with family members already here, in which case their ‘sponsoring’ family members were expected to facilitate their access to services. The healthcare professionals reported that many people they saw on ‘sponsored’ visas had not been linked to the service. In many cases ‘sponsors’ were also in need of services and support and were not in a position to be primarily responsible for facilitating service access for others. (Note: since the time of data collection, the policy regarding this type of visa has been changed so that now those who arrive on a ‘sponsored’ visa receive the full suite of settlement services support). The participants who had a community worker reported that it is likely that even if they were told about the MCH service in their first six months of settlement, it is likely that they forgot about it, as there were other settlement priorities such as housing, employment and learning English that took precedence.
Refugee health nurses
The refugee health nurses reported that they identified people in need of the MCH service when conducting home visits as part of the ‘refugee health assessment’ and they facilitated making an appointment for them. However, it was reported by several of the refugee health nurses that the refugee health nurse program did not have the capacity to identify and meet the demand of all newly-arrived parents and children. This indicates that there are likely to be parents and children arriving in Melbourne who are not identified as eligible and hence are not formally introduced to the MCH service.
Refugee mentor program
The Refugee Family Mentoring and Resource Program
involves ‘mentors’ from Assyrian/Chaldean, Karen/Burmese and South Sudanese backgrounds working directly with families to support their access to early childhood services including MCH services, kindergartens, early intervention and family welfare services [45
]. This model supports families through organised playgroups [46
] and operates differently for each cultural group to meet the needs and circumstances of the playgroup participants.
At two Karen playgroups the refugee mentor was effective in introducing parents who arrive with pre-school aged children to the MCH service. The refugee mentor’s role involves organising mothers and children to attend their ‘key ages and stages’ visits and working closely with the MCH nurse to ensure mothers are seen in this group setting. This model is working so well that parents are ‘referred’, usually by healthcare providers, to the playgroup rather than to the MCH service itself.
It was evident that the model at the Karen playgroups enhanced access to the MCH service for this group of people and likely that the group setting provided an opportunity for culturally supportive discussions about child health and development. However, consideration must also be given to ensuring that women have access to individual appointments, with an interpreter, where they may feel less constrained about discussing issues of concern with the MCH nurse. When the bilingual community workers and the managers were asked if the women attending group sessions would be receiving the same level of care as an English-speaking mother with an individual appointment it was reported that they would be getting the same level of care because of the skills of the MCH nurse in being alert to broader issues:
"…the nurse might look like she’s just weighing and measuring the baby but they’re on top of everything, they know, they’re watching the interaction, so even if that’s not verbal, if there are concerns the nurse does pick up on them (Manager of community workers)"
Several participants from Iraqi and Assyrian Chaldean backgrounds were not linked to a refugee mentor and had not heard of the MCH service. One Iraqi participant had heard about the service from her husband who had arrived in Australia prior to her.
Promoting continued engagement with the MCH service
Many participants across all cultural groups described how important the service was for them. The concepts of preventive health, well-child checks and early detection of child development delays were new for all participants. One participant explained the value of the MCH service for her and her community:
"It is very, very useful and important for us because each time we go back we talk to maternal and child health and they ask the question like okay, if your child is five months old this is how much he weighs and that’s how much he grows. She show us a graph and the proportions and everything and then say this year your child’s able to do that at this stage - so we know the child’s development, very useful for me to know that. (Karen FG)"
The ‘refugee mentor’ model functioned differently for the Assyrian Chaldean community. The women in this group had been in the country longer and could understand basic spoken English but were not confident in speaking it. The refugee mentor encouraged mothers to make their own appointments at the MCH centre. This was working well for some although several had not heard of the service before. Several Iraqi mothers reported that they didn’t realise until they used the service that the nurse also checked the mother’s physical and emotional health, they described this as a new concept and felt it was important to them.
"She had all three children here in Australia, and always the nurse was following her up, even her emotional [health], every month. She followed the children's health and mum's health too and always if she couldn't visit or a different nurse [couldn’t visit], the nurse would ring her and ask her about her emotional [health] and how she's feeling…but she's surprised because in Iraq, in her country, she didn't hear about that, like straight away [the MCH nurse would follow-up and check] they were feeling okay after they had their babies. (Assyrian Chaldean FG)"
Again, the ‘refugee mentor’ model worked differently for the South Sudanese mothers. This group had not identified having the MCH nurse visit their playgroup as a priority. Although there were some mothers with children born in Melbourne who were using the service, others had used it previously but had encountered significant barriers for continued utilisation of the service. One mother reported that she had walked to a MCH centre with her children and was given a phone number and told to return home and call to make an appointment. Another mother had a new baby and was told that her preferred centre, where she already took her other children, was too busy and that she would have to go to another one which was further away from her home and difficult for her to walk to with her multiple children. She did not want to question the direction to attend another centre because she didn’t want to appear as though she did not care about her children.
"…I ask them why you send me to a place I don’t know? I can’t talk or I can’t make complaint because it’s for my health my baby…I have to go, I don’t have a choice. I am the one who care about my baby. So now I have to walk very far. (South Sudanese FG)"
Voluntary nature of MCH service
Several MCH nurses reported that it was often difficult for them to call parents to remind them that they were due for an appointment aligned with the ‘key ages and stages’ visits while also trying to explain that the service is free and completely voluntary. Some mothers reported that they would like to see the nurses more often than the 10 ‘key ages and stages’ with the gap between 2 and 3.5
years in particular, considered too long. Most parents were unaware that they could access the MCH service for individual consultations even if it was outside of the ‘key ages and stages’ visits. However, the MCH nurses in one area reported that although they would welcome people approaching them, they did not actively encourage it, as they were extremely busy and felt they did not have the capacity for additional appointments. When mothers were asked where they would seek information on their child’s health and development, should they ever need it, responses included: family, friends and their General Practitioner (GP), rarely was the MCH nurse viewed as a source of information.
The refugee health nurses in one area explained that although their service is similar in that it is free and voluntary to use, they employ an Arabic Liaison worker to call families to make appointments. They found that this helped to promote understanding of their service and they also reported that they had few cancellations or appointments that needed to be rescheduled. They felt that if families received a phone call from someone who spoke their language it made it more personal and therefore they were more likely to trust the service and allow the nurses to visit them in their home.
Participants identified transport difficulties in getting to the MCH centre. Although some women could walk to their closest MCH centre, others reported that they had no access to private transport, that public transport was difficult to use as it was not close their home or problematic to use while managing several young children, including walking toddlers and infants in prams. Participants reported that at times public transport was unreliable, making it difficult to get to appointments on time. One refugee health nurse reported how she oriented her appointment times to reflect the local bus timetable that many of her clients used.
Continuity promotes engagement
Building a relationship between the nurse and client was reported as critical for building trust and for continued engagement in the service, with consistency between nurse, interpreter and client preferred. This was identified as a key component of trusting and productive relationships to support child health and development and maternal wellbeing. One MCH nurse reported that it took her one year of developing a trusting relationship with a mother of refugee background before the mother disclosed her violent situation at home with her partner.
"Continuity of staff is another thing, because if you see, every time you come, if you have a problem and you see a different person you're going to disengage with the service because you don't want to be going over the same things. Yes, I do have mums saying "I don't want to have to repeat this over and over." (MCH nurse)"
Most women spoke very little English and were not studying English as they were involved in full-time child rearing. Key language barriers impacting on MCH service use and described below included: working with interpreters, using telephones, appointment reminders, access to translated information and working with bilingual staff.
Working with interpreters
There were mixed experiences across the different locations regarding ease of access to interpreters. Some of the healthcare professionals reported that interpreters often relied on public transport to get to appointments which was, at times, unreliable, while others were unwilling to travel long distances to get to MCH centres or people’s homes. For both MCH nurses and participants, there was a preference for in-person interpreters. Telephone interpreters were used when necessary, although they were reported as problematic (mobile phones cutting out, telephones with no loud-speaker/hands free option or limited volume). Health professionals reported that using the same interpreter with the same clients assisted with developing a good relationship with the family.
"The phone interpreter is too impersonal. And I found that a lot of them use mobile phones so you're constantly cutting out. You don't know who this person is. And if you end up using the same interpreters on a regular basis then the mothers get used to the interpreters and vice versa and you can build a really nice relationship. (MCH nurse)"
The length of appointment time was also reported by health professionals as not long enough even though they were allocated extra time to work with an interpreter. They stated that often there were complex or multiple issues that needed to be considered and there was not enough time to do everything that was required.
Participants reported that interpreters were not always used at appointments and that they often relied on using body language and facial expressions to communicate. Some participants, mostly the Karen and South Sudanese reported that they replied ‘yes’ to the health professional even if they didn’t fully understand what was being asked.
"Q: When you go to the maternal and child health nurse is there an interpreter there?"
"A: No, just show, do the body language"
"Q: Body language yeah, so you can’t really ask any questions?"
"A: No, we just say yes, yes"
"Q: Has there been an opportunity to use a phone interpreter?"
"A: We just need to go and have our immunisation done so maybe we don’t need the interpreter (Karen Focus Group)"
Several Bhutanese, Iraqi and Assyrian Chaldean participants reported that when they felt it was important for them to have an interpreter they asked for one because they did not want to misunderstand any health–related information that might compromise their child’s health.
Several health professionals reported that having a central telephone line to the MCH service in their area worked really well for them to call and make appointments for their clients. However, this method was not favoured by mothers who preferred to directly call a familiar nurse to make an appointment. The following examples demonstrate the challenge for refugee background families to make appointments using telephones.
"A: Actually I haven't been to the maternity nurse with my son that much because I was very busy with my parents and my father was very sick and I was the only one who was taking care of him. So I didn't have a chance to take him to the nurse."
"Q: Would you ever feel like you could call the nurse to ask her [about her concern]?"
"A: I called one time, but when I called her she told me I have to call [the City Council] because they are the ones who make, arrange an appointment with you. So when I called [the] City Council, the time they gave me [an] appointment but this time I'm very busy, when its school time, when I was with my dad at the hospital… (Assyrian Chaldean FG)"
In another example, a mother knew she had to make an appointment for her child to see the nurse; however it took her three days to build up the confidence to pick up the phone and ring to make an appointment. The mother explained that she knew she would have to leave a voicemail and was not confident that her English was good enough for someone to be able to understand her. She called and left a message but realised a few days later that she didn’t leave a phone number for the nurse to return her call and had to repeat the process.
"…a lot of problem when you leave a message on the phone. I think it’s good for some people, they leave the message and they call them back but some other people they are afraid. They don’t know English and how they go on the [answering] machine. For me, it took me 3days to make an appointment myself, I got the card, the number and I got the phone but I can’t…because it scares me. (South Sudanese FG)
In Victoria, there is a free MCH advisory service phone number available 24 hours, 7
days a week for the public to use. The majority of participants had not heard of this service before. For the few participants who had attempted to use it, they had found the telephone number in the MCH child health record book but had little success using it. They reported that accessing an interpreter took too long and instead went directly to the local hospital.
Importance of reminders
Mothers explained that it was easy for them to forget appointments that were made in advance and those that received reminder calls were appreciative of them and felt this assisted with keeping scheduled appointments. Mothers who had not received reminder calls reported that this would be helpful to them.
And you write it somewhere on the paper if you forgot, its hard sometimes to remember where and when is your appointment…they should call you to remind you[if] they miss the appointment because they can’t, they forget to write [the appointment information] in the [child health record]book and they [the mother] forget to call back to make another appointment. (South Sudanese FG)
Some health professionals also reported that providing a map or instructions for how to get to the MCH centre was very useful, because often parents were confused between hospitals, GP clinics, community health centres and MCH centres – even if they had been to the MCH centre previously.
Access to translated information
In contrast to those groups supported by a refugee mentor, a group of Karen participants had minimal engagement with the MCH service. Although they all reported visiting their local MCH centre at least once, and had an appointment with the nurse, they spoke about the frustration of knowing that the child health information available in the waiting room was important but that they could not read it.
"Q: Is it useful going to the maternal and child health nurse? Do you find that you get the information that you want?"
"A: If we can [understand] English it would be very beneficial because there is a lot of information on the walls"
"Q: Would you like to be able to read in English or would you like that information in Karen?"
"A: Yeah if someone comes and gives us information this would be good and talks in Karen yeah (Karen FG)"
Mothers also reported receiving referral letters in English, for example a referral from a GP to a specialist, and not only having to find someone to read the letter but not understanding how or where to go to send letters by facsimile. MCH staff also noted the lack of follow-up in relation to referrals. They reported that many refugee children required specialist healthcare and were concerned that this care was not being delivered as a failure of the referral process.
Working with bilingual staff
The Karen bilingual worker was also an accredited interpreter and she facilitated the group appointments at the playgroup and this worked well for participants and the nurses. It was reported that because she could assist with not only language, but also aid in cultural understanding, that the nurses felt much more confident in working with that particular community. It is Victorian government policy that all healthcare providers work with an accredited interpreter at appointments with non-English speaking clients; this has implications as not all bilingual workers (who are often trusted by the community) have interpreter accreditation. Several nurses reported the difficulties with engaging clients from African countries. The South Sudanese refugee mentor also reported these difficulties, as they persisted even though she had attempted to resolve these using similar strategies to the Karen refugee mentor. This still remains unclear and requires further exploration.
What is working well and what could be done better
When asked about their experience of using the MCH service, all community participants who had used the MCH service spoke highly of the service they received and had no complaints. Participants’ comments implied that the health professionals ‘knew best’ and so they did not question the service they received or have any suggestions for service improvement. A Karen mother explained:
"For maternal and child health they are higher than us, how can we give them advice? They already understand everything…because we tell them our problem and they answer our problem. (Karen FG)"
Supporting MCH nurses
The MCH nurses spoke about fulfilling multiple settlement roles outside their scope of practice, such as that of social workers or case managers. This occurred because they had developed a trusting relationship with the mother who then felt she could help her with other issues. The MCH nurses reported that they would like to be better informed about other services and programs being delivered to refugees to ensure they are complementing one another rather than duplicating or ‘undoing’ the work being done by others. Furthermore, the MCH nurses and other healthcare professionals reported concerns about the wellbeing of refugee background people without any family or community support, highlighting that there are some people that are ultimately even more vulnerable and requiring support. The MCH and refugee health nurses suggested that it would also be useful for them to know what programs and support services were available so that they could link their clients to them rather than feeling as though they are leaving them isolated.
"They’re the ones you worry about because they are doing it tough. (Refugee health nurse)"
The MCH nurses reported that they had recently participated in ‘cultural competency’ training; however, it did not include a specific focus on working with refugee clients. As mentioned previously, some MCH nurses reported difficulty engaging with clients of African backgrounds and felt that culturally specific training would be helpful.
Increasing home visits
Providing home visits was seen as critically important for continued engagement with the MCH service. The ‘enhanced’ stream of the universal MCH service responds to the needs of vulnerable children and families at risk of poor outcomes, in particular where there are multiple risk factors [47
]. Most families of refugee background would be considered ‘vulnerable’ however, it was not evident that they had been offered or were currently receiving this service. Although mothers did not explicitly report that they would prefer home visits (as they may not have known that this service was available to them) it was clear that continued utilisation of the service needed to be made easier for them. The capacity for MCH nurses to provide home visits whether by the universal or the enhanced service, varied across the different areas. Where MCH nurses were conducting home visits, for example with families with several young children and limited access to private transport, the nurses reported that this assisted with establishing an on ongoing relationship that builds trust to support parents’ retention in the service. Perceptions of personal safety were also identified by healthcare professionals as reasons for clients preferring home visits compared to walking or catching public transport to MCH centres. This was not in relation to feeling unsafe, being harmed or living in an unsafe neighbourhood, but fear of the ‘big unknown’ that comes with moving to a new and unfamiliar area.
Improved client records
The MCH nurses reported that they kept their own personal records of client information – rather than centrally located databases. In one local government area, they were able to produce a list of the languages other than English spoken by new mothers enrolled at the MCH service. The MCH nurses explained that they would not easily be able to identify from their client databases whether their clients were of refugee backgrounds. The MCH nurses reported that the information they collect from new clients does not always include the mother’s (or child’s) country of birth or their year of arrival to Australia. They all reported that this is something they would like to be able to do in order to have a better understanding of who their clients are and that it wouldn’t take much more additional time to complete this as part of their record keeping for clients.
Co-location of services
To meet the many needs of refugee clients (as well as other vulnerable parents) there was strong support from the MCH nurses and healthcare professionals for the co-location of early childhood, social support and English language services.
"…because if you have the playgroup working with the Maternal and Child Health in the same building you need multi-faceted buildings, so you could have English classes. So if you've got…a hub, a population, you need to have the English classes in the same building rather than have to have them go somewhere else. One stop shopping, if we can do that they will manage a lot easier. So if they need counselling they can meet the counsellor, so they're not going off to some strange place to see a counsellor to talk about all their traumas, they can actually know that this person they've met, they've seen and they're already in the same building. (MCH nurse)"