Preventing health disparities among migrant children and youth: Delivering culturally competent health careMirko ProsenUniversity of PrimorskaFaculty of Health Sciencesmirko.prosen@fvz.upr.si

Children and young people on the move:Towards a more precise definition of their best interestsPortorož, 19 - 20 November 2015

CONTENTS

1. Introduction2. Migration, health, and health policies3. Vulnerability of migrant children and

youth: Health status perspective 4. The role of health care system in

preventing health disparities5. Ensuring culturally congruent nursing

care6. Conclusion

INTRODUCTION

• In Europe there is a long history of migration within and from outside its countries. Over the last decades, the patterns of migration changed dramatically, especially if we consider the changed „push and pull“ factors.

• The changes in patterns of migration are nowadays, more then ever before, fast and unpredictable and thus difficult to control.

• Among all migrants, an unaccompanied children and youth are probably the most vulnerable, especially when we discuss their health status (or even more, their possibilities to access the health care system in the host country).

INTRODUCTION

• All European Union member states have legally recognized the right to the highest attainable standard of health for everyone in their populations.

• However, migration may involve poor access and barriers to health care services due to different reasons and finally the question remains if the health care delivered was culturally sensitive and congruent (competent).

• Consequently, health disparities may arise!

INTRODUCTION

• Pursuing health equity means striving for the highest possible standard of health for every individual and giving special attention to the health care needs of those most vulnerable.

• This also includes delivering culturally congruent (competent) health care.

• Culturally congruent health care is a basic human right, not a privilege, so every human being should be entitled to culturally congruent care (Jeffreys, 2006).

MIGRATION, HEALTH, AND HEALTH POLICIES

• Migrants travel with their health profiles, values and beliefs, reflecting the socio-economic and cultural background and the disease prevalence of their country of origin.

• Such profiles and beliefs can be different from those of the host country, and may have an impact on the health and related services of the host country as well as on the health of and usage of health services by migrants (WHO, 2010).

• In particular, refugees and asylum seekers do not usually remain in the country of the first asylum, that is why their health status and access to health care presents even a greater problem (Taylor, 2006).

MIGRATION, HEALTH, AND HEALTH POLICIES

• Most migrants are healthy, young people, and some may even benefit from „healthy migration effect“ when they first arrive in their (first!?) host country. However conditions sourrounding the migration process can increase vulnerability to ill health (WHO, 2010).

MIGRATION, HEALTH, AND HEALTH POLICIES

• Policies and strategies to manage the health consequences of migration have not kept pace with growing challenges related to the volume, speed, and diversity of modern migration, and they do not sufficiently address the existing health inequalities, and determining factors of migrant health, including barriers to accessing health services (WHO, 2010), socioeconomic status, (English) language proficiency, residential location, stigma and marginalization (Avery, 2001).

MIGRATION, HEALTH, AND HEALTH POLICIES

• This can be seen as a paradox of acculturation and health of migrants in some developing countries and the same can be expected regarding health of migrant children and youth (Avery, 2001; Andrews et al., 2010).

• The expectations is that new migrants would have worse health problems as they arrive in the final host country and better health status as they assimilate (integrate), but the opposite is true (Avery, 2001).

MIGRATION, HEALTH, AND HEALTH POLICIES

• The public health approach to migrant health has moved from traditional approach, based on the principle of exclusion of migrants with certain health conditions, to modern approach, focusing on inclusion and reduction of inequalities and social protection of health in the context of multi-country and multi-sectoral approach (WHO, 2010).

• In 2008 WHO Secretariat prepared a report identifying four basic principles for a public health approach to adress the health of migrants and host countries.

MIGRATION, HEALTH, AND HEALTH POLICIES

VULNERABILITY OF MIGRANT CHILDREN AND YOUTH

• Within migrant population, children and youth are at increased risk for health problems, especially those who are un unaccompanied.

• That is why United Nation Convention on the Rights of the Child and migrant children‘s rights to healthcare, protects this vulnerable population (IOM, 2009).– Article 24: Right to the highest attainable standard of

health– Article 2: Right to non-discrimination– Article 3: The best interests of the child– Article 6: Right to life, survival, and development– Article 12: Right to express views freely

VULNERABILITY OF MIGRANT CHILDREN AND YOUTH

Article 3: The best interests of the childArticle 3: The best interests of the child

•The best interest of the child must be considered in all actions affecting his/her well-being, in accordance of their specific situation, including health and migration status, cultural background etc.•Goverments, throuh legislation must establish efective mechanisms to monitor children‘s well-being and the realization of their rights.•Hospitals/health care services should implement guidelines coming from international organizations (WHO, UNICEF).

VULNERABILITY OF MIGRANT CHILDREN AND YOUTH

Article 3: The best interests of the childArticle 3: The best interests of the child

•It is important to point out that in provision of health care, it can sometimes be complex to define the best interest of the child. (CLINICAL

PRACTICE CASE)•Health professionals should try to define it in a participatory way with the child, his/her parents or family (WHO, 2010). •Particulary for an unaccompanied children/youth we must keep in mind that nurses and other health professionals (MD), are obligated to practice advocacy.

VULNERABILITY OF MIGRANT CHILDREN AND YOUTH

• Advocacy involves engaging others, exercising voice and mobilizing evidence to influence policy and practice. It means speaking out against inequity and inequality (Canadian Nursing Association, 2015).

VULNERABILITY OF MIGRANT CHILDREN AND YOUTH

• Migrant children are at increased risk for numerous health problems that are related to their social conditions. Studies suggest that migrant children are more vulnerable to respiratory and ear infections, bacterial and viral gastroenteritis, intestinal parasites, skin infections, dental problems, pesticide exposure, infectious disease, poor nutrition, anemia and short stature (IOM, 2009).

VULNERABILITY OF MIGRANT CHILDREN AND YOUTH

• Also, during the migration process migrant children tend to be more exposed to intentional and unintentional injuries, family violence and mental health problems (Carta et al., 2005; IOM, 2009).

Foto: Reuters

VULNERABILITY OF MIGRANT CHILDREN AND YOUTH

• Numerous studies have pointed out a higher prevalence of unmet health needs among migrant children often related to reduced use of health care services and delayed or inadequate medical care (Chemtob et al., 2003; Weathers et al., 2004; IOM, 2009).

VULNERABILITY OF MIGRANT CHILDREN AND YOUTH

• IOM (2009) reports that studies indicate that migrant children and adolescents or belonging to minority groups have worse health indicators than the national population.

• Some of the health problems identified among miniorities adolescents are related to nutrition, obesity, domestic accidents, tobacco and drug use, sexual behaviour (less parental control, teenage pregnancy) among others.

THE ROLE OF HEALTH CARE SYSTEM IN PREVENTING HEALTH DISPARITIES• Health care services should provide high quality

services of health promotion, prevention, treatment and care.

• In their programmes, they need to consider the different life settings of children and adopt partnerships and protocols with governmental and non-governmental actors at community/local level.

• The quality of services rendered is dependent upon contex where they are inserted and follows a logic of response to the context – inputs, processes and outputs (WHO, 2010).

THE ROLE OF HEALTH CARE SYSTEM IN PREVENTING HEALTH DISPARITIES

ENSURING CULTURALLY CONGRUENT NURSING CARE

• Nurses, as one of the largest group of health professionals in health care system which stand at the point of entry into this system, must be committed to eliminating health disparities and promote socially just health care systems.

• Nursing is a profession that is based on a holistic holistic approachapproach to health care delivery. This also includes taking into account patients’ cultural needs.

• Transcultural nursingTranscultural nursing, an area of study and practice with a human care focus developed by Madeleine M. Leininger, has led to the development of nursing knowledge and skills to improve patient care.

ENSURING CULTURALLY CONGRUENT NURSING CARE

• Cultural competence involves systems, systems, agencies and providersagencies and providers having the ability to respond to the unique needs of populations whose cultures are different from the “dominant” culture (Cuellar et al., 2008).

• This requires nurses to see themselves as “becoming” “becoming” culturally competent, rather than “being”“being” culturally competent (Campinha-Bacote, 2001).

ENSURING CULTURALLY CONGRUENT NURSING CARE

• When working with migrant children and youth this starts with cultural health assessment and continues with developing nursing actions that promote positive health behaviour among this vulnerable population group. The letter can be done using several transcultural nursing concepts, models and theories.

ENSURING CULTURALLY CONGRUENT NURSING CARE

• There are numerous theories and models that can be, more or less implemented into nursing clinical practice. However, two of them are usually in focus:

• Theory of Culture Care Diversity and Universality (Madeleine Leininger)

• The Process of Cultural Competence in the Delivery of Health Care Services (Josepha Campinha-Bacote)

ENSURING CULTURALLY CONGRUENT NURSING CARE

• SUNRISE MODEL (M. Leininger)

ENSURING CULTURALLY CONGRUENT NURSING CARE

• THE PROCESS… (J. Campinha-Bacote)

ENSURING CULTURALLY CONGRUENT NURSING CARE

My observasion of the clinical practice confirm:

•The failure to provide culturaly appropriate services is not always deliberate but is underpinned by ethnocentricity which assumes that people from other cultures find mainstream provision acceptable and effective (Tilki, 2006).

CONCLUSION

• Societies have become increasingly multi-cultural and multi-etnic.

• The consequent increased diversity in health determinants, vulnerability levels and needs among society members is challenging the capacity of health care systems to deliver affordable, accessible and migrant-sensitive services, and calls for a migrant-sensitive workforce (Puebla Fortier, 2010).

• Particulary the needs of unaccompanied migrant children and youth should be consciously and systematically incorporated into all aspects of health care services.