The main objectives of the project are as follows:
Afghans have been migrating to Australia since the 1860s and currently the number of Afghan community in Australia is 35000. The number is rising mainly through humanitarian program. They have been a victim of many civil war and human right abuses. Hence, most of the Afghanistan-born people settled in Australia are mostly asylum seekers and refugees with history of trauma and displacement. Many health practices in Afghan refugees differ from that of Australian Community. Firstly, they are unfamiliar with the Australian health care system and they are reluctant to seek health care services too. Even if they seek health services, there is a preference to be seen by the health care staffs of the same gender (Afghan community profile 2017).
The review of literature on unmet needs of Afghani refugee in Australia reveals that mental health issues disproportionately affects Afghan refugees due to prolonged exposure to war. Refugees are in general vulnerable to high psychological distress and in Afghan refugees, it is mostly due to pre-migration and post-migration traumas. The problem is intensified as they do not receive any prior psychological support in their own country due to weak mental health infrastructure. Their experience of atrocities, loss of family members and stressful escape experience is the reason for high comorbidity of mental illness. Hence, the mental health problem is mediated by mental health and language conflicts. Low utilization of mental health care is also high due to attitudes of stigma and lack of trust in Australian health care methods (Alemi et al. 2014). Therefore, this finding suggests that there is a need to adapt medical health problem that promotes utilization of mental health care services among Afghan refugees living in Australia.
Valibhoy et al., (2017) gave another insight into the experience of Afghan refugees in Australian mental health service and the survey with young refugees gave the answer to the research question. Mental health service utilization in this group was particularly influenced by the young refugee’s preconceptions about mental health practitioner, sociocultural context and help-seeking attitudes. They had a stigmatizing concept about being a mental health client and another barrier to service utilization was the poor narration of personal experience and symptoms of health care staffs. Therefore, the need for cultural sensitivity in delivering mental health service mainly arose in this research study as socio-cultural context mainly influenced their service utilization pattern. There is an urgent need to establish a condition that promotes therapeutic relationship between mental health service and Afghan refugees.
Afghan refugees settled in Australia are highly vulnerable to post-traumatic stress disorder (PTSD). An analysis of the beliefs regarding the causes and risk of PTSD among two refugee groups in Australia showed that Afghan refugees regard coming from a war-torn country as a major reason for the development of PTSD. The participant’s response also indicated that they regarded the role of higher order powers in the etiology of mental health problems. This proves that impact of religious and spiritual teaching also influence utilization rate of health care services among this group (Slewa-Younan et al., 2017). This finding is also consistent with the research by Toar et al., (2009) which also reveals the prevalence of PTSD, depression and anxiety among asylum seekers and refugees. The rate of utilization of health care service in this group was done by means of assessment of frequency of contact with health care practitioners, number of hospital admissions in last one year and use of prescribed medication in the past two weeks. The study finding gives the idea that high post migration stressors along with presence of one or more chronic disease leading to PTSD and anxiety in refugees. Despite high self-reported problem of psychological disorder in this group, majority of them are not utilizing Australian mental health services adequately.
As Afghan refugees are one of the largest source of refugee settlement in Australia, there a need to promote better health outcome in this group. The review of recent evidence regarding the problems/ or unmet needs in this group illustrates high prevalence of psychological distress and mental illness in this group. Another major unmet need is that despite high psychological disorder, the health service utilization rate is too low. This is mainly because of poor awareness regarding Australian health care system and impact of sociocultural context in treatment choices. Hence, the analysis of the reason for these problems in Afghan refugees indicates that the implementation of targeted health promotion program in this group by putting special attention to cultural sensitivity in health care delivery. This is important to preserve the diversity of the nature and deliver culturally competence services (Haintz, Graham, & Mckenzie, 2015).
To address the problem of the prevalence of psychological distress in Afghan refugees and poor rate of service utilization in this group, it is proposed to implement a culturally sensitive health promotion program to raise awareness about mental health in Afghan refugees and the importance of seeking help from mental health care professionals and community nurses. This would help to bridge the gap between current use of mental health care services and the knowledge and beliefs regarding treatment in Afghan refugees (Renzaho et al., 2013). To improve the mental health of refugees, it is planned to provide trauma-based CBT (Cognitive behavioral therapy) intervention to highly vulnerable people. It is feasible in reducing PTSD among refugees (Unterhitzenberger et al., 2015). Furthermore, to enhance the rate of utilization of mental health service among this group, Andersen’s model will be applied in the health promotion program. The model will help staffs to understand the needs of patients in care and identify the barrier and facilitators to help-seeking behavior among Afghan refugees. This will make health professionals sensitive to cultural and clinical needs of Afghan refugees and enhance the access to service (Dhingra et al., 2010). It is proposed to achieve the desired outcome of high mental health service utilization and positive health outcome for Afghan refugees through culturally sensitive health care program within one year.
The following are the resource needed for the implementation of the proposed health promotion program-
The implementation of the culturally sensitive health promotion program by the utilization of the Andersen model is considered important for the Afghan refugees because it would help to narrow the gap in mental health service utilization rate which according due to socio-cultural beliefs of refugees. The analysis of the unmet needs in Afghan refugees residing in Australia revealed lack of refugee focused health service in Australia. Although the mental health services are available, however they are not conducive to socio-cultural preference of this group. Besides this, stigmatizing beliefs about mental illness also discourages Afghan refugees to seek adequate support from mental health service. Hence, with this problem, the culturally sensitive health care program has the scope to bring improvement in current process of health care delivery and align it to the cultural needs of the target group (Netto et al., 2010).
The implementation of the proposed program is a step ahead toward refugee focused mental health care system so that all barrier and facilitating factors in care for Afghan refugees are recognized. Refugees face problem in accessing and utilizing the primary health care service due to their attitude and beliefs about illness. The engagement of the community by means of culturally sensitive health care program will help to enhance partnership between Afghan refugees and mental health services (Cheng et al., 2015). The culturally sensitive health promotion will be given by means of language assistant service, verbal and written instructing informing patients about the risk factor associated with mental illness and importance of revealing personal factors in life to achieve targeted intervention. It will help in the interpretation of challenges in Afghan refugees and address them in a systematic manner. By this means, patient-desired intervention can be provided to make them comfortable with western clinical methods and establish trusting relationship with health care staffs and community (Tucker et al., 2011). This is important because review of barriers has revealed that many refugees do not seek support from health care service due to lack of trust (Alemi et al. 2014).
The important element of community level health practices involves promotion of healthy living in target group, prevention of health issues, treatment of disorders, rehabilitation and evaluation of outcome. The health promotion program is unique and specific to the needs of the Afghan refugees. It is in relevance with the Neuman’s care model which is based on the assumption that many unknown and universal stressors exist in client, which further aggravate their health status and each client have their own way of responding to the environment (George, 2011). With this concept, the resistance to seeking help behavior is high in Afghan refugees due to the presence of post and pre-migration stressors in their life. Hence, staff training in cultural sensitive care and awareness and knowledge about mental health among Afghan refugees is deemed to bring favorable outcome as expected from the objective of the project.
The main unmet need of the Afghan refugees living in Australia is that of poor utilization of health care services and to address this problem, the application of Andersen model into the health promotion program has been proposed. The rational for including this model in the program is that this program will facilitate identifying conditions that can promote utilization in this group (Alexander, Brijnath, & Mazza, 2015). According to this framework, a client’s pattern of accessing and using the health service can be understood three characteristics- predisposing factors (health belief, social structure and demographic), enabling factors (available health facilities, personal factors and psychological characteristics) and need factors (the conditions under which the health service is utilized (Smith & Scheid, 2014; 2013). Hence, the utilization of this framework in health promotion program will have great implications for community level clinical practice. It will increase awareness about refugee group belief about the cause of mental health problems and this will modify the choice of interventions delivered to Afghan refugees.
To evaluate the outcome of the health promotion program on increasing mental health utilization rate among Afghan refugees, self-reported data will be collected from participants six months after the program. The survey by means of self-reported response of participants will evaluate the change in beliefs about the cause of psychological disorder in this group and analyse the change in their health beliefs and health seeking behavior after the program. Another important aspect of the evaluation process will to collect data from mental health clinic regarding the increase in number of visits of Afghan refugees for treatment compared to last six months data. By this means, the success of the program can be evaluated. Furthermore, participants experience regarding the health promotion program will help to identify any limitation or weak area where more corrective actions. This will help to collect the required information regarding the bridge in gap between current intervention and health beliefs of the Afghan refugee groups.
Afghan community profile. (2017). www.dss.gov.au [online] Available at: https://www.dss.gov.au/sites/default/files/files/settle/communityprogiles/community-profile-afghan_access.pdf [Accessed 1 Apr. 2017].
Alemi, Q., James, S., Cruz, R., Zepeda, V., & Racadio, M. (2014). Psychological distress in afghan refugees: A mixed-method systematic review. Journal of Immigrant and Minority Health, 16(6), 1247-1261. doi:10.1007/s10903-013-9861-1
Alexander, K. E., Brijnath, B., & Mazza, D. (2015). Parents' decision making and access to preventive healthcare for young children: Applying andersen's model. Health Expectations, 18(5), 1256-1269. doi:10.1111/hex.12100
Cheng, I., Wahidi, S., Vasi, S., & Samuel, S. (2015). Importance of community engagement in primary health care: The case of afghan refugees. Australian Journal of Primary Health, 21(3), 262. doi:10.1071/PY13137
Dhingra, S. S., Zack, M., Strine, T., Pearson, W. S., & Balluz, L. (2010). Determining prevalence and correlates of psychiatric treatment with Andersen's behavioral model of health services use. Psychiatric Services, 61(5), 524-528.
George, J. B. (2011). Nursing Theories: The Base for Professional Nursing Practice, 6/e. Pearson Education India.
Haintz, G. L., Graham, M., & Mckenzie, H. (2015). Navigating the ethics of cross-cultural health promotion research. Health Promotion Journal of Australia: Official Journal of Australian Association of Health Promotion Professionals, 26(3), 235-240. doi:10.1071/HE15050
Netto, G., Bhopal, R., Lederle, N., Khatoon, J., & Jackson, A. (2010). How can health promotion interventions be adapted for minority ethnic communities? Five principles for guiding the development of behavioural interventions. Health Promotion International, 25(2), 248-257.
Renzaho, A. M. N., Romios, P., Crock, C., & Sønderlund, A. L. (2013). The effectiveness of cultural competence programs in ethnic minority patient-centered health care—a systematic review of the literature. International Journal for Quality in Health Care, 25(3), 261-269.
Slewa-Younan, S., Guajardo, M. G. U., Yaser, A., Mond, J., Smith, M., Milosevic, D., . . . Jorm, A. F. (2017). Causes of and risk factors for posttraumatic stress disorder: The beliefs of iraqi and afghan refugees resettled in australia. International Journal of Mental Health Systems, 11(1) doi:10.1186/s13033-016-0109-z
Smith, G. H., & Scheid, T. L. (2014;2013;). An application of the andersen model of health utilization to the understanding of the role of race-concordant doctor-patient relationships in reducing health disparities. (pp. 187-214) Emerald Group Publishing Limited. doi:10.1108/S0275-4959(2013)0000031011
Toar, M., O'Brien, K. K., & Fahey, T. (2009). Comparison of self-reported health & healthcare utilisation between asylum seekers and refugees: An observational study. BMC Public Health, 9(1), 214-214. doi:10.1186/1471-2458-9-214
Tucker, C. M., Marsiske, M., Rice, K. G., Nielson, J. J., & Herman, K. (2011). Patient-centered culturally sensitive health care: Model testing and refinement. Health Psychology, 30(3), 342-350. doi:10.1037/a0022967
Unterhitzenberger, J., Eberle-Sejari, R., Rassenhofer, M., Sukale, T., Rosner, R., & Goldbeck, L. (2015). Trauma-focused cognitive behavioral therapy with unaccompanied refugee minors: A case series. BMC Psychiatry, 15(1), 260. doi:10.1186/s12888-015-0645-0
Valibhoy, M. C., Kaplan, I., & Szwarc, J. (2017). “It comes down to just how human someone can be”: A qualitative study with young people from refugee backgrounds about their experiences of australian mental health services. Transcultural Psychiatry, 54(1), 23-45. doi:10.1177/1363461516662810
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