This study has documented and synthesised the perceptions and experiences of MCH services in Australia for people of refugee backgrounds and their service providers. With 18 service provider participants and 87 community participants from several different cultural groups, this study has been able to appropriately engage with participants typically described as ‘hard to reach’ and therefore hard to ‘research’. A cultural competence approach was used to underpin this study with various community involvement at all stages of the research process.
Cultural differences, language difficulties, lack of awareness of available services, and lack of health provider understanding of the complex health concerns of refugees can all contribute to inhibited access to healthcare. The findings indicate that the issues affecting initial and continued access to the MCH service by people of refugee backgrounds are multifaceted and arise from socioeconomic disadvantage (e.g. access to private transport), pre-arrival experiences, and differences in language and culture. These demonstrate the importance of considering the results within a socioecological framework in order to determine what multi-level adjustments to the MCH service might be effective in promoting improved and continued access for families of refugee backgrounds
The results suggest that families who have children born in Melbourne have reasonable initial access to MCH services, however, a clear gap in settlement services was identified in relation to linking parents who arrive in Australia with young children to the MCH service. The success of this linking process depends on the ability of the sponsor of the family; the knowledge of the community guide/case worker; or simply whether the information is provided to the newly arrived family at a time when it can be retained, given all the other demands and stresses associated with settlement. Although this issue has been identified previously
 the gap remains, with no strategic, coordinated or formal mechanism for on-arrival settlement services to identify families with young children and link them systematically with their local MCH service. Given that this service has a significant role in early detection of developmental delays and health problems for children and mothers, it is critical that this is addressed.
A significant barrier for continued engagement, with not only the MCH service but any other service for mothers of refugee-background is a low-level of English proficiency. For those who could understand spoken English, most were not confident in speaking English especially to strangers, over the phone or leaving voicemail messages. Most parents reported wanting to learn and practice English, although many were not studying due to full-time child rearing roles. The MCH service needs to be mindful of the language difficulties experienced by refugee backgrounds mothers and respond to these service access barriers appropriately. There needs to be alternative ways in which mothers who are not confident in using telephones and leaving voicemail messages can make appointments. Bilingual community workers or interpreters could assist in this way by telephoning parents to book them in for their appointments and helping them with either community transport or organising how they are going to travel to get to their appointment. Guidelines have been developed to support organisations and the bilingual workers they employ
. Group visits should also be encouraged; however, MCH nurses need to allow for mothers to comfortably raise any issues of concern with them; this may be achieved by making individual appointments with those mothers, facilitated by an interpreter or bilingual community worker, where they exist, or by providing each mother with an opportunity to meet the nurse in a private room during the group visit. For longer term solutions, extending the co-location of MCH and other social and health services with flexible English language classes may be a useful means of supporting access to these and other services and promoting positive settlement for families of refugee backgrounds.
Participants reported their experience of using MCH services as positive, though participants may have withheld information in the focus group setting because they did not wish to disclose negative experiences in front of their peers, the researchers, their community representatives/bicultural worker, or the interpreters. Bandyopadhyay and colleagues in their study of birthing experiences in Australia suggest that immigrant women (including but not exclusively refugee background women) view their local community as ‘very mother and baby friendly’ compared to women proficient in English. The authors suggest this might be because they find that the services and supports are better than in their country of origin or that immigrant mothers do not want to be critical of their new country or that they simply have lower expectations of community services and supports
. These possibilities are also plausible in this study.
Although other studies
 have identified lack of finances as a constraint for people of refugee backgrounds to access health services, this was not identified as an issue as MCH services in Victoria are provided for free. However, access to private transport and efficient, reliable and accessible public transport, were reported as significant barriers for parents to access health services, particularly for arriving on-time at scheduled appointments. MCH nurses reported the need for being flexible in their services delivery times and often making appointments that reflected local bus timetables. Home visits by professionals are used widely as a strategy to provide support to families with identified vulnerabilities or risk factors
. Increasing MCH nurses’ ability to conduct home visits would support ongoing and long-term retention of families in the service. A systematic review revealed that for women and families at high risk for either family dysfunction or postpartum depression, home visitation by a nurse, resulted in a reduction in depression scores (as measured by the Edinburgh Postnatal Depression Scale)
. Such home visits need to be conducted in a sensitive manner, given that previous Canadian research, although not with culturally diverse participants, has demonstrated that mothers receiving home visits felt the nurse was ‘watching over them’ which created a sense of fear and a lack of trust
. This was not raised as an issue in this study with refugee background women. However, it does highlight the importance of effective engagement that is sensitive, including an appropriate interpreter, in order for a good relationship to be formed, to not exacerbate any feelings of vulnerability. This is supported by recent Australian research conducted to promote improved maternity care for women of refugee backgrounds
The study findings also revealed that the different levels of health service entitlements by visa category may further complicate the provision and use of MCH services for providers and clients, though this may now improve in light of recent policy changes in this area, as previously mentioned. This has been previously reported by Davidson and colleagues as an area of concern requiring attention
. The healthcare professionals were concerned about those arriving on ‘sponsored’ visas whereby the sponsor themselves would also be considered vulnerable and not in a position to be supporting newly arrived people in accessing needed services. Furthermore, those identified as arriving alone and considered to have ‘refugee-like’ experiences were also of concern to healthcare professionals. Critical here is for the MCH service to be able to identify whether clients are of refugee background in order to tailor their services appropriately. As stated previously, a recent state-wide report examining the health status of refugee children and young people reports that a range of data collection systems are used by MCH services and that although maternal country of birth is recorded and could be used as a proxy for determining refugee background, it is not possible to extract and use this data
. It is recommended that state-wide client records are established and routinely collected so that refugee background clients can be identified and their ongoing retention in the MCH service monitored.
Internationally, community-wide interventions have utilised universal health services to improve preventative services for children and families, though not necessarily refugee background families. In the United States Margolis and colleagues conducted a large observational intervention study that aimed to achieve changes in the delivery of health care, particularly the interaction between those providing the care and low-income pregnant mothers to improve health and developmental outcomes for children
. Health care staff received training, support and supervision; there were structured protocols for care delivery, and regular feedback data about implementation of the program. The authors reported high levels of family participation in the services, changes in the delivery system, and improvements in preventive health outcomes. Intervention group women were significantly more likely to use contraceptives, not smoke tobacco, and have a safe and stimulating home environment for their children. Children were more likely to have had an appropriate number of well-child care visits and were less likely to be injured. The authors also reported that many improvements continued to be seen since project completion. From this study it was concluded that multi-level, interrelated interventions directed at an entire population of mothers and children hold promise to improve the effectiveness and outcomes of health care for families and children.
A national study conducted in the United States investigating parent satisfaction with well-child care for young children, reported that Hispanic parents, particularly those responding to a survey in Spanish (rather than English) gave lower satisfaction ratings
. Although, overall, parents generally reported high levels of satisfaction with well-child care visits, the authors suggested that it is important to understand how parent perceptions of time adequacy and their ability to ask questions about topics that are important to them, relate to the amount of information that health care providers are able to convey. The authors suggest that allocating more time for appointments is appropriate given that the number of recommended topics to cover in each appointment has increased over the years
. It is also reported that health care providers use the Parent Evaluation of Developmental Status (PEDS) to help them provide more responsive and targeted care and information on issues that are of concern to parents
. In Victoria, the MCH nurses are already required to complete this instrument with parents as part of the 10 ‘key ages and stages’ assessments, however, it is not known how appropriate and relevant this tool is for families of refugee backgrounds. Furthermore, our findings indicated that mothers of refugee backgrounds would like to see the same MCH nurse at their appointments, in the United States is has been demonstrated that having a regular clinician is associated with greater volume of preventive visits for children and is associated with fewer emergency department visits and hospitalisations and more frequent parent reports of discussing specific health topics
. However, visit frequency and continuity of clinician shows minimal impact on timeliness of preventative care and adherence to recommended guidelines. Inkelas and colleagues report that in the United States, for young children, having a regular clinician yields the greatest interpersonal quality gains in community health clinics and for African American and Hispanic children in contrast to non-Hispanic white children and they suggest that having a regular clinician may narrow the disparities gap between racial and ethnic population subgroups witnessed in primary health care
. Furthermore, programs and policies to improve parental education, health literacy, the quality of service provider communication and quality improvement strategies for health care systems are critical to improve ‘family-centred’ care and have the potential to reduce racial and ethnic health disparities
. Although, it is also acknowledged that service provider training and supporting clinicians to promote high quality patient interactions for patients who have varying levels of education, health literacy and English proficiency are keys areas requiring further attention
Innovation, flexibility, and culturally competent service models appear to be critical for ensuring that services interact with the contexts and experiences of refugee families to optimise their start in a new country. There are different models of service delivery that showed promise in terms of improved access to MCH services. These include the use of bilingual workers/refugee mentors, utilisation of playgroups to build service awareness and engagement and social support, strategies to promote self efficacy, group appointments, and co-location of services. The ‘refugee mentor’ model was working well for promoting MCH group appointments with Karen families, however, this is provided they are attending playgroup in the first instance. Research is needed here to assess whether this model is likely to enhance or hinder mothers’ capacity to access services for themselves as they become more settled. Furthermore, while this was reported to be a successful model by both providers and users of the service for promoting access to the MCH service, there is the potential for this to be a limited service – with each parent having less opportunity to discuss any individual concerns – compared with the individualised service received by English speaking parents. Similar concerns exist for clients when no interpreter is used – i.e. even though the MCH nurses may be able to “assess more than parents realise”, the parent does not have the opportunity to discuss any particular concerns that may not have been evident to the nurse, for instance intimate partner violence. In developing a model of best practice for refugee maternity care, Correa-Velez also advocated for continuity of care, quality interpreter services, educational strategies for both women and healthcare professionals and the provision of psychosocial support to women from refugee backgrounds
. Learnings from our research suggest that there may not be one ‘model’ of best practice for promoting maternal and child health for refugee background families, but a suite of strategies that are flexible and adaptable and are reflective of the clients’ cultures, languages, existing social groups and resources of local service providers – both mainstream and culturally-specific.
This research has identified a range of holistic strategies to improve access and engagement with refugee background families, however, in many cases the options are limited by the need for efficient use of scarce resources. In other cases, such as the introduction of a central telephone booking service, we have demonstrated that such efforts which have aimed to improve access for many are actually counter to the expectations and needs of the clients. Participants faced extreme difficulties in terms of having the confidence to use telephones to make appointments, particularly when they were required to leave voicemail messages. MCH services could proactively work in partnership with bilingual community workers to call clients directly to make appointments. Where these workers are not available, interpreters could also be utilised for this purpose. In many cases, it was the role of the ‘refugee mentors’ to initiate service access for parents of refugee backgrounds and to enhance the cultural knowledge and capacity of healthcare professionals and their organisations. The MCH service provides an opportunity to focus on the dynamics between parents and children and to locate the issues facing refugees in their wider family and community context. Given the social isolation and lack of knowledge of services and systems (for example, education as well as health) for refugee background families, MCH services also potentially play a vital role in linking families to communities and services more broadly. The role played by bicultural workers should be recognised and utilised in a way that benefits clients and service providers. This, of course, is only possible in areas with high prevalence of a particular language. Therefore, alternative models for client engagement should be trialled. One such model could be a ‘drop in’ service whereby an allocated day and time could be promoted to come to the MCH service with an interpreter available for that time. If large numbers were to arrive at the time period, it would provide an opportunity for other healthcare providers to attend to meet the clients to introduce themselves and their service, as well as an opportunity to conduct community health promotion sessions on particular topics. Another model to be trialled would be MCH nurses attending at venues where parents already gather, such as playgroups, kindergartens and English language centres, to conduct group information sessions that promote the MCH service, provide health information and enable that first initial trust-building contact that could lead to parents wanting to make individual appointments at the MCH centre with a nurse who is now familiar to them. The importance of building trusting interpersonal relationships between nurse and client is well established and Jack and colleagues report that the quality of these relationships should be continuously assessed and perspectives of mother’s satisfaction of these relationships sought
Meaningful engagement with refugee families is critical for sustainable health service utilisation. If this does not occur it can ultimately further isolate and marginalise refugee families with infants and young children. To promote the responsiveness of the MCH service to the needs of people of refugee backgrounds requires awareness of the diversity of that population in key aspects such as culture and experiences prior to arrival and in the course of settlement. The ‘refugee mentor’ model described here is one that has the potential to promote effective communication and cooperation, and avoid cultural ‘blind spots’ and can lead to a progressive depth of understanding between the MCH nurse (or any health service provider) and the client. This will hopefully and ultimately improve referral to specialist care where required, clinical diagnosis, and health and psychosocial outcomes for refugee background children and families.
The study was undertaken in two areas of outer urban Melbourne and the findings may not be applicable to other locations in Victoria (e.g. rural and regional areas) or more generally. The sampling frame includes multiple cultural groups across several different settings but there may be sociocultural issues that were not uncovered in this study that apply to other groups.