TALKING ABOUT HEALTH: INNOVATIONS IN HEALTH COMMUNICATION

Sunnybrook Convention Centre, Warwick Farm 7^th December 1999.

FAMILIES IN CULTURAL TRANSITION PROGRAM: resources to assist immigrants and refugees to deal with the process of resettlement in Australia.

By Cherie Lamb

Introduction

Health communication is often presented to health workers in terms disseminating facts about communicable diseases and injury prevention, but from a mental health perspective it means much more than this. The World Health Organisation defines health as “state of physical, mental and social wellbeing and not merely the absence of disease and infirmity". It is therefore about lifestyle and ensuring that all Australians have the best possible access to services to that they can make informed choices from a range of available options. People need to be informed and empowered so they that they can deal with change. Refugees in particular need much more than what would traditionally be categorised as health information to maintain good health as they deal with pressures of resettlement in Australia. This morning I will introduce an innovative program designed to promote better health for people from diverse communities living in Australia.

Aims

The Families in Cultural Transition Program which I will now refer as FICT, aims to equip migrants and refugees to:

Understand the ideas behind Australian society and institutions in order to know their right and ensure that these rights are upheld

Detect difficulties, avert crisis situations and solve problems that may arise in the family as a result of cultural and intergenerational differences

Recognise the differing perspectives men, women, children and adolescents may develop in Australia in response to the new culture; and

Contribute to overcoming isolation in new arrivals by the development of support network.

Background

The FICT program was developed by STARTTS, funded by grants from the Department for Women and the NSW Social Policy Directorate in 1995/1995. Tony Savdie and Louise Carey were employed to research, develop, write and pilot the program. The authors developed high quality material through dedicated research and much trial and error involving the communities by STARTTS.

STARTTS, for those of you who are not familiar with the organisation, is primarily a counselling service, offering assistance to refugees and survivors of torture and organised violence from all over the world. The service also engages in community development, youth work, research training and early intervention. Although STARTTS is a state-wide service it is administered by the South West Area Health Service.

Why do we need this kind of program?

Exile and migration place enormous pressures on the family unit. Each member of the family experiences migration and resettlement differently. For many immigrant families roles change and are likely to become permanently redefined. Men who were previously breadwinners often find themselves unemployed and their wives may need to enter the workforce for the first time. Alternatively , couples may spend much more time at home together on a very low income due to unemployment.

Parents may depend more heavily on their children for communication with the external environment and children will necessarily have to make more decisions in the household and utilise more power than in age appropriate. They are exposed to the new environment in much higher doses than their parents and are under enormous pressure to adapt and often conform to mainstream culture. Children often need to operate in two separate worlds and this may become a potential source of conflict when the world of their peers is juxtaposed to their parent’s more traditional expectations. In a worst case scenario family conflict may escalate into marital breakdown, domestic violence, inadequate or excessive parenting and possibly social isolation for all or some family members. Children may withdraw, become depressed, or aggressive, and they may develop sleep disorders or chronic somatic complaints.

Counsellors at STARTTS have observed that this change in family dynamics is common throughout all cultures. This program was therefore developed by drawing upon a wealth of clinical expertise and cultural advise from people from many parts of the world.

Program design and approach to learning

This program recognises and values the fact that adult learners bring with them a whole toolkit of resources such as educational background, past experiences, skills, history, culture and values which can be used to investigate new material. The activities have therefore been designed as exploratory tasks rather than the more traditional one way flow of information from teacher to students.

People learn in different ways. Some like to experiment and draw conclusions, other like to discuss ideas and receive feedback, some like the excitement of playing games, still others prefer to quietly reflect upon information. In the design of the program the authors developed a learning cycle in which the individual participant does something, the experience is observed, interpreted and reflected upon. The experience is then discussed and analysed with others in the group, then inferences are then drawn, either individually or collectively.

In order to integrate newly acquired skills into daily life it is important is to have the opportunity to practice immediately in situations requiring these skills. In the FICT program communication and problem solving skills are taught and rehearsed in a supportive environment.

Methodology

The methods and techniques used in the program take into account various learning and teaching styles. The participants are stimulated with a range of activities such as: discussions, case studies, values clarification scenarios, brainstorm, paired discussion, small and large group discussion, interviews, games role play and community mapping exercises. Occasionally guest speakers are organised to impart specialist knowledge and advice to group members about immigration, housing and other matters that the group identify as being of utmost importance. Learner generated materials from discussions and brainstorms are also recorded and distributed back to the group as a record their own solutions to problems.

What is the FICT Kit?

The FICT program consists of a package of resources including a nine module program, two board games, handouts and overheads. The modules can be used individually or as part of a ten week program. It contains approximately 30 hours of consecutive fact to face activities. Adult education strategies are combined with a range of life skills materials utilising a psycho-educational approach to learning. Courses are usually run by trained bilingual facilitators in a relevant community language.

The modules are as follows:

1. Introduction and Settlement
2. Support Systems
3. Money
4. Trauma and Healing
5. Families
6. Children
7. Gender
8. Youth
9. Enjoying the Environment

a.    The FICT program is a time limited group intervention incorporating various modalities, including:

b.    Cognitive approaches that provide information to help participants understand the psychological impact of their experiences and a framework to understand post traumatic stress disorder;

c.     Approaches allowing participants a supportive forum in which to disclose details of their difficult or traumatic experiences. The opportunity to discuss personal experiences and the impact of these can increase participants insight and therefore sense of control over their own lives; and

d.    The development of social and support networks and self help activities

What issues does FICT deal with?

FICT deals specifically with issues such as violence against women, conflict within families, gender role reversal, youth culture in Australia, drug and alcohol issues, trauma and healing and corporal punishment. The innovative communication strategies used in the program enable these sensitive issues to be dealt with in a non-confrontational manner, allowing people to express deeply held values whilst being introduced to values of the host culture. Domestic violence and assault of children have legal implications. Participants are introduced to Australian law through case studies and are given the opportunity to discuss their feelings and attitudes towards government interventionist areas which may be seen as private or personal and which may have previously been dealt with as family matters.

What activities does FICT include?

In the FICT program practical activities are based around specific tasks. Tasks may include: using a street directory and yellow pages directories to find support services, role playing an interview using the telephone interpreter service, or working in small groups to sequence a series of pictures that identify the stages of grief and loss. Examples of other activities include: the acquisition of active listening skills; practical hints on budgeting; strategies for communicating with schools; identification of the symptoms of post traumatic stress in children; talking to teenager; identifying the value of unpaid women’s work and discovering free or low cost places to visit and enjoy as a family. Group participants are encouraged to work together and use the skills they have learned to play a recreational excursion to celebrate the completion of the course.

Recreation can often be a hard concept to sell to refugees who invariably feel guilty for enjoying themselves whilst their loved ones may be missing or suffering. The program extols the virtues of good physical and mental health. At the end of the program participants create closure by giving each other symbolic imaginary gifts representative of their time together and to encourage each other to continue to grow.

The Games

The program comes complete with two board games, the New Connections Game and the Sydney Walkabout Game. Both are innovative examples of the ways in which games can be used to promote health literacy. Individuals and communities magnify their general state of health and wellbeing by becoming knowledgeable about available health, welfare and recreational services, by having more control over their own environment, by gaining an understanding government structures, by being able to use the public transport system and by gaining self advocacy skills. Knowledge enables people to make healthier choices about lifestyles.

The games are both educational and entertaining. New Connections provides a forum in which individuals can get to know each other by providing discussion starters and outlining hypothetical situations with a potential for conflict that will help people explore the differences between their own culture and country of origin and that of their new environment. As participants travel around the board and land on certain squares they can pick up three types of cards. “Information cards” give specific details of free government and non-government services; “Titbit cards” explain Australian idioms, history and aspects of culture; and thirdly, “Situation cards” act as discussion starters. Participants are encouraged to discuss how they would have handled a given situation in their country of origin and how they would handle it in Australia.

The Sydney Walkabout Game is a large map identifying the major bus, rail and ferry services operating in Sydney Metropolitan area. The game is used to identify free and low cost recreational activities that participants can enjoy with their families. The philosophy behind this game is that recreation is healthy both physically and mentally and that it should be promoted, especially for refugees who often feel guilty about enjoying themselves whilst other members of their families overseas may be suffering in refugee camps. Familiarity with the new environment increases the amount of control and “ownership” people can have over it, thereby increasing the amount of comfort they can derive from it.

Games were chosen as a medium of instruction for a variety of reasons. Games are fun, they break the ice, they are an effective method of disseminating information without resorting to a lecture situation, and they cater for different literacy levels. New Connections and Sydney Walkabout enable people to integrate on a round table basis, each having a turn to speak and be heard, to give some useful advice or to listen to the ways in which others might deal with situations. Games can fill in gaps in knowledge, they can be inserted into module as an activity and they can be played for any length of time.

Has the program produced quality outcomes?

Since its inception STARTTS has successfully run the program at least 25 times with diverse communities from the following language groups; Arabic, Assyrian, Bosnian, Persian, Serbian and Somali. Many communities workers, health workers and adult educators from both mainstream and etho-specific services have also been trained to facilitate the program in a variety of other languages and are currently using it with their own communities. The Department of Education and Training has taken up the program and is using it with parents of refugee children as part of its agenda for assisting refugees to integrate into NSW schooling system. The Voiceless Children’s Network of the Horn of Africa Communities has also adopted the program to assist with the settlement of Somali, Sudanese and Ethiopian families.

The Psychiatry Research and Teaching Unit at Liverpool Hospital received funding to evaluate some of the FICT groups that were conducted with people from the Former Yugoslavian countries. The results of this research were encouraging, indicating measurable improvements in the mental health status of individual group members and showing that the learning objectives of the program had been met. Group members reported that they were able to participate in a range of previously unfamiliar activities and are now more aware of issues related to changes within the family unit, being the result of resettlement. By the end of the program participants exhibited improved levels of psychosocial functioning and acculturation, whilst their levels of anxiety and depression were reduced.

The advantages of using FICT as a group treatment program

Research and evaluation has strongly indicated the four main advantages of using the FICT program as a method of intervention with people from non-English speaking migrant and refugee backgrounds are:

Reduction in feelings of alienation, isolation and loneliness.

Feedback by group members always indicates that people are relieved to learn that they are not the only individuals to have had the same feelings, thoughts and experiences;

Normalisation of responses

Participants are relieved to find that they are not going crazy. Other people are responding the same way or have similar symptoms and therapists and group facilitators are aware of these responses

Increased motivation

Group and facilitator support gives participants the confidence to experiment with new ideas, to try new things and to venture into the new environment; and

Creation of a supportive network

Perhaps the single most important outcome of the program is that participants are likely to have developed a circle of friends, forming a supportive network of individuals who have been through similar circumstances with whom they can continue to share their lives and experiences after the course has finished.

Conclusion

There is no doubt that the FICT program, by equipping people with skills in how to gain information has made it easier for people to access a range of health and community services to improve their lifestyles and decrease mental health problems. The program empowers people to make healthy choices as individuals and communities. It reinforces STARTTS’ commitment to the communities we serve by providing group participants with relevant and up to date information on housing immigration, social services, banking, women’s health, educational issues and in some instances by providing advocacy.

It also goes beyond this and gives participants the tools to cognitively process their symptoms and experiences and then share these with others. It helps develop a framework in which the changes they are experiencing can be observed and dealt with as part of a wider social problem and not as result of perceived individual failure. Social networks are developed and these assist participants to reconnect with a derive support from members of their own communities. Overall, it is a holistic health communication program, innovative in its design, yet simple for facilitators to use and effective in obtaining the desired objective which is to assist immigrants and refugees to deal with the process of resettlement in Australia.

References:

Aroche, J “A Time Limited Group Intervention with Latin American Political Refugees” Research Proposal for Masters in Clinical Psychology, University of Wollongong.

Coello, M and Aroche, J. Report on a Group Intervention: Stress Management Group for Spanish Speaking Men

Hartgerink, P “Families in Cultural Transition” Paper presented to the First Transcultural Mental Health Promotion Forum, 22 August 1996.

Savdie, A and Carey, L. Families in Cultural Transition: A Resource Kit.