Safeguarding vulnerable families: work with refugees and asylum seekers.
This paper will highlight one of the key findings of a qualitative
study based on the analysis of in-depth interviews with 14 health
visitors describing their experiences working with refugees and asylum
seekers. Despite changes in government legislation to improve
children's services in order to prevent harm to children, this
recent study demonstrated that health visitors were working with the
complexities of needs among refugees and asylum seekers related to
safeguarding both children and vulnerable women. The health visitors
often worked with families and individuals with no support from other
professional services, they worked with failed asylum seekers who were
unable to access other forms of support and they worked with women and
children who were caught in a cycle of domestic abuse due to their
immigration status. They were also working with families who would
disappear from the systems in place to safeguard children.
Asylum seekers, refugees, health visitors, safeguarding
(Care and treatment)
Community health services (Services)
Family (Health aspects)
|Publication:||Name: Community Practitioner Publisher: Ten Alps Publishing Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2011 Ten Alps Publishing ISSN: 1462-2815|
|Issue:||Date: Feb, 2011 Source Volume: 84 Source Issue: 2|
|Topic:||Event Code: 200 Management dynamics; 360 Services information Computer Subject: Company business management|
|Product:||Product Code: E198440 Refugees SIC Code: 8399 Social services, not elsewhere classified|
|Geographic:||Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom|
Although there has been little published research into health visiting practice with refugees and asylum seekers, previous research has found that health visitors considered themselves ill prepared to deal with the complexities of working with refugee women (Drennan and Joseph, 2004).
One of the post-migration factors that may affect asylum seekers and refugee health in the UK is their difficulty in accessing health services (Aldous et al, 1999; Cowen, 2001; Dar, 2000; Fassil, 2000). Barriers tend to be related to language, culture and lack of information, while failed asylum seekers are denied access to health care in an attempt to force them out of the UK even though their country of origin is deemed unsafe by the UN High Commission for Refugees (UNHCR) (Norredam et al, 2005).
In recent years, the UK government has introduced restrictive legislation and policies aimed at limiting the amount of asylum seekers receiving benefits such as free healthcare services. This not only places a burden on migrants trying to flee persecution from their home country and build a new life in the UK, but also places a burden on health visitors when they are expected to follow policies to safeguard children and individuals as well as reduce inequalities in health for the local population that they serve.
In 2008, the Independent Asylum Commission (IAC) nationwide citizens' interim review of the UK asylum system found that the treatment of asylum seekers in the UK fell seriously below the standards expected of a humane and civilised society, particularly the treatment of women, children and torture survivors. For failed asylum seekers, the commission highlighted the enforced destitution of thousands of people in the UK, who had been refused sanctuary with inadequate arrangements for returning people (IAC, 2008).
The work of the health visitor is guided by the strategic policies related to the children's agenda, and in recent years the health visiting profession has endured a period of upheaval as a result of government-led changes to those policies. These changes were instigated by Lord Laming's report on the investigation into the death of Victoria Climbie in 2000 (Laming, 2003). The report was extremely critical of the way that various children's services had been involved with the case but had lacked any integrated working that could have prevented such harm to the child. The report recommended fundamental changes in the way that services to support children and families were to be organised and managed.
This paper presents one of the key findings of a study based on in-depth interviews with health visitors in 2006, at a time when government-led changes to children's services strategies and policies emphasised safeguarding to prevent any further harm to children. This key theme was the complexity of needs related to safeguarding that health visitors were describing in their work with refugees and asylum seekers.
The local borough in which this research was based has a particular issue with people who are transient and stay short term, having considerable impact on local services such as health care (Rees and Boden, 2006). The borough has traditionally been an area with a high concentration of refugees and asylum seekers due to its central London location and diversity, with over 100 languages spoken and community groups that have evolved and that offer support to other nationalities.
Recruitment and sampling
Purposive sampling was used for this study, in which participants were selected for their ability to contribute to the data (Morse, 1991). The sample consisted of 14 health visitors, which was a sample size of approximately one-third of all health visitors working in the borough. The participants were approached following a presentation at their main professional meeting that provided details of the proposed study. They were then asked whether they could be contacted individually to request that they participate in the study. The inclusion criteria was for participants to have worked in the borough for a minimum of two years, as it would be highly likely that they would have worked with refugees or asylum seekers, and all of those selected had attended the initial presentation.
Approval to proceed with the study was granted by the primary care trust research and development team and the local research ethics committee.
In-depth interviews were conducted at various health centres across the borough. When negotiating a time and date to conduct the interview, participants were asked where the most convenient place would be for the interview to take place, and in all cases they chose the health centre in which they worked.
The majority of interviews lasted approximately one hour with some exceptions. The shortest interview lasted 45 minutes, whereas the longest lasted three hours and had to be conducted over two separate occasions.
The interviews were shaped by a topic guide based upon concepts that had arisen from an initial literature review, with the intention that these would assist in meeting the objectives of the research. Participants were asked primarily to describe their experiences of working with refugees and asylum seekers and what problems or difficulties they faced when working with this client group.
Each interview was transcribed and analysis was facilitated using the Framework method (Ritchie and Spencer, 1994). This matrix-based analytical method involved a constant comparative approach throughout, in which the codes and transcripts were continually reassessed and re-interpreted. Themes identified were compared across the data, and interpretations were discussed between the author and external researchers. Using the Framework process, the analytical process is not linear--it is a continuous and iterative process, but has two key stages that characterise its course. The first requires managing the data and the second involves making sense of the evidence through descriptive or explanatory accounts (Ritchie et al, 2003). Quotations were chosen to illustrate the particular issues described.
Complexity of safeguarding-related needs
The needs of refugees and asylum seekers were described as being extremely complex, but the experience of the health visitor was that the needs of the families and individuals did not often present as discrete aspects, but as a combination of many overlapping issues that needed to be dealt with. One of the key findings to emerge was the complexity of needs related to safeguarding that health visitors were describing in their work with refugee and asylum-seeking families.
Because of the complex needs of the families that they came across the participants frequently referred to social services because of concerns about potential risk of significant harm. Determining when to refer a family to social services was fairly consistent among the participants, with all doing so as a precautionary measure in most complex cases. Referrals would be made because of the multiple problems the family were experiencing, with cases of domestic violence being witnessed by the children, maternal or paternal depression, child safety concerns or a family with no recourse to public funds being made homeless.
Sole support agent
At times there was anxiety for the health visitor when social services refused to take on a case and the health visitor was left holding the case with no support. These tended to be those vulnerable families and individuals that had failed their asylum application and had somehow slipped through the net and a referral would be based on the possible harm afforded to a child through lack of accommodation. Social services on many occasions would refuse to take on these cases because there was no evidence of any significant harm to the child. The health visitor would then face the anxiety of being the only professional working with the family, occasionally getting support from voluntary agencies:
'... and the child was a two and a half, three year old, eating total crap and rubbish, sleeping in a filthy bed, all of them together, they were all staying in a bed, and the house kind of falling apart and the social services didn't want to have any responsibility, the doctor, the GP didn't want to have any responsibility and everybody was alarmed and the fact that there was a child protection issue because the two older girls, were older they were something like nine and 11, took the three-year-old to casualty at four o'clock in the morning because, you know they thought she was being very sick (interview 10).
The concept of health visitors being the sole support agent for the majority of vulnerable families due to lack of resources has been described in much earlier research (Appleton, 1996). It is an issue that should be addressed by both health and social services, since health visitors should not be providing others' services simply because they do not exist.
The health visitors also described mothers who would stay with, or move in with an abusive partner because they had nowhere else to stay. Incidents of women suffering threatening behaviour, violence or abuse from their partners or family members were described by most of the participants:
'The mother had finally left after years of abuse, she was beaten black and blue, she never left the house for years, the kids would walk themselves to school and back, she never left the house, and the kids witnessed all the violence at home, they witnessed the mother wetting herself every time the father went to hit her' (interview 6).
The participants were working with families who had witnessed conflict in their mother country, they then had difficulty making cultural adjustments once they were in the UK and this often put a strain on the families. They came across arranged marriages and even forced marriages that no longer had the extended family support to help them work. There was the cultural challenge of working with families in which the father was seen to be the head of the household and believed to have the right to beat his wife. Another cultural issue was the stigma that the mother would face from her own community if she left her husband, often facing the prospect of being disowned from her own family. The main concern in these instances was how to safeguard the mother and the children.
All of the health visitors had received training to respond effectively to mothers and children experiencing domestic violence and all had previous experience working with families affected by domestic violence. An immediate referral to social service was always made once abuse was suspected because of the concerns about the safety of the children and documentation would be made of any injuries or disclosures of domestic violence. The health visitor would provide the mother with information on support services such as the local women's refuges. However, being able to effectively assess the situation was not always easy as it could be difficult to meet with the mother without other family members being present.
Cycle of abuse
One of the problems that was discussed repeatedly was the fact that many of the women would be trapped in a cycle of abuse as a result of their immigration status. Having come over to the UK on their husband's visa, if they left the husband they would then have no rights to be in the UK and would be faced with deportation:
'In her case she has gone back to the partner who has been abusing her, because on her own she has no recourse to public funds. So although social services have a duty to care for the child, that doesn't mean they will look after her as well, so theoretically speaking the child could be taken into care and she could be sent home, or they could both get a ticket back together, or in this case they could both go back to the violent relationship because there is nowhere else to go. That is an example, I mean that happens every week probably, we all hear about that, it happens all the time (interview 9).
The lack of recourse to public funds in these cases meant that there was potential for harm not only for the mother, but also to a child staying with the perpetrator of domestic violence:
'The difficulties are much more around the no recourse issue and the fact that we are seeing people who are experiencing violence, as an example because that's what I see mainly, who have no recourse to public funds and are kind of trapped in violent situations mainly if they try and leave [the husband] then they are just going to have to be sent back to where they came from (interview 9).
Disappearing from the system
On many occasions the participants voiced their anxieties regarding these families. Their professional responsibility of safeguarding children as well as vulnerable adults was questioned when families were becoming destitute and effectively disappearing from the systems designed to keep them safe:
'Neither [parent] had recourse to public funds, she was reliant on him for her rent and her food and there was domestic violence, she was actually quite badly beaten before the baby was born and her face was black and blue, apparently according to A&E, and so they were concerned about the welfare of the child but she said to me that she had to go back to him because she had no other place to stay, so after a referral to social services they said again that they would only provide stuff for her if she again agreed to [sign up for deportation], they would do this for only a certain amount of time and then she would have to go back, so she disappeared ... I don't know where she went (interview 6).
One of the recurring concerns that the participants talked about was when they worked with families who failed the asylum process and would disappear from the systems in place to safeguard children:
'Well for example there is a Mongolian family who are in a similar situation and they had overstayed their visa and they had a very young baby and the baby was quite low birth-weight erm that was an issue and they went underground, I don't know what happened to them, we tried to track it all through social services but we lost them (interview 6).
It was apparent from the stories of the participants that they were coming across many of these people in their everyday work who had the added problem of being refused access to health care, and with the fear of deportation contributing to their unwillingness to engage with services. Despite strategies and policies aimed at reducing health inequalities for the most vulnerable, the contrast between these and the government's restrictive policies toward asylum seekers--particularly when refusing health care to those who had failed the process--was apparent. The concern of the health visitors was of being unable to follow up on the care of the children within these families that disappear from the system. This resulted in the fear that cases of abuse and neglect toward children could occur due to the lack of intervention from protective services.
The study found that in many cases, the health visitors were concerned about safeguarding children and adults who were vulnerable due to their immigration status. In recent years, legislative changes have restricted failed asylum seekers from accessing health and social care services and as a result they may face destitution, and this was apparent within the findings. The impact on the health visitors' ability to safeguard, at a time when children's service strategies and policies were promoting safeguarding to be of paramount importance, was evident.
The complexities of needs related to safeguarding that the participants described were not only relevant to children but also addressed the issue of safeguarding vulnerable adults, such as those experiencing domestic violence. It has been recognised that there are high incidences of refugee and asylum-seeking women facing domestic violence and have specific needs that require tailored responses distinct from those appropriate for women from black and minority ethnic communities in general (Rambarzini, 2005). These include the issue of a woman accompanying an abusive partner and being seen as his dependent, therefore her claim for asylum will be dependent on her partner's claim. Cultural attitudes among their community may result in rejection by the family or community if disclosure of abuse is made. Furthermore, the barriers to accessing services due to lack of awareness, fear of deportation and inability to speak English have also been recognised. Additionally, those who are failed asylum seekers are often prevented by governmental policies from accessing the services that they require (Juma, 2009).
The findings of this local study highlighted that many of the health visitors were coming across families who were facing destitution because of their lack of access to services. The adverse effects of social exclusion and poverty on parenting capacity and children's development have been well documented by extensive research (Bernard and Gupta, 2006; Bradshaw, 2001; Ghate and Hazel, 2002).
Since this study was carried out, there has been some recognition in government that immigration policies were having a negative effect on children. The newly developed UK Border Agency (UKBA) has outlined steps to ensure that immigration procedures will be responsive to the needs of children (UKBA, 2008). A further immigration Bill has been published containing the duty to safeguard and promote the needs of children (HM Government, 2009). However, one of the missed opportunities that the Refugee Council (2009) highlight in the Bill that they believe needs to be addressed urgently is the plight of destitute asylum seekers. They refer to the people from countries where there is conflict, generalised violence and/or well documented violations of human rights, such as Zimbabwe, Iran, Sudan, Afghanistan, Somalia, the Democratic Republic of Congo and Eritrea. These people cannot be returned home simply because it is deemed unsafe by the UNHCR, yet they are denied health care in an attempt to force them out of the country and are forced to live on vouchers or receive no formal support at all. A recent tally into destitution among refused asylum seekers carried out by the Asylum Support Partnership found that destitution was widespread (Smart, 2009), with roughly half the visits to their agencies being from people who were destitute (1972 cases). Half of those destitute were from four countries known to be unsafe to return to--Iraq, Iran, Eritrea and Zimbabwe--and 13% of destitute people had dependent children.
At a time when commissioning of NHS services is to become the responsibility of new GP consortia, community practitioners working with vulnerable populations will need to explore opportunities to highlight concerns to their managers and to commissioners in order to ensure that services are commissioned effectively.
This small study did have limitations that need to be taken into consideration. For example, the author researched health visitors who worked for the same organisation as himself. There is an inherent potential bias in qualitative research when researching in the researcher's own workplace (Butler, 2003). Data could be flawed due to working relationships with participants who are colleagues, leading to a compromise in openness and telling the truth. In an attempt to address this, the potential participants were presented with details of the study prior to participation, outlining the aims of the study and the research questions. By having a clear understanding of these aims, including the need for narratives of difficulties that the potential participants faced in their everyday work, it is hoped that the possible bias of dishonesty in the interviews was reduced.
This research highlighted the burden placed on the health visitor when trying to work within guidelines that safeguard children and families and reduce inequalities in health for the more vulnerable population groups in society. These complexities had an impact on the quality of their work with refugees and asylum seekers. They believed the complexities posed a challenge as to how effective they could be in their practice.
It is hoped that these findings will contribute to the literature and generate further discussion in terms of generating policy and promoting good practice. New ways of joint working may prevent the difficulties that health visitors have experienced when working with vulnerable populations such as refugees and asylum seekers. When deciding how to invest in the most appropriate services to provide for vulnerable local populations, it is important that commissioners have an awareness of these issues in order to commission services effectively.
No potential competing interests declared.
* Restrictive legislation limits asylum seekers from accessing health care in the UK
* In-depth interviews with a purposive sample of health visitors in one London borough found that they were working with the complexities of needs among refugees and asylum seekers related to safeguarding vulnerable children and women
* Refugee and asylum-seeking women and children were caught in a cycle of abuse due to their immigration status and vulnerable families would disappear from the system
* Health visitors working with vulnerable populations need to explore opportunities to highlight concerns with their managers and commissioners
The author thanks Dr David Pevalin, the School of Health and Human Sciences at the University of Essex and Central London Community Healthcare NHS Trust for supporting this research.
Aldous J, Bardsley M, Daniell R et al. (1999) Refugee health in London. London: The Health of Londoners Project.
Appleton JV. (1996) Working with vulnerable families: a health visiting perspective. Journal of Advanced Nursing23(5): 912-8.
Bernard C, Gupta A (2006) Black African children and the child protection system. British Journal of Social Work 38(3): 476-592.
Bradshaw J. (2001) Poverty: the outcomes for children. London: Family Policy Studies Centre.
Butler J. (2003) Research in the place where you work: some ethical issues. Bulletin of Medical Ethics (185): 21-2.
Cowen T. (2001) Unequal treatment: findings from a refugee health survey in Barnet. London: Refugee Health Access Project.
Dar S. (2000) Health care for asylum seekers. British Medical Journal 321(7265): 893.
Drennan V, Joseph J. (2004) Health visiting and refugee families: issues in professional practice. Journal of Advanced Nursing49(2): 55-163.
Fassil Y. (2000) Looking after the health of refugees. British Medical Journal 321(7252): 59.
Ghate D, Hazel N. (2002) Parenting in poor environments: stress, support and coping. London: Jessica Kingsley.
HM Government. (2009) Borders, Citizenship and Immigration Act 2009. London: HMSO.
Independent Asylum Commission/IAC. (2008) Fit for purpose yet? Report of interim findings of the Independent Asylum Commissions nationwide review of the UK asylum system. London: IAC.
Juma G. (2009) Refugee Council response to the government consultation paper 'Together we can end violence against women and girls'. London: Refugee Council.
Laming H. (2003) The Victoria Climhie Inquiry: report of an inquiry by Lord Laming. London: HMSO.
Morse JM (Ed). (1991) Qualitative nursing research: a contemporary dialogue (second edition). Newbury Park: Sage.
Norredam M, Mygind A, Krasnik A. (2005) Ethnic disparities in health: access to health care for asylum seekers in the European Union: a comparative study of country policies. European Journal of Public Health 16(3): 285-9.
Rambarzini E. (2005) Joint response to the Mayor of London consultation on the second London Domestic Violence Strategy. London: Refugee Council.
Rees P, Boden P. (2006) Estimating London's new migrant population: stage 1: review of methodology. London: Greater London Authority.
Refugee Council. (2009) Joint parliamentary briefing from the British Refugee Council, the Scottish Refugee Council and the Welsh Refugee Council: Borders, Citizenship and Immigration Bill 2009 House of Commons second reading 2nd June 2009. London: Refugee Council.
Ritchie J, Spencer L. (1994) Qualitative data analysis for applied policy research. In: Bryman R, Burgess R (Eds). Analyzing qualitative data. London: Routledge.
Ritchie J, Spencer L, O'Connor W. (2003) Carrying out qualitative analysis. In: Ritchie J, Lewis J (Eds). Qualitative research practice: a guide for social science students and researchers. London: Sage.
Smart K. (2009) The second destitution tally: an indication of the extent of destitution among asylum seekers, refused asylum seekers and refugees. London: Asylum Support Partnership.
UK Border Agency. (2008) Code of practice for keeping children safe from harm. London: UK Border Agency.
John Burchill DPH, MSc, PGDip, RHV, RGN
Services manager, Central London Community Healthcare NHS Trust
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