Background

Caring for Asian Children Resource

eCALD Supplementary Resources

Asian Population

The Asian population in the Auckland Region was over 402,000 in 2016 representing 23% of Auckland’s total population (Statistics New Zealand, 2015). The most predominant Asian ethnicities in the region are Chinese (38.5%); Indian (34.6%), Korean (7.2%) and Filipino (7.0%) peoples. Close to a quarter of Asian peoples in the Auckland region have lived in New Zealand for less than 5 years (Walker, 2014).

Asian, populations have a much younger age structure than European populations, with relatively high proportions at the child and childbearing ages, and low proportions at the older ages (Statistics New Zealand (SNZ), 2015). In the last decade, there has been a significant increase in births to Asian women in the Auckland region. The following graphs show the Auckland region’s birth numbers and projections to 2025 by ethnicity (Auckland & Waitemata DHB, 2012).

WDHB – Asian births are expected to rise from 21% (2012) to 32% (2025).	ADHB – Asian births are expected to rise from 29% (2012) to 32% (2025).	CMDHB – Asian births are expected to rise from 18% (2012) to 22% (2025).

Annually the New Zealand government accepts a UNHCR mandated refugee quota of 750 places. In 2018, this number will increase to 1000 quota refugees per annum. Refugees also arrive as asylum seekers and through the refugee family sponsored category. A quarter of refugee populations are under the age of 15 years (McLeod & Reeve, 2005). Refugees to New Zealand from Asian backgrounds come from: Vietnam, Laos, Cambodia, Afghanistan, Sri Lanka, Burma, Bhutan and China. Pediatric refugees have complex medical and psychological needs (Rungan et al., 2013). Refugee children are at risk of developmental and mental health problems due to their refugee experiences of trauma, violence and deprivation and of migration stressors on arrival in New Zealand (Rungan et al., 2013).

To begin with, having knowledge of the current demography, health determinants, health utilization and key health issues of Asian children will enhance service planning and development. The next sections will address: the socioeconomic status of Asian populations; the health status of Asian children; child health in refugee populations; and caring for Asian children.

Socio-economic status

The Auckland Region Asian population has a higher level of education than the Auckland total but a smaller proportion of adults earning over $30,000 and households earning over $50,000. The Asian population has about the same level of home ownership as the Auckland total, a higher rate of unemployment, and a lower rate of people on the unemployment benefit (Walker, 2014).

Health status

Summary of the health status of Asian children

Below is a summary of the health status of Asian children of the data presented under Appendix 3.

Mortality	There were no significant differences between the infant mortality rates of the three Asian groups examined and European/Other infants (Mehta, 2011). There were no significant differences in the rate of deaths from all causes among Auckland children aged 0 to 14 years belonging to the three Asian groups as compared to European/Other children (Mehta, 2011).
Child (0-14 years) Potentially Avoidable Hospitalisations	Across the Auckland region, Chinese boys aged 0 -14 years have a significantly lower rate of potentially avoidable hospitalisations (PAH) as compared to European/Other children, but there were no significant differences between the PAH rates of Indian, Other Asian and European/Other boys. Among girls aged 0 to 14 years, Chinese girls had a significantly lower PAH rate as compared to both European/Other and Indian girls, and a lower rate as compared to Other Asian girls although this difference was not significant. There were no significant differences in the PAH rate of Indian, Other Asian and European/Other girls across Auckland (Mehta, 2011). The top three causes of PAH among children from each of the ethnic groups examined were ENT infections, dental conditions or asthma. The PAH rates for both dental conditions and asthma among Other Asian and Indian children were significantly higher than among their European/Other counterparts (Mehta, 2011).
Low Birth Weight	In all areas examined, a greater percentage of Indian babies born between 2008 and 2010 had a birth weight below 2500 grams as compared to European/Other babies. The proportion of Chinese and Other Asian babies with low birth weight was similar to European/Other babies in all areas except ADHB, where a greater percentage of Other Asian babies had low birth weight as compared to their European/Other counterparts (Mehta, 2011).
Immunisation Coverage	Chinese, Indian and Other Asian children had similar or higher rates of being fully immunised at two years, and five years of age, as compared to European/Other children. Chinese children had the largest proportion of fully immunised children at both two years and five years among all the ethnic groups examined (Mehta, 2011).
Oral Health	Auckland Regional Dental Service data regarding oral health in five year olds and eight year olds indicates that a lower proportion of Chinese, Indian and Other Asian five year olds across the three DHBs had caries-free teeth as compared to European/Other five year olds. Chinese five year olds had the worst oral health of the ethnic groups examined. Although the proportion of Asian eight year olds that had caries-free teeth was lower across the three DHBs than for European/Other eight year olds, the differences across the ethnic groups examined were small (Mehta, 2011). Among Auckland children between 2008 and 2010, Other Asian children had a significantly higher hospitalisation rate for dental conditions as compared to European/Other children. Indian children had a slightly greater rate of dental hospitalisations and Chinese children had a similar rate as compared to their European/Other counterparts (Mehta, 2011).
Youth health	Asian students participating in the Youth ’07 survey mostly reported positive family home and school environments, positive and rewarding friendships and adult relationships, and about 40 percent noted the importance of spiritual beliefs (Parackal et al., 2011). However, most Asian students, did not meet current national guidelines for adequate intakes of fruit and vegetables or daily physical activity, and were less likely than NZ European students to report using contraception. The prevalence of smoking had decreased among Chinese students but not among Indian students compared to the 2001 survey, and Chinese and Indian students were less likely to be current drinkers or to binge drink than their NZ European counterparts. Mental health problems, particularly depression, were a particular concern among the Asian secondary school student population, and while most Asian students reported good health, a number of barriers to accessing health care when required were noted, including lack of knowledge of the health system, as well as cost and transport issues (Parackal et al., 2011).
Lifestyle	Asian Health in Aotearoa in 2011 - 2013: trends since 2002-2003 and 2006-2007 (Scragg, 2016). Nutrition The pattern of food security in the households of Asian children was similar to that for European & Other children, while Māori and Pacific children had poorer food security. The proportion of Asian children eating breakfast at home every day (a protective factor against obesity) increased from 2006-07 (79%) to 2011-13 (91%). All Asian ethnicities, along with Māori and Pacific, had lower proportions of people eating the recommended daily number of serves of fruit and vegetables (≥5) than Europeans. Physical activity Asian children generally had similar patterns for method of transport to school, and for hours of TV watching, as European & Other. These patterns have changed little from 2006-07 to 2011-13. Adults from all three Asian ethnic groups, along with Māori and Pacific, were less likely to be physically active than European & Other. Activity levels for Asian men and women have changed little over the three survey periods from 2002-03 to 2011-13. Smoking South Asian, Chinese and Other Asian women were less likely to smoke tobacco than European & Other women, while the prevalence of current smoking in men was similar for all three Asian ethnic groups combined and European & Other (both 17%). There was no change in the frequency of tobacco smoking by Asian men or women over the three survey periods from 2002-03 to 2011-13. The percentage of children that lived in a house where people smoked inside was similar for all ethnic groups, aside from Māori and Pacific who had the highest levels. The percentage of adults that lived in a house where people smoked inside was lower among South Asians (4%) and Other Asians (3%), compared to European & Other (7%). Smoking inside the houses of all three Asian ethnic groups has decreased from 2006-07 to 2012-13 in households of both children and adults (6% to 2%, and 10% to 4%, respectively, for all Asian ethnic groups combined). Body size South Asian, Chinese and Other Asian children had similar prevalences of overweight and obesity to European & Other children. Mean BMI of South Asian, Chinese and Other Asian children did not change between the 2006-07 and 2011-13 survey periods. Acculturation A longer period of residence in New Zealand by Asian people was associated with increased likelihood of being an alcohol drinker, while other lifestyle variables were not related to duration of time lived in New Zealand. Chronic Disease The most common chronic diseases in New Zealand children of all ethnicities were asthma and eczema. Eczema was more common in children of all three Asian ethnicities (17% combined), and also in Māori (21%) and Pacific (20%) children, compared to European & Other (13%).
Child health in refugee populations	In Rungan et al’s (2013) study of refugee children arriving in New Zealand, more than half (53%) were from Asia (53%) including: Myanmar (40%), Bhutan (10%), Afghanistan (8%), Nepal, Sri Lanka and Bangladesh (each contributing ≤2% of the sample). The Auckland Regional Public Health Service (ARPHS), Refugee Health Screening Service assesses the health of all newly arrived refugees. The findings of the 343 children screened, were that: The most common infectious diseases were latent tuberculosis (15%) and parasitic infections (15%). In those older than 1 year old, who had rubella and measles serology information, immunity was found in 50% and 59%, respectively. Hepatitis B immunity was found in 68% of children. Complete vaccination certificates were available for 66% on arrival to New Zealand. Vaccinations were administered to 73% of children while at the Mangere Refugee Resettlement Centre. Iron deficiency and vitamin D deficiency were the main non-infectious diseases found and were present in 33% and 12%, respectively. The total requiring referral for further medical assessment or support was 58% with 19% requiring referral to more than one service.

NB Appendix 1, 2 and 3 provides more information on current demography, health determinants, health utilization and key health issues of Asian children.

Caring for Asian children

In this resource, the term ‘Asian’ refers to the collective set of Asian ethnic groups, who although not homogeneous in nature, share certain value orientations, health beliefs and practices. These groups represent many diverse cultures, languages, religions, socio-economic status, education levels and migration experiences (Ho et al., 2003). Asian Peoples in New Zealand come from countries in West Asia (Afghanistan and Nepal), South Asia (covering the Indian sub-continent), East Asia (covering China, North and South Korea, Taiwan, Hong Kong and Japan), and South East Asia (Singapore, Malaysia, the Philippines, Vietnam, Thailand, Myanmar, Laos and Kampuchea) (Mehta, 2012)).

‘Asian’ groups include every category of immigrant: skilled migrants; refugees; those on temporary work visas, foreign fee-paying students on fixed term visas; and New Zealand-born Asians (third and fourth generation New Zealanders).

New Zealand-born Asians and 1.5 generation Asians (who were born overseas and relocated to New Zealand at a young age) are generally more acculturated to New Zealand culture, than newcomers. Within a family, the degree of acculturation may vary between the younger generation and the older generation or between those who have longer residence in New Zealand and those who are new arrivals.

There is increasing interethnic marriage and relationships in New Zealand society (Didham & Callister, 2014). Rates of interethnic marriage are significantly higher in Asian populations in the 1.5 generation and among the New Zealand born than in the overseas born (Didham & Callister, 2014). Maintaining ethnic belonging is central to the identity of many Asian women in interethnic marriages or relationships. Being in a cross-cultural marriage does not preclude the pressure from family and community to observe traditional birthing, postnatal and parenting/grandparenting practices. New Zealand born and 1.5 generation women may be living with mothers or mothers-in-law who have an expectation that their daughter or daughter-in-law will follow their cultures’ traditional child rearing practices.

Traditional Asian culture is very (extended) family oriented with a high priority placed on family, unity, dignity, respect, spirituality and humility. There are significant differences between Asian collectivist and western individualist views about decision-making, family structure, gender roles and parenting.

Asian cultures, religions and languages have a significant impact on health beliefs and practices, influencing the way in which Asian people explain their health and illness, and how they respond to and access health services. Cultural backgrounds also influence patient’s and family’s behaviour, family structure, decision-making, child rearing practices, caregivers’ roles, dress codes and dietary preferences.

Cultural groups have different ways of understanding illness and will attribute different causes to the origin and symptoms of their sickness. How illness is explained is strongly influenced by families’ cultural/religious backgrounds. To a large degree, these values also define the acceptable symptoms of the illness as well as the behaviour, expression and role of the sick person. Health beliefs are often complex and may change overtime with acculturation. For some Asians, after a long period of settlement in New Zealand, there may be little or no reliance on traditional practices. Some families will revert back to traditional health practices when they find that illness is not responding well to Western medicine. Younger Asians who are New Zealand born or the 1.5 generation may not hold any traditional health beliefs and practices. To assess acculturation levels and to avoid stereotyping, individual assessment is essential.

Migration to a new country with a totally different culture may require a long period of adjustment. Racism and discrimination in New Zealand make the process of adaptation more difficult for migrants (Scragg, 2016).

Cultural competent care

To provide culturally competent care for Asian children and their families, it is recommended that health providers consider the following:

Having knowledge of the current demography, health determinants, health utilization and key health issues of Asian children will enhance service planning and development.
Becoming familiar with Asian cultural values, beliefs and practices, and the influence of these on families’ responses to health services and decision-making processes.
Understanding the impact of migration and the ‘refugee’ experience.
Acknowledging and showing respect towards traditional health beliefs and practices, even though you may disagree with the practices. It is best to work alongside families and negotiate a mutually and culturally acceptable outcome. This approach is most likely to build trust and rapport between the health practitioner and the family.
Avoiding assumptions that extended family and community support networks are available.
Showing genuine concern and providing practical support to Asian families especially those who are unfamiliar with the New Zealand health system eg sourcing suitable health and social services/networks. This is particularly helpful when the family you are working with have limited English language skills.
Being mindful of the potential intergenerational issues that can occur between the young patient and his/her family members especially with their older family members.
Being aware of interethnic marriages and potential conflicts over traditional child rearing practices and decision-making between family members.
Understanding the influence and role of grandparents who may be the primary care-giver of the child or young person.
Assessing health literacy and English and native language fluency. Provision of information about diagnosis, services and treatment in the client’s language.
Using professional interpreters. NB: not using children or family members to interpret.