Working with refugees-a manual for caseworkers and volunteers

Introduction: The Australian Government encourages the regional settlement of refugees and it is expected that 45% of refugees to Australia be regionally located. Wagga Wagga, an inland regional city in New South Wales (NSW), a destination for both primary and secondary migration, offers settlement for refugees under the Australian Integrated Humanitarian Settlement Strategy (IHSS) and the Settlement Grants Program. Refugees currently represent 1% of Wagga Wagga’s 60 000 population. For people previously living in cities or crowded camps with a background of disruption, torture and trauma, relocation to rural areas of Australia is confronting, and they require dedication and effort from those supporting resettlement. Currently, caseworkers working for settlement agencies do not have formal training. Volunteers are offered induction days and information sessions but have training needs beyond this. Methods: Two projects were undertaken during 2007 and 2008. Refugee services in regional and rural NSW and their efficacy were reviewed, exploring models of care in four NSW locations and clarifying needs via a literature search. Training and resources available to caseworkers and volunteers were also investigated. The objective was to design and construct a basic manual addressing the needs of this workforce informed by a literature search and consultation with key stakeholders in refugee resettlement. Literature searches of electronic databases, relevant websites and journals informed the questions for participants of focus groups and semi-structured interviews. Additional data were obtained via self-report questionnaires from caseworkers, volunteers and mainstream agencies. Information was also disseminated to refugees, inviting community to participate in focus groups. Results: Our study supported others noting difficulties associated with the settlement of refugees in regional Australia, and recommendations of improvements were developed using the social determinants of health. The supporting workforce encounters a multitude of issues when working with newly arrived refugees, including language barriers, client expectations and challenges in


Introduction
The Australian Government has encouraged increased regional settlement of refugees 1 , and the intention to regionally locate 45% of arriving refugees has been reported 2 .Commencing in the mid-1990s and increasing since 2005, Wagga Wagga, a New South Wales (NSW) regional city, has become a refugee destination for both primary and secondary migration under the Integrated Humanitarian Settlement Strategy (IHSS) and the Settlement Grants Program (SGP) 3 .Wagga Wagga has a population of 60 000 of which refugees comprise approximately 1%.
Backgrounds of disruption, torture, trauma and previous crowded camps or city life makes regional/rural relocation confronting for refugees, who require dedication and effort from those supporting resettlement 2 .Timely physical and psycho-social review and targeted intervention helps minimise interruption to settlement and is the goal of settlement agencies contracted to the IHSS.
However The Refugee Council of Australia (RCOA) voices concern about the effectiveness of current Australian systems for refugee resettlement 4 : While rural and regional settlement has brought some welcome benefits for both refugee communities and the regional areas in which people have settled, there is a range of problems associated with service delivery and coordination of services that impact significantly on individuals and families.
Refugees arrive in Australia with vastly different cultures and beliefs, carrying traumatic life experiences unfamiliar to the wider Australian population.Their cultural identity is challenged by navigating a society with different beliefs and traditions from their own, learning a new language, adapting to new foods and learning new systems for health, welfare and education 5 .Refugees tackle these issues with coping mechanisms diminished by experiences of loss, grief, torture dislocation and family disruption 5 .The stress of resettlement can be eased by social connection and community ties to others of similar cultural background, which increases a sense of belonging and social identity [6][7][8] .Understanding these factors should be inherent in those involved in refugee resettlement.
In Australia, humanitarian entrants are assisted with settlement by community based and commercial service providers (SPs) contracted to the Department of Immigration and Citizenship (DIAC).The SPs are generally staffed by professional caseworkers and supported by volunteer organizations under the IHSS program 9 .However models of service provision differ, depending on organisational structures and locally available resources (Stage 1 of the present project).As training caseworkers and volunteers is the responsibility the individual SP, the provision and depth of training can vary greatly 10 .
It is widely acknowledged that volunteers play a crucial role in refugee resettlement 9,10 ; therefore, as non-professional workforce it is vital that they are appropriately trained to work with people who may have intensive needs 11,12 .A paucity of research exists regarding the roles, needs and training of volunteers and caseworkers who work within IHSS settlement services.The development of a reference manual for settlement workers was therefore recommended.

Background of methods
The study was performed in two stages over 2 years, and was due to the dedicated efforts of two University of New South Wales (UNSW) medical students undertaking an independent learning project in year 4 of their course at UNSW's Rural Clinical School at the Wagga Wagga Campus.

Stage 1
Ager and Strang propose that successful resettlement and integration for refugees depends on access and achievement in 4 key domains: employment, housing, education and health 12 .Stage 1, therefore, analysed settlement services in NSW by reviewing and comparing the health systems available in two metropolitan (Canberra and Sydney) and two regional (Coffs Harbour and Wagga Wagga) services, concentrating on: • service provision in rural and regional Australia • healthcare provision, access and utilisation

• mainstream agencies
• resettlement and its effects on the social determinants of health.
Perspectives of mainstream agencies: Insights provided by mainstream agencies varied according to the extent of interaction with refugee clients, caseworkers and volunteers.All mainstream agencies identified language barriers as their major difficulty in working with refugee clients, and their lack of understanding of various systems such as tenancy and welfare work in Australia.Most agencies reported that they were provided with some prior background information about refugees, and that often this information was provided by IHSS caseworkers and volunteers.The background information provided to agencies interviewed, additional information they believed necessary to providing enhanced services to refugee clients, and other issues raised in focus groups are shown (Table 1).

Stage 2
Ethics approval was granted by the UNSW and Greater Southern Area Health Service.Stage 2 involved canvassing opinions regarding the usefulness and content of the proposed reference manual.Focus group and interview questions were developed according to findings from the literature review, with the aim to involve several groups of major refugee resettlement stakeholders in providing balanced feedback, and to facilitate development of a practical and relevant resource.
Resettlement service workers and mainstream service providers involved with refugees during the process of resettlement were recruited.Information pamphlets designed for each target group were provided to the managers of relevant services (including humanitarian entrants who had completed the IHSS program) for distribution to potential participants.Focus groups questions and self-report questionnaires were designed and, at the commencement of each focus group, participants signed consent forms for both the discussion and its audiorecording.If a participant did not consent to audiorecording, notes were handwritten.All data were de-identified and analysed for common content and threads.One hundred participants contributed to the project over both stages via 19 focus groups, 14 semistructured interviews and 8 self-report questionnaires.
While examining tools to assist caseworkers and volunteers in their work of refugee support, suggestions were noted in the literature that training provided to caseworkers should include an understanding of the migration process, experiences in transit, reasons for leaving the country of origin and how these factors affect family function.
Questions used included reflections on prior education and training, unexpected issues arising in work with refugees, resources currently used, and suggestions for important material to be included in a manual.

The manual
The literature review gave direction to what should be included in such a manual: • information on refugees and their experiences • life in refugee camps • information on torture and trauma and mental health issues • needs of refugees on arrival • cultural competence • outline of the IHSS program.
The findings from all interviews consistently supported the concept of developing a manual, and participants recommended types of information and resources for inclusion.They emphasised that searching for and acquiring information was time-consuming and frustrating.It was reported that manuals were available but were often related to compliance with DIAC requirements, rather than providing information and resources helpful for resettlement workers.

Stage 1
During focus groups, caseworkers raised several difficulties for refugees when dealing with agencies involved in resettlement.As a consequence, these also caused difficulties for caseworkers and volunteers (summarized in Table 2).
These concerns included: • inadequate funding/resources • cross-service co-ordination • liaison protocols within and external to the consortium • planning for secondary migration • short time-frame for IHSS (6 months) and impact on continuity of care • local agencies held accountable for IHSS strategy shortfalls • agency success being dependent on funding expertise within the organisation.
A lack of sensitivity and understanding of the refugee needs, backgrounds and journeys was a common theme in Stage 1.This supported the need for a manual for reference and education of those working with refugees.Stage 2 of the project commenced on the basis of further needs and concerns raised by caseworkers and volunteers during focus groups.

Stage 2
Cultural: Volunteers requested more detailed information on the IHSS system, as well as background information on refugees, countries of origin and the nature of conflicts fled from.Some of the more experienced volunteers and caseworkers sought information on what to expect in working with refugees, highlighting that even a straightforward task such as taking a family to the doctor was usually complicated and therefore time-consuming.
Volunteers from Coffs Harbour, in particular, suggested the inclusion of a range of strategies for working with refugees.
Caseworkers identified that they may become de facto elders during resettlement, being expected to fulfil the traditional roles of community leaders.They highlighted the difficulty of establishing the boundaries in such situations.
Many focus group participants stressed that information on culture was important, in particular details about common countries of origin, information on social cues, differing taboos within cultures and life in refugee camps.They wanted a manual to highlight the need for resettlement workers to set aside their personal values and to allow the client to lead during interactions.Owing to the complexity of resettlement, it is important that all those who work with recently arrived refugees are sensitive to these concerns and address them within a culturally acceptable framework 7,14 .Where possible, suggestions were incorporated in the manual.
Practical tools: At almost every focus group it was stressed that the manual should be user-friendly and contain practical resources.Caseworkers in particular requested that the manual be simple to use and written in simple language.All participants reported that overcoming the language barrier posed considerable difficulty with new arrivals, compounded when refugees were illiterate in their own language.Because of this, pictorial tools were repeatedly suggested as a potential solution.
To address this request, tools were sourced from internet resources and other Australian agencies, and permission for reproduction obtained.Following extensive searches a large volume of material was obtained in commonly spoken refugee languages and pictorial form, and a decision was made to include a resources CD with the manual, rather than to provide a hard copy of each resource.Volunteers requested that some useful phrases be developed to help break the ice and enable IHSS workers and refugees to learn about each other and each other's culture.Flash cards were developed to assist in initiating conversations, and designed to initiate curiosity about cultural and alternative values System information: Several mainstream service providers had suggestions about inclusions for the manual, including service profiles of their organisations and information about the types of assistance they provided for refugee clients.
Details of common services utilised were also found relevant by caseworkers and volunteers, such as details about and the length of English language programs.Technical and Further Education (TAFE) teachers requested that clients be made aware of standards of personal hygiene prior to commencing TAFE classes, so that broaching the subject of hygiene during class would not be unexpected or awkward for clients.
One issue arising from most focus groups with volunteers was that of being unfamiliar with local services and their locations.Lists of commonly utilised services (banks, real estate agencies, Centrelink, educational institutions, doctors' practices and specialists) were requested, with contact details.This was developed for local services in Wagga Wagga, and a template made available for use elsewhere.
Caseworkers and volunteers had requested that the manual be locally relevant, yet adaptable for conditions in different areas.

Manual design
After analysing the content of focus groups issues, six broad areas were identified that gave direction in the construction of the manual: 1. Language barrier 2. Client expectations 3. Alterations in family life 4. Living skills 5. Cultural differences 6. Burnout and boundaries.
Practical problems in each of these areas expressed by participants are shown (Table 3).Many of the issues identified during focus groups reflected available literature, particularly difficulties faced by caseworkers and volunteers in addressing alterations in family structure and changing family roles [6][7][8]13,14 . Availble, suitable housing for clients was universally reported by caseworkers and volunteers as problematic in both stages of the project (Table 4), and this was supported by literature from Australia and overseas 9,12 .
Focus groups with humanitarian entrants reported that it was difficult to access housing due to a lack of rental history, and that houses were sometimes not of a desirable standard.Several perspectives raised in the focus groups of humanitarian entrants differed from those of the caseworkers and volunteers.The humanitarian entrants said that it was vital that IHSS workers did not make assumptions about their clients.While it is true that many clients had limited English and experience of Western-style households, some humanitarian participants reported that they already had good English on arrival and had lived in Western-style houses prior to arrival in Australia.They reported that some questions asked by volunteers were embarrassing, such as being shown how to use household appliances and being asked, 'Have you used this before?'It is therefore clear that volunteers and caseworkers must establish their client's level of knowledge and tailor service delivery accordingly.
In both stages of the study humanitarian entrants reported several difficulties on first settling into Australia.Cultural differences, such as addressing elderly people by their first or given name in Australia, were hard when entrants were used to addressing older people with great respect.Entrants expressed concern that sometimes they had been given inaccurate information, indicating some substance to the statement from DIAC 9 concerning the accuracy of information presented during the settlement period.Despite the difficulties of the initial settlement period, humanitarian entrants reported that they appreciated the way that volunteers and caseworkers had assisted them in many different ways since their arrival.
Based on such findings, sections of the manual were developed to address specific issues.Section headings reflected focus groups discussions, with sub-chapters expanding issues identified in the literature review.The ultimate chapter structure is shown (Table 5).Factsheets were also designed to be used with the manual and accessible via the Refugee Council of Australia's website.
Volunteers frequently expressed concerns about managing disclosures of previous torture and trauma.This was distressing for most workers and had the potential to cause considerable distress.It was therefore decided to include a section on stress management for settlement workers.The research team stressed that if a caseworker or volunteer became unsure or uncomfortable in any situation they should seek advice from a manager in their organisation.
Some suggestions for the manual were not able to be incorporated.For example, a request was made by volunteers for an organisational checklist to be included; however, researchers believed it was inappropriate for the manual to be a source of policy and procedure directives for IHSS workers, which may vary among IHSS agencies and change over time.

Caseworker manual
A basic manual has been developed according to findings from available literature and in consultation with stakeholders in refugee resettlement.The manual further explores the issues highlighted in this report, and its limitations are acknowledged.There is a need for development of agency-specific resources that can provide directives to volunteers in particular, such as policy and procedure guidelines and checklists for activities such as household and neighbourhood orientation.
Multilingual and audiovisual resources on common topics (eg using banks, traffic safety and tenancy laws and obligations in NSW) would be extremely useful for caseworkers and volunteers, as well as for the refugees themselves.The responsibility for developing and distributing such resources is with relevant government departments; however, private organizations such as banks or real estate agencies may also address this need.

Further research
Further research into all aspects of refugee resettlement is much needed, especially with respect to settlement into rural regions of Australia.Many aspects of refugee resettlement are poorly explored in the literature (eg housing, employment, finances and education).Further exploration is also needed of the roles of caseworkers and volunteers in enabling refugees achieve resettlement milestones and ease their transition into Australian society.A follow-up study to assess the usefulness of the manual, as well as the need for further chapters, is warranted.
Refugees from all backgrounds have complex needs on arrival in Australia, including the need to become familiar with a new culture, learn English, find appropriate housing, enrol children in school, navigate new technologies and systems, as well as address complex physical and mental health issues 6,12,14,[17][18][19][20][21][22][23] .Owing to the complexity of these issues it is important that all those who work with recently arrived refugees are sensitive to concerns and issues, and are able to address them in a culturally acceptable framework, with access to appropriate tools and resources.

A
literature review was conducted at the outset of each stage using MEDLINE and PubMed, with manual searches of the Journal of Refugee Studies, Australian Family Physician (journal of the Royal Australian College of General Practice), and DIAC and RCOA websites.Search terms use in MEDLINE and PubMed databases were: • immigration policy • refugee; resettlement; rural • rural and regional Australia • caseworker; volunteer; IHSS • manual; resources; publications.

Table 1 : Issues raised by mainstream agencies in focus groups Agency Information Provided/Source Suggested Useful Information Issues Raised in Focus Groups
AMEP, Adult Migrant English Program; DIAC, Department of Immigration and Citizenship; MCWW, Multicultural Council Wagga Wagga; TAFE, Technical and further education.

Table 2 : Problems raised: mainstream agencies
DOCS, Department of Community Services; TIS, Translating and Interpreter Service.