Asian Health Services
3 Mary Poynton Cres, Takapuna (North Shore office)
Waitakere Hospital, 55-75 Lincoln Rd, Henderson (Waitakere office)
Ph: (09) 486 8314 | Extn: 42314
Fax: (09) 486 8347
Waitemata DHB, Auckland Regional & National Strategies
Growing Culturally & Linguistically Diverse Migrant & Refugee Populations
Health Needs of Asian Migrants & Refugees
The health goal for National Refugee Resettlement (NRRS) and the New Zealand Migrant Settlement and Integration Strategies are to provide accessible, culturally responsive and equitable health and disability services to peoples from Asian, Refugee and Culturally and Linguistically Diverse (CALD) Migrant backgrounds. International studies show that CALD populations have:
disparities in health status compared to national groups even when adjusted for income and health conditions
barriers to health care and disability services
under-utilisation of the health and disability services that are available
The consequences of not improving access to the primary and secondary health and disability services are continuing and costly high health needs in Asian / MELAA populations. Failure to address these needs will jeopardise delivery of health actions in the whole of government settlement and integration strategies.
Improving access for Asian, refugee and CALD migrant groups to primary health services, and improving the cultural responsiveness of the services provided, is vital to the improvement of health outcomes in culturally diverse groups.
In New Zealand, little or no proficiency in English is a barrier to accessing primary health services. The successful integration of people from non-English speaking backgrounds into primary prevention, health promotion, screening and treatment programmes will prevent long-term patterns of poor health in Culturally and Linguistically Diverse groups.
The Waitemata DHB Annual Plan 2014/15 plan aims to improve the overall health status of Asians, new migrant and refugee populations living in the Waitemata District with a continued focus on identified areas of high need, and strategies to overcome barriers such as:
access to health services
staff cultural competency
The Ministry of Health Operational Policy Framework 2015/2016 requires that all DHB’s consider ethnic peoples:
Each DHB (in both its funder and provider functions) must aim to reduce health disparities and achieve health equity by improving health outcomes for other population groups including Pacific and ethnic peoples.
Each DHB must aim to reduce health outcome disparities between various population groups within New Zealand (including Pacific and ethnic peoples) by developing and implementing services and programmes as well as monitoring results in consultation with those population groups concerned.
DHBs should ensure all ethnic peoples have access to health services that are timely, appropriate and culturally sensitive.
Each DHB must take account of the particular needs within the community to be served, in order that access to services and communication in relation to those services are effective and responsive, and that services are safe and effective for all people.
It is expected that each DHB will:
Deliver services in a culturally appropriate and competent manner, with acknowledgement of and respect for the integrity of each consumer’s culture
Include significant local groups or service-specific ethnic and other cultural groups in assessing satisfaction with services, in order to facilitate consultation and encourage involvement in planning, implementing, monitoring and reviewing services
Deliver services to the highest clinical and quality standards (taking into account the need for cultural as well as clinical safety) within available funding
The following strategic documents have included the need for DHB consideration to ensure responsiveness of mental health and addiction services for people from diverse culture and ethnic groups:
Rising to the Challenge: The Mental Health & Addiction Service Development Plan 2012–2017. Ministry of Health (2012)
Te Tahuhu: Improving Mental Health 2005-2015: The Second NZ Mental Health & Addiction Plan
Te Kokiri: The Mental Health & Addiction Action Plan 2006-2015
Waitemata District Health Board Mental Health & Addiction Plan 2009-2015
The following legislation requires health practitioners and health services to ensure that their services are culturally responsive and competent for consumers from culturally and linguistically diverse backgrounds:
The Health and Disability Commissioner Act (1994) and the Health and Disability Code of Rights (1996) give consumers the right to be provided with services that take into account the needs, values and beliefs of different cultural, religious, social and ethnic groups. The Code gives consumers the right to freedom from discrimination, coercion, harassment and exploitation.
Right 5 of the Code of Health and Disability Services Consumers’ Rights gives clients the right to effective communication
The Mental Health (Compulsory Assessment and Treatment) Act 1992 and the 1999 amendments promote a culturally sensitive approach to treatment
The Health Practitioners Competence Assurance Act (2003) incorporates the basic principles of ongoing competence, requiring the Medical Council and other health registration bodies to ensure the cultural competence of medical practitioners
Download a copy of the summary information below.
Changes to the New Zealand Immigration Act 1987 led to much greater diversity in migrants’ countries of origin. The countries of Asia have become important new migrant sources for New Zealand since the early 1990s.
There was a significant increase of about 15,000 of Fiji-Indian migrants. The next largest increase from Asian countries was from China, with a net gain of about 11,000 people between the censuses, representing an increase of 14%.
Other Asian countries with increases of 1,000 people or more were, in rank order: Sri Lanka; Malaysia; Thailand; and Vietnam.
Most countries of Asia have supplied work migrants in recent years, with an annual average of about 65,000 qualifying a year.
Between July 2008 and June 2013 India was the largest source of short- to medium-term work migrants, with an average of 18,100 per year, followed by China (16,027), the Philippines (8,225), South Korea (5,722), Japan (4,659), Malaysia (3,700), Thailand (2,899), Indonesia (1,561), Taiwan (1,273) and Sri Lanka (1,173).
New Zealand’s refugee quota through the United Nations High Commissioner for Refugees, of about 750 a year, has contributed to new Asian populations in New Zealand.
The largest number of refugees by nationality were from Myanmar, with 1,952 Burmese refugees arriving between July 2006 and June 2013.
New Zealand has promoted itself as a destination for international students since the 1990s. The number of international students from 2006 to 2013 was an average of 56,000 originating in Asian countries annually.
China has consistently been the largest source of international students.
Arrival periods are important in relation to issues of settlement and
integration, and have an impact on the characteristics of migrants from
By 2013 the Asia-born population comprised more than 200,000 usual residents in Auckland.
Although relatively few Asia-born migrants arrived before 1987, there were some populations of note. The largest number of ‘old immigration policy migrants’ were from India, and it should be noted that a similar number of Indian migrants in this period came from Fiji. The second largest number of earlier migrants were from China, with significant numbers also from Malaysia, Hong Kong, Singapore, Vietnam and Cambodia. Many of those from the last two countries arrived as refugees in the 1970s and 1980s.
Some Asian migrant groups have a high proportion who are ‘early new policy migrants’ (arrived 1987-1996). This is the case for Taiwan, Hong Kong and Malaysia.
In proportionate terms, ‘middle migrants’ (arrived 1997-2006) were especially significant for the three largest source countries: China, India and South Korea.
It is important to note that a significant proportion of those identifying with an Asian ethnicity in the 2013 census were born in New Zealand (about 21%). The patterns shown in the 2013 Census data reveal that:
The earlier refugee populations have relatively high proportions born in New Zealand, as shown for Laotian, Cambodian and Vietnamese.
Over 20% of the Chinese and Indian populations are New Zealand born. Some of these are descendants of much earlier migrations from the 19th century onwards, while others are the children of more recent migrants.
Koreans had the lowest proportion of New Zealand born in 2013, due to their relatively recent immigration and significant levels of out-migration and return migration to Korea. s.
Those of Chinese ethnicity come from a diverse range of birthplaces. As well as China and New Zealand, significant birthplaces for those of Chinese ethnicity were Malaysia, Taiwan, Hong Kong (SAR), Singapore, Cambodia, Vietnam and Indonesia.
Ongoing immigration from India had made this the largest place of origin accounting for about 40% of the population, with another 30% from Fiji. Other countries of the Indian diaspora, such as South Africa and Malaysia, stand out as significant birthplaces.
Throughout Auckland 15 Census Area Units (CAUs) have more than 50% Asian populations – in the southeast, in the central business district (CBD), in various parts of the Auckland isthmus and in central parts of the North Shore.
In some cases these concentrations are largely Chinese or Indian, but in others there is a considerable mixture of these and other groups. The geographical distribution of Auckland’s Asian population varies considerably between groups.
Friesen, W. (2015). Asian Auckland: The Multiple Meanings of Diversity. Auckland: Asia New Zealand Foundation.
Gomez, D., King, R. & Jackson, C. (2014). Demographic Profile Report 1: Census 2013 Auckland Usual Residents Snapshot. Auckland Regional Public Health Service. Auckland.
For more publications relating to Asian, Middle Eastern, Latin and African populations please refer to our eCALDTM website
There are three ways in which refugees arrive in New Zealand:
The Refugee Quota Branch (RQB) of Immigration New Zealand (INZ), MBIE is responsible for managing New Zealand’s annual refugee quota programme. Through the refugee quota, New Zealand contributes to the global community’s efforts to assist refugees in need of resettlement. The size and composition of the refugee resettlement quota is set by the Minister of Immigration and the Minister of Foreign Affairs and Trade, after consultation with the UNHCR, relevant Government departments, NGOs and existing refugee communities.
All refugees considered for resettlement under New Zealand’s annual Refugee Quota Programme (except certain applicants who are nuclear or dependent family members of the principle applicant) must be recognised as a refugee under the UNHCR’s mandate and referred to the UNHCR according to prescribed settlement guidelines.
In recent years, New Zealand’s annual resettlement quota has been maintained at 750 places with a focus on the needs and priorities identified by the UNHCR. The Government aims to ensure that the quota remains targeted to refugees in greatest need of resettlement, while also balancing this with New Zealand’s capacity to provide good settlement outcomes to those accepted under the programme.
Quota refugees may be considered under the following categories:
Women at Risk
Medical / disability
On arrival, quota refugees spend a six-week orientation period in Mangere Refugee Resettlement Centre.
Those entering the country under this category are relatives of refugees already living in New Zealand. The Refugee Family Support Category (RFSC) has replaced the former Refugee Family Quota policy. The objective of the RFSC is to help refugees living in New Zealand to settle by allowing the sponsorship of family members for residence in New Zealand who do not qualify for residence under any other immigration policy. The sponsored relatives may be refugees, but this is not a requirement of the policy. The application costs and the air travel are generally met by relatives who are themselves often struggling with their own resettlement costs and challenges. There are 300 residence places available under the RFSC annually.
Asylum seekers usually seek protection on arrival at our borders, or when their temporary visa expires. Claims for refugee or protection status are confirmed or rejected by Immigration New Zealand depending on whether their circumstances meet the criteria set out in the UN Convention Relating to the Status of Refugees, the Convention against Torture (and Other Cruel, Inhuman or Degrading Treatment or Punishment) and Articles 6 and 7 of the International Covenant on Civil and Political Rights. There is a right of appeal to the Immigration and Protection Tribunal. Those who are successful in either the first instance or on appeal are eligible to apply for permanent residence and later, New Zealand citizenship.
For further information refer to the Ministry of Health (2012) Refugee Health Care: A Handbook for Health Professionals
For migrants and refugees, English is often not their first or second language and can be used with varying degrees of proficiency
WATIS Interpreting Service has been providing language interpreting support for 90 dialects/languages to 10,000+ non-English speaking migrant and refugee clients who accessed Waitemata DHB services since year 2002.
The utilisation of interpreters for Waitemata DHB secondary health services are increasing annually
Friesen, W. (2015). Asian Auckland: The Multiple Meanings of Diversity. Asia New Zealand Foundation.
For more publications relating to Asian, Middle Eastern, Latin and African populations please refer to our eCALDTM website.
Health concerns among Asian populations in Auckland include:
Among Chinese: diabetes prevalence among older men and middle-aged and older women, diabetes in pregnancy, child oral health, cervical screening coverage, cataract extractions and terminations of pregnancy.
Among Indians: CVD, diabetes (including during pregnancy), child oral health, child asthma, low birth weight deliveries, terminations of pregnancy, cervical screening coverage, family violence, hysterectomies, cataract extractions and total knee joint replacements.
Among Other Asian populations: stroke and overall CVD hospitalisations, diabetes (including during pregnancy), child oral health, child asthma, cervical screening coverage, terminations of pregnancy and cataract extractions.
Previous analyses of Asian data from the New Zealand Health Survey and Youth ’07 have also noted the lower prevalence of fruit/vegetable intake and physical activity, and higher prevalence of adult obesity, among Chinese, Indian and Other Asian adults and youth as compared to other ethnic groups.
Coronary procedures rates, dispensing of pharmacotherapy for CVD, Care Plus (chronic disease management) enrolments and the proportion of diagnosed diabetics receiving annual reviews were appropriately high among Indian people (given the burden of CVD and diabetes in this population) as compared to European/Other people.
A similar proportion of Asian and European/Other smokers registered in hospital were also advised to quit smoking.
However, low PHO enrolment rates among Chinese across Auckland and all Asian sub-groups in Waitemata DHB, as well as low cervical screening coverage across Auckland Asian women were noted compared to corresponding European/Other rates.
Asian people in Auckland also have lower rates of access to mental health services, disability support services and aged residential care compared to other ethnic groups.
The healthy migrant effect abates over time as acculturation occurs. Crucially, comparison of data from the current HNA with HNAs of Asian health in Counties Manukau DHB (2008) and Waitemata DHB (2009) indicate that this is already occurring. CVD mortality rates are rising among Indians, and the burden of diabetes is increasing in Other Asian communities and, to a lesser extent, among Chinese people in Auckland.
Key health issues noted by the health service providers interviewed included the lack of preventive behaviours such as healthy diet and adequate physical activity, high anecdotal rates of smoking among Asian people (particularly Chinese communities), the high and increasing burden of CVD and diabetes among South Asian people, mental health issues, care and abuse of older Asian people, sexual health issues particularly around termination of pregnancy among Asian students, family violence, and significant immigration and settlement stress.
Key cultural differences identified included the hierarchical and collectivistic orientation of many Asian cultures, the importance of religion, the stigmatisation of certain health issues such as mental illness and disability, proactively seeking health care for non-stigmatised conditions, use of alternative therapies, very high expectations of health professionals and the difference in gender roles.
Language and lack of knowledge of the New Zealand health system were barriers to appropriate health care that were mentioned by all health service providers interviewed. Other barriers included cultural differences in assessment and treatment, lack of cultural competency among health professionals, stigma associated with health issues, concerns about lack of confidentiality, transport difficulties and cost issues.
Facilitators to appropriate health care included education about the New Zealand health system, other health-related education, improving the cultural competence of health professionals and services, Asian workforce development, improved inpatient and community support, Asian-targeted health services, co-ordination and linkage of health services, and obtaining regular health service-related feedback from Asian communities.
[Mehta, S. (2012). Health Needs Assessment of Asian People living in the Auckland region. Auckland, Northern Regional Alliance Ltd (NRA)]
Barriers to accessing healthcare perceived by overall migrants and refugees include:
Little knowledge of NZ healthcare system, services and entitlements
Language and / or literacy barriers; insufficient interpreting services; discourages their utilisation of primary health system
Lack of cultural awareness of health providers; which impact on the service delivery and practice on the health of migrants and refugees; some migrants and refugees have expectations and health seeking patterns different from common norms in NZ
Stigma associated with mental health prevents individuals and family members of migrants and refugees assessing appropriate assessment and treatment services
Financial barriers, cost of consultation fees, medicine and travel (poor public transport systems), especially impact on refugees with minimal assets and have more complex health needs requiring them to have access to a range of health services
Health needs of refugees relating to pre and post settlement experiences include:
The results of a study of refugees on arrival in Auckland demonstrate a well-known fact that refugees and asylum seekers resettled in countries of second asylum have high health needs. [McLeod, A. & Reeve, A.M. (2005) The health status of quota refugees screened by New Zealand's Auckland Public Health Service between 1995 and 2000 ]
The only overseas screening carried out for quota refugees destined for New Zealand is for active tuberculosis and HIV infection. Tuberculosis must be treated before travel to New Zealand, and the number of quota refugees with HIV infection accepted for resettlement is limited to 20 per year.
The data also shows that health concerns traditionally found in the population of resettlement countries also occur in refugees, for example diabetes and hypertension, hence the possible need to include appropriate screening among refugees, as well as screening for more unusual diseases.
Quota refugees are generally malnourished rather than undernourished.
The high prevalence of smoking, particularly among males, offers an area where health education should offer significant benefits.
By contrast, some diseases common in the New Zealand population, particularly those associated with asthma and atopy, are uncommon among refugees.
The health needs of refugee women include gender sensitive services; contraception, antenatal and postnatal care; FGM services (Horn of Africa countries)
Alleviation of psychological upset is an important health need among quota refugees, although it appears to be a greater concern in asylum seekers; this may be due to the uncertain state in which asylum seekers find themselves. Nevertheless, for quota refugees, it still represents one of the most common reasons for referral to secondary services.
The Middle Eastern, Latin American or African (MELAA) ethnicity grouping consists of extremely diverse groups with dissimilar cultures, religions and backgrounds. In 2006, 1% of the New Zealand population identified as MELAA and half of them lived in Auckland. Many are from refugee backgrounds. Today, 28,637 people in Auckland identify as being MELAA; approximately 14,000 are Middle Eastern, 3000 are Latin American and 11,000 are African. This group is one of the fastest growing population groups and has unique health needs not entirely met by mainstream health services [Perumal, 2011].
[Perumal, L (2011). Health Needs Assessment of Middle Eastern, Latin American and African people living in the Auckland region]
Middle Eastern people are the largest of the MELAA groups in Auckland. Since 1994, refugees from Iran and Iraq have formed the largest population of New Zealand’s refugee intake and overall they make up the largest Middle Eastern population in Auckland. 50% identify as Muslims and 30% as Christians. Middle Eastern people have:
a young population, with a large proportion of children
the largest proportion of people who have lived longer in New Zealand compared with other MELAA groups
the greatest proportion of people who are not conversant in English (11%); 50% spoke Arabic
a greater proportion of people living in high deprivation areas and are more likely to live in crowded houses, compared with Europeans
a higher unemployment rate, a higher percentage of people on a benefit and a lower mean income, despite having similar qualifications to Europeans [Perumal, 2011]
Middle Eastern people have [Perumal, 2011]:
a higher rate of ambulatory sensitive hospitalisations (ASH) and emergency department (ED) utilisation than Others, despite having a high primary health organisation (PHO) enrolled population
higher rates of access to some surgical interventions including angioplasty and coronary artery bypass graft (CABG) operations, compared with Others
a lower utilisation rate of secondary mental health services but a higher percentage of people then needing acute inpatient admission at contact compared with Others
the lowest coverage for cervical screening of all compared ethnicities (in women)
a higher prevalence of cardiovascular disease (CVD) and diabetes than Europeans and other MELAA groups; also have higher rate of deliveries complicated by diabetes than Others
a similar proportion of ‘regular smokers’ as Europeans
the highest rate of hospitalisations from dental conditions, the highest proportion of children with caries and the highest mean number of diseased, filled or missing teeth in children of all compared ethnicities
higher rates of hospitalisations from respiratory diseases (asthma, pneumonia and bronchiolitis) than Others
the lowest proportion of babies who were fully/exclusively breastfed (at each milestone age)
a higher rate of termination of pregnancy than Others in women aged ≥30 years.
African people are the second largest MELAA group in Auckland. Similar to Middle Eastern people, they initially came to New Zealand as refugees from the late 1980s (predominantly from the Horn of Africa). By the early 2000s, the majority came as migrants from South Africa and Zimbabwe. As these two ethnicities are classified as ‘European’ in New Zealand, Ethiopians and Somalis are the largest identifiable African groups in Auckland. Most Africans identify as Christians (65%). African people [Perumal, 2011]:
are a relatively young population compared with Europeans
have the greatest proportion of people living in the most deprived areas within the MELAA group and the greatest disparity in deprivation distribution compared with Europeans
may live in more crowded circumstances compared with all other ethnicities; they have the largest proportion of people with ≥ 6 residents per household and the lowest proportion of people living in houses with ≥4 bedrooms
have the highest proportion of one parent households of all compared ethnicities
have similar school qualifications to Europeans but a higher unemployment rate, lower mean annual income and a higher proportion of people on the unemployment benefit.
African people have [Perumal, 2011]:
higher rates of PHO enrolment and lower rates of ASH and ED utilisation than Others
a lower than expected proportion of people with a community services card (CSC)
the lowest breast cancer screening coverage of all compared ethnicities and a much lower unadjusted cervical screening coverage than Europeans (in women)
a higher proportion of patients who did not attend (DNA) specialist outpatient clinics than Europeans in all three Auckland DHBs
a higher cost of dispensed pharmaceuticals per person from age 10 to 59 years (due to HIV medications) but a lower value of nominal costs per person for laboratory tests compared with Others
a reduced utilisation rate of secondary mental health services but a higher proportion needing acute inpatient admission at contact compared with Others
a lower prevalence of CVD but a higher prevalence of diabetes compared with Europeans
a much higher rate of hospitalisations from respiratory diseases (asthma, pneumonia and bronchiolitis) than Others
the second highest proportion of people diagnosed with HIV and AIDS compared with other all other ethnicities, after Europeans- African women had the highest proportion diagnosed with HIV/AIDS of all ethnicities (in women)
the highest hospitalisation rate for tuberculosis
a higher rate of termination of pregnancies and a higher hospitalisation rate from sexually transmitted infections than Others (in women).
Latin American people make up the smallest proportion of the MELAA group. They initially came to New Zealand as part of the mid 19th century’s population of gold seekers. Chilean refugees arrived in the 1970s but by the 2000s, voluntary migrants from Brazil made up the largest Latin American population, most coming as students and working holiday visitors. Latin Americans had the highest PHO enrolment growth compared with other MELAA ethnicities from 2006 to 2010.The majority are Christians (70%) and are mainly Catholic. Latin American people have [Perumal, 2011]:
a more mobile and younger population (consisting mainly of 20-34 year olds) than Europeans
the largest proportion of people with post school qualifications of all compared ethnicities but had a higher unemployment rate and a lower mean income than Europeans.
Latin Americans have [Perumal, 2011]:
had the greatest average annual increase in PHO enrolment between 2006 and 2010
the highest rate of ED utilisation of all compared ethnicities, but lower ASH rates than Others
had higher nominal costs claimed per person for laboratory testing in all age groups compared with Others
a lower coverage for unadjusted cervical screening than Europeans (in women)
a higher rate of utilisation of secondary mental health and addiction services than all compared ethnicities
a lower prevalence of CVD but a higher prevalence of diabetes than Europeans
higher rates of hospitalisations from respiratory illnesses (asthma, pneumonia and bronchiolitis) than Others
the highest rate of hospitalisations from kidney and urine infections of all compared ethnicities
a higher percentage of assisted deliveries and Caesarean sections compared with Others ( in women)
had a hospitalisation rate almost three times the rate of Others for ectopic pregnancies
the highest rate for teenage deliveries, a high rate of termination of pregnancies in teenagers and the highest rate of hospitalisations from sexually transmitted infections (in women), of all compared ethnicities.
Key concerns around the health needs of the MELAA population included the rising prevalence of diabetes and heart disease, the changes in diet, nutrition and physical activity and social issues such as isolation and poverty [Perumal, 2011].
Key cultural differences noted in these communities included the importance of faith and family engagement in health, the differences in gender roles and the varying perceptions of illness and disability.
The main barriers to health care provision was language and communication difficulties, health illiteracy, cost of health care, the lack of cultural understanding by HSPs and the lack of trust and fear of Western health care models.
Enhancers to healthcare include having HSPs that understand their backgrounds, the appropriate use of interpreters, having targeted services, engaging with religious leaders and communities and providing well coordinated services.
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