Author Archive

Health information for new humanitarian arrivals

From 1 May 2018 health services that provide on arrival care to people arriving through the Australian Humanitarian Programme may access the Department of Home Affairs’ health database, Health Assessment Portal (HAPlite).

HAPlite contains health information collected by the Department of Home Affairs prior to a person arriving in Australia, i.e. information collected during Immigration Medical Examination and for some people a Departure Health Check.

Following registration with the Department of Home Affairs, health services may access client records with a ‘HAP ID’ that should be provided by the referring Humanitarian Settlement Program or the Department of Social Services. HAPlite enables health service providers to view complete health examination reports and download records including x-ray image files.

For more information about HAPlite contact health@homeaffairs.gov.au

Country-specific recommendations for malaria, schistosomiasis and hepatitis C screening

Table 1.4: Top 20 countries of origin for refugees and asylum seekers25,26, and country-specific recommendations for malaria, schistosomiasis and hepatitis C screeninga

Country of birth

Malaria27

Schistosomiasis28

Hepatitis C29

(Note: those with risk factors for HCV should be tested regardless of country of origin)

Afghanistan

No

No

No

Bangladesh

Yes

No

No

Bhutan

Yes

No

No

Burma

Yes

Yes

No

China

No

No

No

Congo

Yes

Yes

Yes

Egypt

No

Yes

Yes

Eritrea

Yes

Yes

No

India

Yes

Yes

No

Iran

No

No

No

Iraq

No

Yes

Yes

Lebanon

No

No

No

Pakistan

Yes

No

Yes

Somalia

Yes

Yes

No

Sri Lanka

Yes*

No

No

Statelessb

Yes

Yes

No

Sudan

Yes

Yes

No

Syria

No

Yes

Consider

Vietnam

No

No

No

     There are regional variations in the prevalence of these conditions within some countries. We have taken the conservative approach of recommending screening for all people from an endemic country rather than basing the recommendation on exact place of residence.

     ’Stateless’ in this table refers to people of Rohingyan origin.

Malaria link: http://www.who.int/ith/en/

and: http://apps.who.int/neglected_diseases/ntddata/sch/sch.html

Hepatitis C reference: Lavanchy D. Evolving epidemiology of hepatitis C virus. Clin Microbiol Infect. 2011 Feb;17(2):107–15

*Edit: 13 March 2018: Since the time of publication of the ASID/RHeaNA Recommendations, Sri Lanka has been declared malaria free. See World Health Organisation 

Incorrect birth date: children and adolescents

Refugee children/adolescents may have an incorrect birth date on their visa paperwork, which becomes the basis for all the official documentation in the country of settlement. This issue is not uncommon, especially for adolescents, and may have significant effects on school placement, developmental assessment (including formal assessments such as cognitive testing) and access to welfare, services, and case management support. The reasons for an incorrect birth date are often complex; it may be unknown, due to error, related to calendar discrepancies, or changed to due to family circumstances/conditions in country of origin. Any child with a birth date of 01/01/(year) is almost certainly younger. Families may be reluctant to raise this as an issue, and may be worried about the implications for their migration claim/visa/citizenship.  Often this emerges as an issue some years after settlement.

Correcting a birth date requires an assessment of the family narrative (including contextual migration events, birth order/ages of siblings matched to any known local events or transitions in the migration pathways), reviewing and documenting any existing paperwork or known milestones, and an assessment of the child’s growth, dental eruption, pubertal stage and development with information from schools wherever possible (on peers, learning, maturity/function in the classroom). Our experience is that frequently, undisclosed trauma becomes apparent during age assessment, and it is essential to allow enough time and be prepared to work through this process at a pace that is acceptable to the family. A bone age X-ray or orthopantogram (OPG) is sometimes used as additional information in the specialist setting, but neither bone age nor OPG imaging defines the child/young person’s age. Bone age X-rays provide an estimate of bone age compared to chronological age. The Greulich and Pyle (GP) method[73] is used most commonly (evaluating a single frontal X-ray of the left wrist), however, it is essential to note:

  • The GP method is intended to assess skeletal age knowing the chronological age (not the reverse)
  • The GP method is based on data from white American children from the 1930s; and considerable racial variation is found.[74, 75]
  • The GP method is not precise, the margin of error is typically a 3–4 year range throughout childhood/adolescence
  • Skeletal maturity is affected by additional factors such as constitutional delay in maturation.

Bone age X-rays are most useful in a child who is clearly many years older or younger than their paperwork birth date. Similar principles apply to the use of the OPG.

Incorrect dates of birth can be formally changed using Form 424C under the Freedom of Information Act, through the Department of Immigration and Citizenship: www.border.gov.au/forms/Documents/424c.pdf.

Child protection

Like any other group of children/adolescents in Australia, child protection issues may be identified for children/adolescents of refugee-like background. Child maltreatment is broadly defined as any non-accidental behaviour by parents, caregivers, other adults or older adolescents that is outside the norms of conduct and entails a substantial risk of causing physical or emotional harm to a child or young person. Maltreatment may occur through acts of omission (such as neglect of care) or commission (such as inflicted harm). Subgroups of protective concerns include:[71]

  • Physical abuse – non-accidental use of physical force against a child that results in harm to the child.
  • Emotional maltreatment – Inappropriate verbal or symbolic acts toward a child and/or a pattern of failure over time to provide a child with adequate non-physical nurture and emotional availability.
  • Neglect – failure by a parent or caregiver to provide a child (where they are in a position to do so) with the conditions that are culturally accepted as being essential for their physical and emotional development and wellbeing.
  • Sexual abuse – the use of a child for sexual gratification by an adult or significantly older child/adolescent
  • Witnessing family violence – Child being present (hearing or seeing) while a parent or sibling is subjected to physical abuse, sexual abuse or psychological maltreatment, or is visually exposed to the damage caused to persons or property by a family member’s violent behaviour.

The National Framework for Protecting Australia’s Children 2009-2020[72] emphasises that protecting children is everyone’s business’. Priorities include early recognition and action, support for carers, responding to sexual abuse, and joining up service delivery. Reporting requirements (mandated reporting (including categories of reporting) and failure to disclose offences) vary with jurisdiction, and it is important to be aware of responsibilities and requirements (and seek advice if needed). Forced underage marriage and procurement of female circumcision are both urgent child protection matters, with mandated reporting requirements. For asylum seeker families, current immigration policy and prolonged uncertainty can be substantial drivers for mental illness and parenting issues, and may also act as a disincentive for disclosure of family violence and/or child protection matters. These situations are complex, and require a high index of concern, and a supportive response with specialist input.

Post-arrival health assessment: children and adolescents

All refugee and asylum seeker arrivals should be offered a comprehensive health assessment within 1 month of arrival,[3, 8] or expediently if there is any clinical indication or health alert. This assessment can be offered at any time after arrival if initial contact with healthcare is delayed. Families (and adolescents individually) need to understand the importance and implications of health screening and give informed consent. This means explaining all tests, the conditions being screened, the meaning of a positive test, and the next step in management.

Assessment of newly arrived refugee children and adolescents should focus on:

  • Parent (or self-identified) concerns
  • Excluding acute illness
  • Immunisation status and catch-up vaccination
  • Tuberculosis screening
  • Other infections, including parasites, malaria and hepatitis
  • Nutritional status and growth
  • Oral health
  • Concerns about development, vision and hearing
  • Mental health, trauma and violence exposure
  • Previous severe or chronic childhood illness or physical trauma
  • Confirming the reported birth date
  • Education history
  • Issues arising during resettlement in Australia.

Initial screening investigations

Suggested initial screening investigations are:[3, 8, 9]

All children and adolescents:

  • Full blood examination (FBE) and film
  • Ferritin
  • Hepatitis B serology – surface antigen (HBsAg), surface antibody (HBsAb) and core antibody (HBcAb)
  • Strongyloides serology
  • TB screening – TST or interferon gamma release assay (IGRA). TST is preferred in children less than 5 years
  • Faecal specimen – ova, cysts and parasites (OCP)

Country-based screening

  • Malaria – rapid diagnostic test (RDT) and thick/thin film, if arrival less than 3 months from endemic area* or later if symptoms
  • Hepatitis C serology – Hepatitis C virus (HCV) antibodies, if from endemic area or if clinical risk factors
  • Schistosoma serology – if travel from/through endemic area*

Age/risk-based screening

  • Vitamin D, calcium, phosphate, ALP – if risk factors for low vitamin D (lack of skin exposure to sunlight, dark skin, conditions affecting vitamin D metabolism, and exclusively breastfed infants where there is maternal deficiency and at least one other risk factor)
  • Serum active vitamin B12 – if arrival less than 6 months, food insecurity, vegan, from Bhutan, Afghanistan, Iran, or Horn of Africa
  • Varicella serology – if age 14 years and older if no history clinical varicella infection and no documented varicella vaccination
  • Rubella serology – females of childbearing age. Consider in late adolescence, although not needed if catch-up vaccination in place
  • Sexually transmitted infection (STI) screen – N. gonorrhoea and C. trachomatis urine nucleic acid detection, syphilis serology (note: also HIV, hepatitis B) in sexually active adolescents, or if there is a history of sexual violence/abuse.
  • Syphilis screening should be completed in all unaccompanied/separated children, and children should also be screened for syphilis if their mother has positive serology
  • HIV testing – age 15 years and older, less than 15 years if unaccompanied/separated minor, or clinical risk factors (sexually active, history of sexual violence/abuse, where parents are deceased/missing/known to be HIV positive, other STIs, history of blood transfusions, or where there are clinical symptoms/signs)
  • Helicobacter pylori screening (faecal antigen test on fresh specimen) in children with family history gastric cancer, or symptoms/signs dyspepsia/ulcer disease. 

Urgent specialist assessment/advice is required in children and adolescents with the following presentations:

  • Unwell/febrile (this requires urgent exclusion of malaria and other severe infection)
  • Symptoms suggesting active TB disease (fevers, weight loss/poor weight gain, prolonged cough, other localising symptoms)
  • Malnutrition
  • Clinical rickets or hypocalcaemia
  • Low B12 levels in infants/young children (also maternal deficiency during exclusive breastfeeding)
  • Developmental issues or disability
  • Severe mental health concerns

Pre-arrival health screening: children and adolescents

Pre arrival immigration medical examinations (IME) and screening for onshore protection visa applicants are outlined in the ASID guidelines[3] and DIBP information.[4] The IME for Humanitarian entrants includes urinalysis (5 years and older), interferon gamma release assay (IGRA) or tuberculin skin test (TST) (2–10 years), chest x-ray (11 years and older, or if clinically indicated), HIV screening (15 years and older, or if risk factors are identified) and syphilis screening (15 years and older).[4] Unaccompanied minors (all ages) also have screening for HIV and hepatitis B surface antigen (HBsAg). Refugee entrants may undergo an additional Departure Health Check,[5, 6] and extended screening and vaccinations have been introduced for the recent Syrian/Iraqi cohorts. In practice, children have more limited screening compared to adolescents/adults due to these age cut points.

It is important for clinicians to be aware of the pre-arrival health screening process, as this process has implications for post-arrival healthcare:

  • Check available offshore paperwork.
  • Offshore vaccinations should be entered onto the Australian Immunisation Register (AIR).
  • Children 2-10 years may have had additional tuberculosis screening (commenced from late 2015).[7]
  • TST (screening for tuberculosis (TB) exposure) should not be performed within 1 month of a live viral vaccine (e.g. MMR vaccine given pre-arrival).
  • Albendazole (given as part of the DHC) may result in false negative serology for Strongyloides infection.
  • People from the same source country may have different patterns of offshore health screening depending on their migration pathway and visa type.

People living with disabilities

Key Points

  • In recent years there has been an increase in the number of people from refugee backgrounds settling in Australia who are living with a disability
  • Rapid specialised assessments and advocacy may be needed to promote early referral and access to disability services.
  • Cost of specialised assessments should be minimised given the financial constraints faced by recently arrived people from refugee backgrounds.
  • For eligibility and planning of NDIS services, assessments must include detailed information on the person’s functionality, not just a diagnosis.
  • Cultural considerations may mean that families are less accepting of outside help, including respite care. They are unlikely to be aware of available support services and concepts of care, and of the notions of rights for people who are living with a disability.

Overview

Since 2012, a streamlining of health waiver provisions for offshore Humanitarian entrants has seen an increase in people of refugee background living with a disability settling in Australia.  Clinical assessment, service access and access to aids and equipment can be complex for recently arrived refugee children, adolescents and adults with disability.

The concurrent rollout of the National Disability Insurance Scheme (NDIS) has increased this complexity. The National Disability Insurance Scheme (NDIS) is administered by the National Disability Insurance Agency (NDIA). The NDIS provides support to people with disability and to their families and carers. Support is goal-oriented, with a focus on community participation and accessing mainstream supports. The process of applying for and accessing the NDIS should be explained to the patient/patient’s family.  

Approach to care

The approach to care will be dependent on age and type of disability.

  • In the case of children, a good perinatal and developmental history, as well as history of any severe illness and current nutritional status, can be very informative.
  • In some cases, parental consanguinity may be relevant to enquire about; however, this needs to be done with great sensitivity, due to negative attitudes that families may have already faced here.
  • A thorough physical, developmental and mental state examination (see Refugee health assessment) (See Children and Adolescents), with a focus on the person’s ability to function in day to day tasks and in general, such as work ability, will be important for completing the NDIS referral form, and will assist other health providers with their assessments.
  • Specialised assessments will be needed to promote early access to disability services. This may include referral to a dedicated adult or paediatric disability doctor or team, psychometric testing, an occupational therapist assessment and/or other needs depending on age and type of disability. The clinician may need to advocate with the disability team to ensure that assessment and access to required services is timely.
  • Individuals with disabilities may have never had a formal diagnosis. Specific tests may be needed to define the condition, and in some cases to inform parents of a need for genetic counselling regarding future children. These tests may need to be guided by seeking advice from experts such as developmental paediatricians or an adult disability team.
  • Case management is available for newly arrived refugees/families with complex needs. See: Humanitarian Settlement Program, Specialised and Intensive Services
  • Refugee Health Nurses and Refugee Health Services will be able to recommend relevant referral pathways and low-cost services
  • Specific information can be gained from relevant disability agencies, depending on the type of disability. Examples include services for people with autism, Down syndrome, hearing impairment and visual impairment. There may also be specific disability services to assist those from certain Culturally & Linguistically Diverse backgrounds.
  • Diagnosis and assessment are supported via Medicare through the Better Start for children with disability initiative – MBS item 137 (specialist) and MBS item139 (GP) to determine eligibility for the Better Start program (translated information). However these initiatives are superseded when an application for NDIS access is submitted. A pathway via NDIS is the Early Childhood Early Intervention Approach (ECEI)

Considerations

Centrelink and the NDIA will not accept overseas medical reports at this time, although they may be included as supplementary documentation.

Equipment needs may be urgent, with temporary options (e.g. though NGO/charities and some settlement services) needing to be found before the NDIS or other disability services commence. In some states, community health centres may provide equipment loans.

Access to interpreters for the assessment process and preparing a plan for NDIS support is not free currently. TIS National is however available free for participants to access funded supports in their NDIS plan.


Links

National Ethnic Disability Alliance (NEDA)

Australian Hearing

Australian Government Hearing Services Program (if over 65)  

Vision Australia 

Translated NDIS information and resources 

NDIS information and resources for service providers


References

Hotton, P., Raman S, Brown T. Developmental disability in refugee children and youth in South Western Sydney: double jeopardy. Journal of Paediatrics and Child Health, 2015. 51: p. 7

Refugee Council of Australia. Supporting humanitarian entrants with disabilities – National Settlement Policy Network Teleconference 2014. Available at: https://www.refugeecouncil.org.au/r/spn/140508-SPN.pdf

Diversitat Disability Findings Report 2016. Available at: www.pavetheway.org.au/sites/pavetheway.org.au/files/documents/CALD%20in%20NDIS%20launch%20site%20Diversitat_Disability_Report.pdf 

Men’s health

Key Points

  • Men and boys make up half of our humanitarian intake
  • As a result of their experiences and human rights abuses, men from refugee backgrounds may have a range of health issues additional to those of men in the wider Australian community
  • Identity issues following resettlement can be a significant issue 
  • Men may be hesitant to participate in counselling
  • A cardio-vascular risk assessment may be warranted from age 35 years

Overview

Men from refugee backgrounds have often witnessed, or experienced, physical or sexual violence, including war and torture, which can result in depression, anxiety and post-traumatic stress. 

Some have been combatants in war; others have been imprisoned and/or tortured because of their roles as community leaders, activists or professionals. A small number have been child soldiers or arrived as unaccompanied minors. 

For many new arrival communities, the role of the man has historically been that of decision-maker, provider and ‘head of household’. Some men find it difficult to adjust to new expectations and the new freedoms of their wives and children (especially daughters) when they arrive in Australia. 

Identity issues associated with loss of social and occupational status, racism and changes in gender roles can contribute to mental health problems, long-term unemployment, substance use, domestic violence and family breakdown. 

The provision of services to refugee men may be limited by difficulties for some in developing trust, and reluctance to seek help or disclose a history of torture and trauma. Many men can show a reluctance to admit they are not coping, or acknowledge that post-traumatic stress may be the cause of their anxiety or their depressive or somatic symptoms. They may be hesitant to participate in counselling due to stigma associated with mental health problems, so care is needed in explaining a referral for counselling or assessment. Group approaches that are activity-based and get men talking to each other in a non-threatening environment can sometimes be a way of reducing barriers to talking about problems they are facing in adjusting to Australian life. For some, religious/spiritual guidance or rituals such as prayer may be beneficial. 

Approach to care

  • Some men from refugee backgrounds may prefer to see a male GP.
  • A cardio-vascular risk assessment is warranted, potentially at a younger age than in Australian-born men (i.e. from 35 years of age). 
  • Smoking rates may be high.
  • Men from refugee backgrounds, like their female counterparts, may suffer from war- and torture-related injuries, including the physical effects of sexual torture.
  • Other physical health problems may include poor dental health, diseases associated with long-term exposure to the elements and poor diet, as well as chronic conditions such as hypertension, diabetes and obesity.4 5
  • Bowel cancer screening (FOBT) is recommended for men 50 years and above; also, prostate cancer testing in anyone with relevant history or symptoms

Considerations

Some communities have traditionally had a lack of access to condoms, and religious or other stigma associated with their use; however teenagers and adult men may be sexually active, needing regular advice on safe sex practices as well as screening for STIs.

In some cultures, the age of consent is different from that in Australia; thus it may be advisable to discuss Australian practices and laws concerning sexual relations including age of consent. Australian laws vary between states and also according to the gender of sexual partners.

Specific Groups at Risk

  • Asylum Seekers  – experience high rates of depression, PTSD, psychological trauma as well as limited access to health services and social supports.
  • Former Soldiers – likely exposure to extreme violence, threats to life and abuse. May include boys and adolescents forced into combat roles from a young age.
  • Elderly Men – Physical and mental consequences of the refugee experience may first present in old age. Painful memories can resurface at times of illness or other stress.

Links

Andrology Australia

Australasian Men’s Health Forum

Foundation 49

Male Health Victoria

Men’s line Australia

Men’s Health Week

Prostate Cancer Foundation of Australia


References

1.Byrne, M. (2006). The Other 50%: Refugee Men’s Health NSW Refugee Health Service, Sydney. See also: NSW Refugee Health Service. (2009). Fact Sheet 9: Refugee Men. Retrieved from: < www.sswahs.nsw.gov.au/sswahs/refugee/pdf/Resource/FactSheet/FactSheet_09.pdf >. 

2. Brownhill, S. (2014) Practitioners’ Guide to Men and Mental Health, Men’s Health Resource Kit 4, Penrith, MHIRC, University of Western Sydney 

3. Johnston, V., Smith, L. & Roydhouse H. (2011). ‘The health of newly arrived refugees to the Top End of Australia: results of a clinical audit at the Darwin Refugee Health Service’. Australian Journal of Primary Health, published online December 2011. < dx.doi.org/10.1071/PY11065 >

4. Chaves, NJ., Gibney, KB., Leder, K., O’Brien, DP., Marshall, C. & Biggs, B-A. (2009). ‘Screening practices for infectious diseases among Burmese refugees in Australia’. Emerging Infectious Diseases, (15)11, 1769-72.

5. Webster, K. & Kaplan, I. (2003). ‘Refugee Women and Settlement: Gender and Mental Health’ in Allotey, P. (ed.) The Health of Refugees: Public Health Perspectives from Crisis to Settlement. Oxford University Press.

6. Mathews, B. (2011). Female genital mutilation: Australian law, policy and practical challenges for doctors. Medical Journal of Australia, 194(3), 139-141.

7. Correa-Velez, I & Gifford, S. (2011). Health and settlement among men from refugee backgrounds living in South East Queensland, La Trobe Refugee Research Centre, La Trobe University. Retrieved from: < www.latrobe.edu.au/__data/assets/pdf_file/0009/144945/Correa-Velez,-et-al.-SettleMen-WEB.pdf >.

8. Williams, N. (2011). ‘A Critical Review of the Literature: Engendering the Discourse of Masculinities Matter for Parenting African Refugee Men’. American Journal of Men’s Health, 5(2), 104-117.

Older people

Key Points

  • Older people from refugee backgrounds (that is, aged 65 and above) have higher settlement and recovery needs compared to other refugees, as well as being more likely to have chronic disease.
  • Being elderly and a refugee can increase the effects of stress, anxiety, depression, isolation and vulnerability
  • Acquired English language skills may be lost, with reversion to their first language
  • Minimise re-traumatisation and triggering of painful suppressed memories
  • Symptoms of depression, anxiety and post-traumatic stress can be confused with that of dementia
  • Cultural concerns may impact on acceptance of aged care or interpreter services
  • Consider financial barriers to seeing private specialists and allied health workers.

Overview

In Australia the majority of older people from refugee backgrounds arrived decades ago, escaping from Europe after WWII, and from conflicts in South-East Asia and Central and South America. However, there is an increasing number of older people arriving as refugees from the more recent conflicts in the Middle East. They have experienced recent war trauma, and may be reuniting with family in Australia after many years of separation. These older people tend to have a higher degree of chronic illness and sometimes more complex psychosocial adjustment, when compared to younger refugees. As well as the usual conditions of old age, older people from refugee backgrounds may face health problems from previous deprivation, physical injuries and inadequate access to health care. Symptoms of depression, anxiety and post-traumatic stress can be confused with that of dementia and thus mental health needs may be overlooked. Disruptions to memory, such as dementia, or during hospitalisation and institutionalised aged care, can trigger painful suppressed memories, forcing people to re-live events such as torture or time spent in internment. This is distressing and can manifest in increased anxiety, depression and challenging behaviours.

With the onset and progression of dementia, acquired language skills in English may be lost, with reversion to their first language. This increases communication problems with medical and aged care personnel, and possibly even their family. It highlights the importance of using professional interpreters when assessing older refugees and providing medical care.

Recently arrived older refugees may experience higher levels of social isolation due to lack of family in Australia, limited local community of same age and background, and difficulty in developing trust due to their past refugee experiences. The older refugee may make the assumption that they are at the end of life and not seek medical advice for certain issues, or assistance with mobility, eyesight, dentures or hearing aids. There may be a reluctance to accept assistance from care services due to cultural appropriateness concerns. This is primarily because caring for the elderly is considered a traditional duty of family, and accepting outside help can be seen as shameful and reflecting an inability of family to fulfil this role. 

Approach to Care

  • A thorough social and medical history will be required, as well as the same comprehensive assessment (including vision, hearing and oral health) offered to all newly arriving people of refugee background.
  • Chronic disease assessment and management will be particularly relevant.
  • Catch-up immunisations may include the need for single dose diphtheria/tetanus/pertussis, pneumococcal and shingles vaccines. The need for annual influenza vaccine should be explained.
  • Cancer screening may never have been undertaken – cervical and breast screening in women, and bowel screening in both genders. Sensitive explanation of the benefits of these tests, which may be viewed as unpleasant and foreign, will be required.
  • Comprehensive mental health assessment is required to separate any symptoms of dementia from those of depression, anxiety and post-traumatic stress.
  • It is important to minimise re-traumatisation; listening patiently to a person’s life story and experiences, use gentle and supportive ‘third person’ enquiry, ‘generalising and normalising’ their difficult experiences and current issues, contributes to healing.
  • The cultural context in which services are provided must also be considered; use of interpreters is key, and where possible the use of ethno-specific aged care services.
  • Cost of specialised assessments, allied health appointments and other services should be minimised given the financial constraints faced by recently arrived refugees in particular. Preference should be given to using the public health system whenever possible, and/or bulk-billing specialists, and chronic disease care plans.

Links

Enhancing the Lives of Older Refugees 

UNHCR – Older People

References

Atwell R et al (2007) Ageing out of place: Health and well-being needs and access to home and aged care services for recently arrived older refugees in Melbourne, Australia’. Int Jn of Migration, Health & Social Care 3(1): 4-14.

Joffe H, Joffe C & Brodaty H (1996) ‘Aging Jewish Holocaust survivors’, MJA 165: 517-20.

Paratz E, & Katz, B (2011) “Ageing Holocaust Survivors in Australia” , MJA 194: 194-97.

Steel Z, Silove D, Phan T, Bauman A (2002) ‘Long-term effect of psychological trauma on the mental health of Vietnamese refugees resettled in Australia’ Lancet 360 (9339): 1056-62.

Settlement support

Overview

Prior to leaving country of departure Refugee and Humanitarian Programme entrants may attend the Australian Cultural Orientation (AUSCO) Program, a five-day course that covers a range of topics related to resettling in Australia. 

On arrival in Australia, Refugee and Humanitarian Programme entrants (visa subclass 200, 201, 202, 203 and 204) are provided support through the Australian Government’s Humanitarian Settlement Program (HSP) for 6–12 months. HSP providers work with clients to identify their needs and develop a case management plan to meet initial settlement needs, including:

  • meeting people at the airport
  • assistance with finding suitable longer-term accommodation
  • providing an initial food package and start-up pack of household goods
  • assistance to register with Centrelink, Medicare, health services, banks, schools and English classes
  • orientation to life in Australia, including health, education, employment and Australian laws and culture
  • assistance to fulfil the requirements of health undertakings.

The HSP provides three tiers of support based on client need. Tier 1 provides support to people with the lowest needs, while people in Tier 3 may be impacted by multiple and complex barriers to engaging with appropriate supports. The HSP Case Management Guidelines describe the tiers as follows:

  • Tier 1: ‘Clients generally present with the knowledge and skills required to settle into their new community with minimal assistance from a Service Provider…for example, a client with basic English who has some work experience, but requires some settlement services to assist in connecting to mainstream services, orienting to Australia and navigating employment pathways’.1 (p5)
  • Tier 2: ‘Clients are likely to have experienced high levels of poverty, trauma or health impacts arising from persecution, discrimination, displacement, nutritional deprivation or inadequate medical care…for example, a client with little to no English language proficiency who has been displaced and unemployed for several years. The majority of Clients in the HSP are likely to be identified as Tier 2’.1 (p5)
  • Tier 3 (Specialised and Intensive Services): ‘Clients may display an inability to independently engage with appropriate supports and may be impacted by multiple and complex barriers…for example, a client presenting with significant mental health issues resulting in disengagement with mainstream support services and social isolation’.1 (p6) Tier 3 requires written approval of Department of Social Services (DSS) and has wider scope than the other two tiers as follows:
  • With approval from the DSS people who were granted a protection visa in Australia may access specialised intensive support (visas include subclass 866, 785, 449, 786, 790).
  • People may access this support for up to 5 years after arrival (or are 5 years post visa grant, for those who applied for asylum in Australia).
  • Anyone can refer a person using the approved referral form, which is available on the DSS website. 
  • A client who has previously had HSP services may re-enter the program.

 For further information see Department of Social Services HSP.

People who are ineligible for HSP may be able to access settlement support through community programs delivered through Migrant Resource Centres or other community organisations funded by Settlement Grants Program

Proposers

People who enter Australia with a Special Humanitarian Programme visa, a subclass within the Refugee and Humanitarian Programme (visa subclass 202), must be proposed by an Australian citizen, permanent resident of Australia, eligible New Zealand citizen or an organisation operating in Australia.2 (p4)

Proposers are responsible for travel arrangements to Australia and providing settlement support when people arrive in Australia. However, often proposers ‘have only recently settled in Australia and may overestimate their capacity to provide settlement support.’2 (p5) Under the HSP contract, based on need, the ‘Service Provider must deliver the settlement services to a Client where their Proposer is unable to provide support.’2 (p9)

Support to learn English

Adult Migrant English Program (AMEP) provides up to 510 hours of foundational English language tuition and settlement skills.3 See AMEP providers.

The Australian Government announced a new model for AMEP commencing July 2017 which provides access to a capped program of up to 490 hours of additional tuition for clients who have not reached functional English after completing their legislative entitlement of 510 hours. The Special Preparatory Program provides additional hours of tailored English classes to eligible humanitarian entrants in recognition of their greater learning and support needs arising from difficult pre-migration experiences, such as torture or trauma, and/or limited prior schooling.4 Read more about DSS support to learn English.  

The Skills for Education and Employment program provides language, literacy and numeracy training to eligible job seekers, to help them to participate more effectively in training or in the labour force.5

Approach to care

Patients may ask for support and advice for matters beyond medical matters. In early settlement people may not have large networks. Therefore they may ask people they trust for advice and support, including GPs, nurses or other members of the health team.

Consider a case conference with the patient’s HSP caseworker or a referral to a HSP provider if your patient has arrived through the Refugee and Humanitarian Programme in the past 12 months, and is experiencing difficulties in accessing:

  • English language classes
  • housing
  • income support
  • employment
  • social support
  • advice on legal or migration matters
  • adequate household and personal effects
  • support for complex medical follow-up
  • schooling for their children
  • childcare and parenting support.

For patients who have multiple complex needs and have arrived in Australia in the past 5 years (or are 5 years post visa grant, for those who applied for asylum in Australia) consider referral to HSP Specialised and Intensive Services.

Practice tip: Consider streamlining the referral process by developing a list of local support agencies including phone numbers and addresses.

Considerations

People seeking asylum cannot access HSP. For more information about support services for people seeking asylum see State and territory referrals and Asylum seekers.

Resources

Produced by

in consultation with

                  Refugee Health Network of Australia

Endorsed by

Funded by

The Australian Refugee Health Practice Guide was produced with funds from the Australian Government Department of Health.

Disclaimer

The information set out in the Australian Refugee Health Practice Guide (“the Guide”) is current at the date of first publication and is intended for use as a guide of a general nature only and may or may not be relevant to particular patients or circumstances. Nor is the Guide exhaustive of the subject matter. Persons implementing any recommendations contained in the Guide must exercise their own independent skill or judgement or seek appropriate professional advice relevant to their own particular circumstances when so doing. The statements or opinions that are expressed in the Guide reflect the views of the contributing authors and do not necessarily represent the views of the editors or Foundation House. Compliance with any recommendations cannot of itself guarantee discharge of the duty of care owed to patients and others coming into contact with the health professional and the premises from which the health professional operates.

Whilst the information is directed to health professionals possessing appropriate qualifications and skills in ascertaining and discharging their professional (including legal) duties, it is not to be regarded as clinical advice and, in particular, is no substitute for a full examination and consideration of medical history in reaching a diagnosis and treatment based on accepted clinical practices.

Accordingly, Foundation House and its employees and agents shall have no liability (including without limitation liability by reason of negligence) to any users of the information contained in the Guide for any loss or damage (consequential or otherwise), cost or expense incurred or arising by reason of any person using or relying on the information contained in the Guide and whether caused by reason of any error, negligent act, omission or misrepresentation in the information. Although every effort has been made to ensure that drug doses and other information are presented accurately in the Guide, the ultimate responsibility rests with the prescribing clinician. For detailed prescribing information or instructions on the use of any product described herein, please consult the prescribing information issued by the manufacturer.