Author Archive

Adolescents

Also see children

Key points

  • During adolescence, healthcare visits may be limited; the consultation goal should be to complete a thorough physical and psychosocial evaluation, with an emphasis on preventative care.
  • Adolescents should be seen alone at some point during (or soon after) the initial refugee health screening assessment.
  • Define confidentiality for the medical consultation and (separately) for working with interpreters.
  • Adolescents may have an incorrect date of birth recorded; this can have significant implications for assessing growth, development, learning or school/vocational placement.
  • Mental health problems may present in adolescence. Adolescents may make new meaning from past trauma, and present with mental health concerns in relation to early childhood trauma.

Consider sexual health, sexually transmitted infections (STIs, including hepatitis B), sexual violence, and female circumcision. A sensitive history is required, allowing adequate time. 

Overview

The World Health Organization defines adolescent as 10–19 years, youth as 15–24 years and young people as 10–24 years. Humanitarian populations include a high proportion of children and young people. In 2016, 28% of the Australian humanitarian intake was aged less than 12 years, and 23% were aged 12–24 years. Some refugee adolescents arrive as unaccompanied humanitarian minors; other adolescents of refugee-like background arrive under alternative visas (e.g. orphan relative) or as asylum seekers.  

Adolescent developmental issues include physical and cognitive transitions, emergent autonomy and independence, personal identity and body image, peer relationships and recreational goals, educational and vocational goals, and sexuality. Adolescence can be divided into three general stages of psychosocial development:

Early adolescence (10–14 years)  Late adolescence (15–19 years) Young adulthood (19–24 years)

Rapid growth and physical change, secondary sexual characteristics develop

Gender roles consolidate

Low resistance to peer influences

Low future orientation

Poor self regulation and increases in risk taking behaviour

Identity formation and new interests, including sexual relationships

Pubertal maturation

Growth rate decreases

Progression of intimate relationships

Development of executive and self-regulation skills

Greater future orientation and ability to assess consequences

Increasing autonomy and independence from family

Peak physical fitness and bone density

Further development of reasoning and self-regulation

Education and vocational goals important

Adoption of adult roles and responsibilities

Establishing the social, cultural, emotional, educational and economic resources to maintain health and wellbeing across the life course.

Rapid adoption and use of technology

Risks of injuries/transport injuries, communicable diseases, non-communicable diseases, mental health disorders, substance use, and maternal disorders, with variation between countries in risks and burden.

Adolescents of refugee-like background experience all these transitions in addition those of resettlement. They face balancing the values/expectations of their parents/cultural background with those of their new peers, while developing their own identity and learning a new language, in a new schooling system, in a new country. 

Approach to care

During adolescence, healthcare visits may be limited, and adolescents may seek care from a variety of providers. The goal should be to complete a thorough physical and psychosocial evaluation with an emphasis on preventative care. The initial refugee health assessment provides a starting point to introduce longer-term, developmentally appropriate care in the areas of physical, mental and sexual health.

When consulting with adolescents, helpful strategies include:

  • Seeing the adolescent alone at some point during (or soon after) the initial screening. assessment. This may be more acceptable to parents and adolescents if the health provider sees the family initially, and they are aware this will occur in the future.
  • Establishing confidentiality for the medical consultation (and also for the interpreter).
  • Taking a direct history from the adolescent.
  • Using clear language, open-ended questions, and a non-judgmental approach.
  • Allowing enough time.

HEADSSS screening can be used to assess adolescent psychosocial health:

H – home

E – education/employment (and eating)

A – activities

D – drug and alcohol use

S – sexual activity

S – suicide, depression, self-harm

S – safety from injury and violence

Considerations include:

  • Immigration Medical Examination (IME) for adolescents includes urinalysis (5 years and older), chest x-ray (11 years and older), HIV screening (15 years and older), and syphilis screening (15 years and older). Unaccompanied minors (all ages) also have screening for HIV and HBsAg; onshore protection visa applicants (15 years and older) also have screening for HBsAg and HCV.
  • IGRA testing is more reliable in adolescents for tuberculosis screening.
  • Catch-up vaccination and vaccine licensing varies with age. Adolescents will generally not need pneumococcal or Hib vaccines, they will need HPV vaccine, and the varicella vaccine schedule changes at 14 years.
  • Mental illness may present in adolescence. Adolescents may also make new meaning from past trauma, and present with mental health concerns arising from early childhood trauma.
  • Sexual health is an important area that is often neglected. Many refugee-background young people have low sexual health literacy, and limited opportunities to learn about sexual health. Consider STIs (including hepatitis B), sexual violence, and female circumcision.
  • Family structures and parenting roles may change with migration, affecting settlement and leading to ‘role reversal’, with adolescents having increased responsibility, or taking on parenting roles.
  • Prior schooling may have been limited or interrupted, with implications for educational placement in Australia. Evidence shows refugee young people have similar education outcomes to their native-born peers – ensure a proactive approach and early paediatric review for learning problems.
  • Adolescents may have an incorrect birthdate recorded; this is important to consider when assessing growth, development, learning, or school/vocational placement.
  • It takes many years to learn English as an additional language for academic purposes – explaining this is important, and a way to explore schooling and risk/resilience factors.
  • Seek early paediatric review for complex adolescent health issues, including physical health, learning/behavioural concerns, disability, and age assessment. Paediatric review may also help facilitate access to (and acceptance of) mental health services.

Links

ASID/RHeANA guidelines: Recommendations for Comprehensive Post-Arrival Health Assessment for people from Refugee-like backgrounds (2016 edition)  

The Lancet – adolescent health   

Raising Children Network (focus is 0-15 years) 

Better Health Channel  

Headspace 

RCH Immigrant Health Service website

Communication and interpreters

Overview

The majority of newly arrived people from refugee backgrounds do not speak English or do not speak English well,1 yet research shows that credentialed, professional interpreters are only engaged for a small percentage of consultations in primary care.2

Healthcare providers have a professional obligation to understand their patients’ needs and patients have the right to fully understand the information provided by healthcare workers. For people who have low English proficiency, working with a credentialed interpreter is the best way to ensure this.

There are ethical, quality and safety issues associated with using family, friends, and non-credentialed staff who speak languages other than English to conduct clinical consultations. Such issues include:

  • no certainty of accuracy of medical information conveyed, nor of instructions, dosages or diagnosis
  • exposure to confidential information, or information of a sensitive or traumatic nature
  • placing undue stress on family relations
  • imposing excessive responsibility on children.

Failure to work with credentialed interpreters creates a significant risk of flawed communications, the consequences of which can include ineffective, time consuming or dangerous interventions3 and legal proceedings.4 Optimal communication reduces anxiety as well as facilitating consultation.

Confidentiality is part of a credentialed interpreter’s code of ethics, and the engagement of credentialed professional interpreters form part of the Royal Australian College of General Practitioners Standards for General Practice and the Nursing and Midwifery Board of Australia’s Code of Ethics for Nurses in Australia.5

Credentialing for interpreters and multilingual staff

The National Accreditation Authority for Translators and Interpreters (NAATI) provides credentialing for interpreters. However, credentialing is not available in all languages.6 New, emerging and small language groups may not have accreditation tests. Where credentialing is not available in the language required, healthcare providers should still utilise interpreters employed by the Translating and Interpreting Service (TIS National) or the health services contracted provider. Interpreters contracted by these services adhere to the Australian Institute of Interpreters and Translators (AUSIT) Code of Ethics.7

Code of Ethics and Code of Conduct

Communication of health information is a specialised skill. Multilingual staff who use their language skills while working in various roles in general practice, including doctors, should also have their credentials to communicate information in a language other than English assessed. ‘Bilingual staff who achieved their professional qualification in another language may not require language accreditation to practice their profession in that language.’8

Practices should develop a policy about what information may be communicated in languages other than English for multilingual staff. Some staff may be able to use their skills to communicate low-risk appointment time information. See Centre for Culture Ethnicity and Health, ‘Managing bilingual staff’.

TIS National free interpreting

Private medical practitioners, nurses and other practice staff are eligible to access free interpreting services through TIS National when providing Medicare rebateable services. Pharmacies can also access free interpreting through TIS National when providing medication under the Pharmaceutical Benefits Schedule (PBS). The Doctors’ Priority Line (1300 131 450) gives eligible doctors 24-hour priority access to TIS National phone interpreters.

For more information about TIS National free interpreting service, including how to register, and booking interpreters see TIS National, ‘Frequently Asked Questions’.

Community health services and hospitals

In a community health service or hospital, check existing booking procedures and interpreter access, as arrangements vary from service to service. Make sure all healthcare providers, including non-clinical staff, have access to telephone booking numbers and procedures.

Health literacy and alternate health beliefs

Effective communication requires more than language interpreting and translation. Be mindful that some concepts may not be familiar to a patient. Good communication requires healthcare providers to develop an understanding of the way the patient views the purpose of the consultation, their health condition and measures they take to stay well.

Practice tip: These questions may help healthcare providers assess their patients’ health literacy and develop shared management plans.9

‘What do you think caused this condition?’

‘Have you known people in the past who have had a similar condition?’

‘How did they stay well?’

‘People who have this condition in Australia have found __________ to be helpful, do you think this may help you?’

‘Based on our discussion today, what will you change at home to help manage your condition?’

Approach to care

Interpreter mediated consultations

  • Establish if the person has a preferred language, and has a preference for an interpreter of a particular ethnicity or gender. Do this in advance where possible, and note this information on patient files to assist with planning future consultations.
  • Endeavour to book the same interpreter, where possible, for appointments with the client. This will help promote rapport, trust, and continuity of care.
  • During the consultation:
  • Introduce yourself and your patient to the interpreter and briefly explain the nature of the consultation.
  • Choose seating arrangements that will allow direct communication with your patient. Face your patient and speak directly to them, rather than speaking to the interpreter.
  • Remind the patient, via the interpreter, of the interpreter’s code of ethics and confidentiality
  • Ideally the consultation room should be equipped with a hands-free speaker telephone or two handsets to allow for working with telephone interpreters.

All health services should be able to engage a professional interpreter when necessary, and should have procedures in place to identify when someone may require an interpreter.

For more information about developing policies and procedures to address the needs of patients with limited English proficiency see Centre for Culture, Ethnicity and Health, ‘Developing a comprehensive language services response’.

Practice tip: The Doctors’ Priority Line is available 24 hours a day, 7 days a week on 1300 131 450. This number will take you to the front of the TIS National queue. TIS is also available free of charge for pharmacists, but at the time of writing TIS services are not available free of charge for allied health staff delivering MBS rebateable services.

Practice tip: When a patient calls and is having trouble communicating, ask for their name, phone number and preferred language and tell them you will call them back with an interpreter, then call the TIS Doctors’ Priority Line on 1300 131 450. Once the interpreter has been engaged, ask the operator to call the person back on the number provided.

Practice tip: Translated health information and appointment reminder cards can be useful to ensure patient understanding of health issues, including diagnosis, treatment and management. However, consider a person’s literacy in their first language. It is always good to use multiple modes of communication: verbal, pictorial and written. See Resources.

Practice tip: Teach-Back is a way of checking a patient’s understanding of a medical issue, diagnosis, treatment plan or health education message. It involves asking a patient (or family member) to explain – in their own words – what they need to know or do to check that the person has understood what the healthcare provider has said.

Practice tip: Multilingual reception staff may be an asset to a practice, particularly if you have a staff member from a background similar to the community seen at the practice. This can assist with basic communication about appointment times and contact details, etc.

Practice tip: On all referrals made to other services, include a note that an interpreter is required and the patient’s preferred language (including dialect) and other languages that they speak. Similarly, include a place for ‘interpreter required’ and ‘language spoken’ to be noted on your practice’s referral form.

Considerations

  • A telephone interpreter may be preferred by your patient for confidentiality reasons, especially if they are from a small community or language group.
  • If your patient is concerned about confidentiality, you can withhold their name from the interpreting service, offer to call them by another name during the consultation, and/or request an interpreter from another state where possible.
  • Communication with patients from refugee backgrounds may also be affected by cultural differences and their experiences of torture or other traumatic events. See Approach to consultation and management.

Resources

References

  1. Department of Immigration and Border Protection. Settlement Reporting Facility. Australian Humanitarian Program Entrants 2012-2016 Calendar years, 2017.
  2. Bayram C, Ryan R, Harrison C, et al. Consultations conducted in languages other than English in Australian general practice. Australian family physician. 2016;45(1/2):9.
  3. Vanstone R SJ, Casey S, Maloney M, Duell-Piening P. Melbourne Promoting the Engagement of Interpreters in Victorian Health Services. Brunswick, Victoria: Victorian Foundation for Survivors of Torture (Foundation House); 2013.
  4. Bird S. Failure to use an interpreter. Australian Family Physician. 2010;39(4):241.
  5. Australia Nursing and Midwifery Board. Code of Ethics for Nurses in Australia: Australian Nursing and Midwifery Council, Australian College of Nursing; 2008.
  6. National Accreditation Authority for Translators and Interpreters (NAATI). Available Accreditation Tests: National Accreditation Authority for Translators and Interpreters (NAATI); 2017.
  7. Australian Institute of Interpreters and Translators (AUSIT). Ethics and conduct. 2018; ausit.org/AUSIT/About/Ethics___Conduct/AUSIT/About/Ethics_and_Conduct.aspx. Accessed 07/02, 2018.
  8. Department of Health and Human Services. Language services policy and guidelines. Victorian Government, 2017.
  9. Kleinman. Appendix 2: Kleinman’s Explanatory Model of Illness. In: Hark L, DeLisser H. Achieving Cultural Competency: Wiley-Blackwell; 2009.

Refugee patients in primary care

Key points

  • People from refugee backgrounds, including people seeking asylum, come from a diversity of backgrounds and experiences.
  • People from refugee backgrounds will have similar health concerns to their Australian-born counterparts, but may also have health issues specific to their country of origin and their migration and settlement experience.
  • People from refugee backgrounds have higher rates of long-term physical and psychological problems than other migrants, due in large part to their exposure to deprivation, persecution and human rights violations as well as post-migration stressors.
  • New arrivals from refugee backgrounds will typically be unfamiliar with Australian healthcare services systems and procedures, including the roles of general practice and other primary healthcare services, pharmacy, and hospital-based services.
  • An incremental, person-centred and trauma-informed approach is recommended for recovery and long-term care of people from refugee backgrounds.
  • General practice has a key role to play in undertaking post-arrival health assessments and providing ongoing care.
  • Refugee patients with complex needs may require assistance from other services. Primary care is ideally placed for managing referrals and coordinating multiple services.

Overview

Each year many thousands of people from refugee backgrounds settle in Australia from regions including the Middle East, Africa and South-East Asia, where they have endured conflict, persecution and dislocation from their homes, families and culture.

Reported prevalence of torture and war-related potentially traumatic experiences varies and is difficult to generalise across groups. A 2016 systematic review reported prevalence of torture ranged between 1–76% (median 27%) and that almost all participants across all studies had experienced war-related potentially traumatic experiences.1 This may include forced dislocation, prolonged political repression, refugee camp experiences and loss of, or separation from, family members in violent circumstances.

Many people from refugee backgrounds, including people seeking asylum, have higher rates of long-term physical and psychological problems than other migrants, due in large part to their pre-immigration experiences, which are compounded by post-migration factors. People from refugee backgrounds can experience barriers when accessing primary care and other services. These may be related to trauma symptoms associated with the refugee experience, language, culture, health system literacy, lack of appropriate services, socioeconomic disadvantage as well as policies that restrict eligibility to health and other services.2,3

Approach to care

Accessible primary care is ideally suited to providing an incremental, patient-directed approach to long-term care and recovery for refugee patients in Australia. Developing continuity of care for patients from refugee backgrounds can be promoted by a whole-of-practice approach with attention to trauma-informed care. See Whole-of-practice approaches, Approach to consultation and management.

Patients with complex needs may benefit from primary care with support from settlement, specialist refugee and medical services, mental health and trauma services. Primary care can play a valuable role in coordinating multiple services if these are required. See State and territory referrals.

Health assessments are useful for planning the care of all newly arrived people from refugee backgrounds, including people seeking asylum, even if they are not eligible for the MBS funded health assessment. They remain as useful principles for refugee patients who arrived some time ago, but are new to your care. See Refugee health assessment.

The time-based Medicare Benefits Schedule (MBS) items 701, 703, 705 and 707 can be used for the ‘Health Assessment for Refugees and other Humanitarian Entrants’. These MBS items enable GPs to undertake a complete history, examination, investigation, problem list and management plan for new arrivals, many of whom will not have had access to comprehensive health care for some years.

For information regarding eligibility for the MBS funded health assessment see the Department of Health Medicare Health Assessment Resource Kit.

Considerations

Many patients from refugee backgrounds may:

  • require a professional interpreter (accessible free of charge via the Translating and Interpreting Service National Doctors’ Priority Line on 1300 131 450). See Communication and interpreters for further information about working with interpreters.
  • not have undergone pre-departure screening or may have medical conditions that were not picked up prior to arrival in Australia
  • have physical and psychological effects associated with torture or other traumatic events
  • have spent extended periods in detention in Australia
  • be experiencing medical conditions that are uncommon in Australia
  • be struggling with the practical tasks of settling in Australia, particularly housing and financial problems
  • not know where to get assistance
  • require an approach to consultation and management that accommodates the impact of past trauma, prior experience of health care, cultural differences and the stresses of resettlement. See Approach to consultation and management.

Resources

For country background information:

References

  1. Sigvardsdotter E, Vaez M, Rydholm Hedman A-M, Saboonchi F. Prevalence of torture and other war-related traumatic events in forced migrants: A systematic review. Journal on Rehabilitation of Torture Victims and Prevention of Torture. 2016;26(2):41-73.
  2. Cheng I-H, Drillich A, Schattner P. Refugee experiences of general practice in countries of resettlement: a literature review. Br J Gen Pract. 2015;65(632):e171-e176.
  3. Li SS, Liddell BJ, Nickerson A. The relationship between post-migration stress and psychological disorders in refugees and asylum seekers. Current psychiatry reports. 2016;18(9):82.

Children

Also see adolescents

Key points

  • Around half of all humanitarian arrivals to Australia are aged less than 18 years, with a high proportion of young children.
  • Children who arrived as refugees or asylum seekers will have similar health problems to their Australian-born counterparts, but may also have health issues specific to their country of origin and migration experience.
  • Trauma affects development and family functioning, and interrupted schooling is common – children may need healthcare and support related to their developmental and learning needs.
  • Children may have an incorrect date of birth recorded on their migration paperwork, which is an important consideration when assessing growth, development, learning or school placement.
  • The initial refugee health assessment is a starting point to link children with other universal service systems, and introduce longer-term preventative healthcare.

Overview

The World Health Organization defines children as 0–17 years, adolescent as 10–19 years, youth as 15–24 years and young people as 10–24 years. Humanitarian populations include a high proportion of children and young people. In 2016, 28% of the Australian humanitarian intake was aged less than 12 years, and 23% were aged 12–24 years. Families are often large, and there may be many children within a family group. Some refugee children arrive as unaccompanied humanitarian minors; other children of refugee-like background arrive under alternative visas (e.g. orphan relative) or as asylum seekers.

Considerations in working with children include their developmental stage and ability to express themselves, different types and presentations of medical conditions, and providing healthcare through parents/carers. 

Approach to care

Early childhood is typically a period with multiple healthcare visits. The initial refugee health assessment provides a starting point to introduce longer-term preventative health care, for example, through catch-up immunisation, hearing and vision screening, dental referral, healthy eating advice and developmental surveillance. Additional supports for children are available through maternal and child health nursing, early childhood intervention, and the education system (through pre-schools and schools).

Children of refugee-like background will have similar health problems to their Australian counterparts (e.g. viral illnesses and injuries), but may also have health issues specific to their country of origin and migration experience.

Considerations

  • Immigration Medical Examination (IME) is limited for children less than 11 years compared to adolescents and adults. Screening includes urinalysis (5 years and older), interferon gamma release assay (IGRA) or tuberculin skin test (TST) (2–10 years), chest x-ray if clinically indicated, and HIV screening if risk factors are identified. 
 Unaccompanied minors (all ages) also have screening for HIV and HBsAg.
  • Screening tests differ – they may have lower sensitivity or may not be validated in younger age groups, and the interpretation of test results may vary with age.
  • Paediatric pathology specimen collection should be used to reduce the amount of blood drawn for screening tests.
  • Tuberculin skin test (TST) preferred for tuberculosis screening in children less than 5 years.
  • Catch-up vaccination and vaccine licensing varies with age. Children less than 5 years will need pneumococcal and Hib vaccines and additional doses of DTPa and IPV vaccines; hexavalent vaccine (DTPa-IPV-HBV-Hib) is licensed for use less than 10 years; MMR-V should not be used as the first dose less than 4 years.
  • Medication dosing varies with age and medications may not be licensed for use in children.
  • The impact of trauma and mental health problems may present differently in children. Consider functional impairment, developmental progress, attachment, behavioural and learning concerns, sleep issues and difficulties with attention/concentration, as well as mental health symptoms. Parent mental illness affects child wellbeing, and addressing both parent and child mental health is important.
  • Family structures and parenting roles may change with migration, affecting settlement and child development. Exploring these aspects offers an opportunity to assess risk and resilience factors for children and families.
  • Prior schooling may have been limited or interrupted, with implications for educational placement in Australia.
  • Children may have an incorrect birthdate recorded on their migration paperwork; this is important to consider when assessing growth, development, learning and school placement.
  • Link infants and children with the universal service system, which will also provide a safety net.
  • Seek early paediatric review for complex child health issues, including physical health, developmental/behavioural concerns, disability, and age assessment. Paediatric review may also help facilitate mental health services where needed.

Links

ASID/RHeANA Recommendations for Comprehensive Post-Arrival Health Assessment for people from Refugee-like backgrounds (2016 edition)  

RCH Center for Community Child Health 

Raising Children Network  

Better Health Channel 

Immigrant Health Service  

 

Tips for making referrals

Key points

  • Further investigations and specialist referrals may present significant additional challenges for people from refugee backgrounds, including people seeking asylum, who may require additional practical support.
  • Consider seeking the specialist’s advice about whether a referral is appropriate prior to making the referral.
  • Include information about the need for an interpreter and preferred language in referral to specialists and other health providers.
  • Refer to a public hospital or allied healthcare provider, request that specialists bulk bill.
  • Consider making the first appointment for the patient.
  • In rural and regional areas consider the potential for use of telemedicine to access specialist consultation and interpreting services.
  • Not all people seeking asylum have access to Medicare. For additional considerations when working with people seeking asylum, see Asylum Seekers.

Overview

  • Many patients from refugee backgrounds, including people seeking asylum, require extensive follow-up medical care due to their lack of prior access to quality health care.
  • Undertaking tests and attending specialist appointments can be time consuming and involve a great deal of organisational effort on behalf of the patient, particularly given their lack of familiarity with the health and public transport systems.

Approach to care

  • With the patient’s permission, brief other healthcare professionals involved in their care about their special needs – particularly their need for an interpreter, their preferred language and gender preferences for interpreters.
  • If a patient needs to attend a number of follow-up specialist appointments or an appointment at a major public hospital, provide as much information as possible. This may include those:
  • with complex health needs requiring multiple follow-up appointments
  • experiencing practical barriers to accessing care (e.g. transport, childcare)
  • whose trauma symptoms interfere with their capacity to arrange and attend appointments
  • who have little familiarity with Australian healthcare systems, including those coming from rural communities in developing countries
  • who require a clear explanation about the referral process and information about the time and location of appointments (even very basic information such as the fact that public hospital outpatient services are free to the client, can be helpful and relieve anxiety)
  • who provide consent to contact the specialist or hospital to make the appointment and brief them, by phone or in the accompanying referral letter, about the client’s history, circumstances and special needs.

Considerations

  • Long wait periods prior to, or following, treatment or surgery can be a source of stress to a traumatised client, and arrangements should be made to avoid these wherever possible.
  • The role of specialists and other health practitioners should be explained to the client, as many patients from refugee backgrounds are unfamiliar with the Australian healthcare system and the role of various health professionals.

Resources

For referral information for specific services in your state or territory see State and territory referrals.

Whole of practice approaches

Overview

An empathetic, person-centred, culturally responsive approach is highly valued by people from refugee backgrounds.1 It requires a whole-of-practice approach.

Consider the following at reception:

  • welcoming reception staff, bilingual if available
  • waiting spaces with information in local refugee community languages
  • clear signage about the availability of interpreters
  • flexible waiting spaces for children’s play as well as quiet areas.

Routine recording in practice systems should include:

  • interpreter required, including preferred language and gender preferences
  • country of birth, ethnicity and date or year of arrival
  • contact details of settlement worker/next of kin/supporting family members
  • preference of GP, including gender
  • updated contact details at each appointment.

The following should be considered when booking appointments:

  • long appointments
  • interpreters if needed
  • flexibility with appointment times
  • appointments with practice nurse availability, particularly when organising catch up vaccinations
  • an appropriate appointment reminder and recall system, such as text messages or in-language appointment reminders
  • a follow-up system for non-attenders
  • large consulting rooms to accommodate big families.

Clinicians should consider:

  • bulk billing
  • requesting previous health records if available
  • case conferences for patients with complex needs
  • coordinating care with refugee health nurses if available
  • Teach-Back Method of communicating.

Considerations

People from refugee backgrounds may be unfamiliar with Australian systems such as the need to make appointments, understanding prescriptions and repeat prescriptions, and referral to specialists.1 They may have conflicting settlement demands or be experiencing anxiety, sleep or memory problems, which may affect attendance and concentration.

Patients may be unfamiliar with the roles and qualifications of general practitioners (GPs) and other healthcare providers.

Resources

References

  1. Cheng I-H, Drillich A, Schattner P. Refugee experiences of general practice in countries of resettlement: a literature review. Br J Gen Pract. 2015;65(632):p171-p176.

Refugee health assessment

Overview

Offer a comprehensive post-arrival health assessment to every child, adolescent and adult from a refugee background who is new to your care, preferably within one month of arrival.

Always use person-centred care principles that consider the impact of past trauma. Use language and gender appropriate interpreters. See Approach to consultation and management, Communication and interpreters.

Key points

A refugee health assessment includes: migration history; a full medical history, including current concerns, developmental history in children and adolescents and psychosocial history; physical examination; investigations; and development of a management plan. For children and adolescents, history may be taken from a parent or carer where appropriate.

In some states and territories, post-arrival health assessments are provided by a specialised refugee health service. In primary care, refugee health assessments can be supported by refugee health nurses or practice nurses. Refugee health nurses provide specialised support and assistance for primary care clinicians and people from refugee backgrounds. For the contact details of your local refugee health nurse or refugee health service, see State and territory referrals.

Practice tip: The Health assessment for refugees and other humanitarian entrants’ is funded up to 1 year post arrival or visa grant date through the Medicare Benefits Schedule (MBS) (Items 701, 703, 705 and 707). The assessment can be completed over a number of consults. For eligible visas see ‘Health assessment for refugees and other humanitarian entrants’.

Practice tip: The Refugee Health Assessment template can be used to assist GPs and nurses to undertake a health assessment. 

Approach to refugee health assessment

When offering a health assessment, ensure the patient – including a parent/caregiver for children and adolescents – understands that the assessment is voluntary, and give clear explanations about the process. Be aware that screening for asymptomatic illness and disease prevention may be unfamiliar concepts for some people from refugee backgrounds.

Take a gradual approach to post-arrival health assessment, aiming to build rapport. Start with the patient’s current concerns. This is to determine if active disease is present and to develop a trusting relationship. This discussion can also help you determine the patient’s level of health literacy. Next, take a detailed medical and psychosocial history, and then perform a physical examination. The complete assessment should be conducted over several appointments. Potentially sensitive issues such as sexual health and mental health screening can be addressed after rapport has been established.

Practice tip: Explain that the health assessment and investigations are simply to ensure good health and will have no negative consequences for visa status.

Practice tip: Free translation of personal documents including medical documents and qualifications is available. The Free Translating Service provides translation into English of medical reports or vaccination certificates (in the form of an extract or summary) within the first 2 years of a patient’s eligible visa grant date. More information

The following section is derived from Recommendations for comprehensive post-arrival health assessment for people of refugee-like backgrounds(ASID/RHeaNA Recommendations) for use in primary care. 

History

Migration history

  • Country of birth, countries of transit and any time in detention centres
  • Current visa status

Medical history

Practice tip: Consider requesting a fee waiver for the transfer of previous health records from another practice.

  • Current health concerns
  • Past medical history, family history, medications, allergies
  • Determine which screening tests and vaccinations have been completed pre-migration and since arrival in Australia. For information about access to pre-departure health information through HAPlite. Note: the Immigration Medical Examination (IME) is more limited in children. See Children, Adolescents.
  • History of or contact with:
    • tuberculosis (TB), malaria, parasistic infections
    • hepatitis B Virus (HBV), hepatitis C Virus (HCV), human immunodeficiency virus (HIV)
    • sexually transmitted infections (STIs)
    • respiratory symptoms, gastrointestinal symptoms, systemic/localising symptoms
  • Immunisation history including:
    • written documentation pre and post arrival
    • Bacille Calmette Guerin (BCG) scar
    • natural infection such as HBV and varicella
    • previous vaccine reactions
  • Chronic non-communicable diseases and issues such as:
    • cardiovascular disease (CVD), diabetes, chronic obstructive pulmonary disease (COPD), thyroid
    • injuries, accidents and hospitalisations
    • hearing, vision and dental problems
    • other disabilities and adaptive function problems
  • Lifestyle/risk factors including:
    • Smoking, alcohol intake, substance use (including substances common in certain areas e.g. betel nut, sheesha, khat)
    • Risk factors for low vitamin D
    • Nutrition (food access, current nutritional status)

Additional considerations for specific patient groups and health concerns:

Child/adolescent health – the assessment should include all of the above (as appropriate) as well as growth, development, education history, perinatal and postnatal history. See Children, Adolescents.

Women’s health – the assessment should include all of the above, past and current pregnancies/births, contraception, breastfeeding, cervical and breast screening, female circumcision/traditional cutting, intimate partner violence

Sexual health (men, women and adolescents) – risk factors for acquiring an STI; contraception

Practice tip: Individuals may not want to disclose their sexual history, but should still be offered STI screening confidentially and sensitively. Some concepts may need to be explained, such as sexual intercourse, sexual contact, sexually transmitted infections and risk i.e. unprotected sex. Be aware and sensitive to a history of sexual violence/abuse at all ages and genders.

A useful approach may be:

‘People can get infections from having sex. Would you like testing for these infections?’

‘Sometimes people are forced to have sex. You do not have to tell me details, but if this has happened I think you should have testing. There is lots of help available when you are ready’

‘Anything we talk about is confidential and I cannot tell anyone, except if you or someone else might be at risk of serious harm. Interpreters are never allowed to tell anyone about consultations.’

Would you like to know more about your risk? Do you have any other questions about your sexual health?’

For more information about discussing sexual health and STIs with people from refugee backgrounds see Sexually Transmissible Infections. 

Psychosocial history

For the mental health and social and emotional wellbeing component of the assessment:

  • Consider the family and household composition (i.e. support network and safety in the home)
  • Assess settlement stressors – ask if the patient has any particular worries getting settled. Consider factors such as supports in Australia, housing difficulties, finances and current studies, separation from significant family members, past education and occupation and time spent in immigration detention
  • Observe appearance, affect and behaviour
  • Ask about sleep, appetite, energy, mood, anxiety symptoms, memory, concentration and relationships/family functioning
  • For children/adolescents, in addition to all of the above, ask about behaviour, schooling, nightmares and enuresis (bed wetting).

It is generally not advisable to ask directly about a person’s experience of torture or other traumatic events. However, the potential impacts on psychological health should be assessed.

Practice tip: A useful form of questioning might be: Terrible things have often happened to people who have been forced to leave their countries. I do not need to know the details about what you have been through, but have you had any experiences that might be affecting your health or how you are feeling now?

  • When mental health concerns are evident, consider further mental health assessment including suicide risk assessment
  • Continue to monitor for psychosocial problems as the presentation of these can often be delayed
  • Consider recall for rescreening after 6–12 months for those who visit your service less frequently

See Approach to consultation and management, Psychological effects of torture or other traumatic events.

Physical examination

  • Skin conditions, including hair and nails, BCG scar
  • Fever – exclude malaria
  • Ear, nose and throat (ENT) and dental examination – look particularly for middle ear disease and dental caries
  • Blood pressure (BP)
  • Body mass index (BMI), nutritional status – weight, height, waist/hip ratio* (adults), head circumference (children)
  • Pallor/murmur as a sign of anaemia – consider causes such as iron, B12 and folate deficiencies and lead toxicity among other causes
  • Signs of other micronutrient deficiencies – e.g. dry eyes (vitamin A), skin (zinc, vitamin C, other), gums (vitamin C), lips/tongue (B-group vitamins, including B12), hair/nails (zinc, other), goitre (iodine), teeth/rickets (vitamin D)
  • Cervical, axillary and inguinal lymphadenopathy – consider TB and HIV
  • Cardiorespiratory exam – consider TB, COPD, murmurs, CVD
  • Hepatosplenomegaly – consider chronic malaria, chronic liver disease including HBV, schistosomiasis, TB, HIV
  • Evidence of torture or other injuries
  • Neurology – consider gait, tone, power, reflexes and coordination
  • Visual acuity – all ages. For African people >40 years and others >50 years, refer to optometry for a glaucoma check

*Note there may be different normal values for different ethnic groups

Investigations

Screening investigations for conditions of high prevalence should be offered to all new patients according to their individualised risk as recommended by ASID & RHeaNA1,2 and the RACGP(see Table 1^) if not previously completed.

Make sure that you have informed consent for all investigations and that you offer STI screening confidentially.4

The ASID/RHeaNA recommendations for commencing risk assessment of diabetes and CVD are earlier than those given by the RACGP in the Guidelines for preventative activities in general practice,3 and so have been included in Table 1. Complete all other recommended screenings as per the RACGP Guidelines. See Table 4 for further screening and management links.

Additional investigations are determined by presenting symptoms.

Table 1: Recommended initial screening investigations for people from refugee backgrounds1-3

*ASID/RHeaNA panel did not reach consensus on these recommendations.

**Do not delay pathology if fasting tests are difficult to organise.

FBE – full blood examination, HBsAg – hepatitis B surface antigen, HBsAb – hepatitis B surface antibody, HBcAb – hepatitis B core, MBS – Medical Benefits Schedule, HIV – human immunodeficiency virus, IME – Immigration Medical Examination, TB – tuberculosis, TST – tuberculin skin test, IGRA – interferon gamma release assay, IgG – immunoglobulin G, HbA1c – glycosylated haemoglobin, CVD – cardiovascular disease, Ca – calcium, PO4 – phosphate, ALP – alkaline phosphatase, STI – sexually transmitted infections, PCR – polymerase chain reaction, OCP – ova, cysts, parasites, RDT – rapid diagnostic testing, Ab – antibody, HCV – hepatitis C virus, RNA – ribonucleic acid

^Table 1 does not appear in this format in the ASID/RHeaNA Recommendations. Table 1 has been oriented towards the primary care setting and relies heavily on the ASID/RHeaNA Recommendations.

Practitioners should check with their local refugee health or infectious disease services if they have concerns about which tests to include. See State and territory referrals.

Practice tip: Add recommended investigations, according to the countries of origin/transit commonly seen in your practice and other risks, to your pathology favourites in your computer software list.  A summary table of country-based risk can also be printed. See ASID/RHeaNA country specific recommendations for malaria, schistosomiasis and hepatitis C screening.

Practice tip: Under Medicare, there is an upper limit on the number of pathology services payable in a single episode requested by a GP. This is referred to as coning. If more than three items are requested, MBS will only pay for the three most expensive items. This may impact on the ability of some GPs to undertake post-arrival refugee screening. It is recommended individual GPs discuss this issue with their local pathology provider.

Management plan and referral

  • Ensure all investigation results are discussed and their significance explained.

Practice tip: Provide opportunities for the patient to ask questions or seek clarification about results and management. Some patients will have come from cultures where this is not encouraged.

  • After review of the history, examination and investigations, formulate a problem list. This may include:
    • Clinical findings e.g. diagnoses, undiagnosed symptoms, positive test results
    • Catch-up immunisation (all patients should be offered catch-up vaccines to the equivalent Australian age)
    • Psychological and/or developmental concerns
    • Settlement concerns
    • Preventative health – complete screening as per RACGP Guidelines (see Table 4). Note that some investigations may be unfamiliar to people from refugee backgrounds and therefore require additional time for informed consent. Chronic disease risk factor management should be considered
  • Provide a management plan for each problem, including referrals if required

Practice tip: Provide education about eHealth record. As people frequently move in the early settlement period, offer a patient-held record of the completed health assessment and vaccinations.

Practice tip: Commence immunisation catch-up and register all vaccines (including offshore vaccines) on the Australian Immunisation Register (AIR) as soon as possible to avoid Centrelink implications (reduced family benefit payments). Once the first set of catch-up vaccines are on AIR, payments will be optimised and remain at this rate if catch-up is continued and completed.

Table 2: Management of infectious conditions1,2

*FBE is also performed as an investigation for anaemia. This is listed in Table 3.

**Notifiable disease.

FBE – full blood examination, HBsAg – hepatitis B surface antigen, HBsAb – hepatitis B surface antibody, HBcAb – hepatitis B core, TB – tuberculosis, TST – tuberculin skin test, IGRA – interferon gamma release assay, CXR – chest X-ray, LTBI – latent tuberculous infection, HIV – human immunodeficiency virus, PCR – polymerase chain reaction, IMI – intramuscular injection, NAAT – nucleic acid amplification test, ID – infectious disease, Ag – antigen, TG – Therapeutic Guidelines, LFTs – liver function tests, RDT – rapid diagnostic test, HCV  – hepatitis C, RNA – ribonucleic acid

Table 3: Management of non-infectious conditions1,2

FBE – full blood examination, Hb – haemoglobin, Ca – calcium, PO4 – phosphate, ALP – alkaline phosphatase, IM – intramuscular

Table 4: Useful links for further screening and management

IgG – immunoglobulin G, ASID/RHeaNA – Australian Society for Infectious Diseases/Refugee Health Network of Australia, RACGP – Royal Australian College of General Practitioners, FGM/C – female genital mutilation/cutting, CVD – cardiovascular disease, COPD – chronic obstructive pulmonary disease, CKD – chronic kidney disease, ENT – ear, nose and throat, NDIS – National Disability Insurance Scheme, MCH –  Maternal and Child Health

Considerations

  • Consider other Medicare item numbers when planning further appointments with patients, e.g. care plans, case conferences, and mental health items

Resources

References

  1. Chaves NJ, Paxton G, Biggs BA, Thambiran A, Smith M, Williams J, Gardiner J, Davis JS. Recommendations for comprehensive post-arrival health assessment for people from refugee-like backgrounds: Australasian Society for Infectious Diseases and Refugee Health Network of Australia; 2016.
  2. Chaves NJ, Paxton GA, Biggs BA, et al. The Australasian Society for Infectious Diseases and Refugee Health Network of Australia recommendations for health assessment for people from refugee-like backgrounds: an abridged outline. The Medical Journal of Australia. 2017;206(7):310-315.
  3. Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice. 9 ed. East Melbourne: RACGP; 2016.
  4. Australasian Sexual Health Alliance. Australian STI Management Guidelines for use in primary care. 2016; www.stiguidelines.org.au.
  5. Gastrointestinal Expert Group. Gastrointestinal. Therapeutic Guidelines. Melbourne: Therapeutic Guidelines Limited; 2016.

Prescribing tips

Overview

  • Taking medications correctly requires the use of effective communication techniques to reduce non-adherence, adverse events or failure to take medication as prescribed. Failure to do this increases the risk of medication errors.1
  • Many people from refugee backgrounds, including people seeking asylum, come from areas where pharmaceuticals are poorly regulated and understood.

Approach to care

It is important that the person understands how, why, and when to take the prescribed medication. This can be achieved by:

  • Working with professional interpreting services when necessary.1 See Communication and interpreters.
  • Providing translated material where possible. Note that translated material may not be readily available in all languages, particularly for newly arrived or small communities or language groups.
  • Asking the interpreter to write instructions in the patient’s language.
  • Using diagrams rather than written words; available through online tools such as EASIDOSE and/or images of medications on MIMS on line.
  • Using health literacy principles that confirm the patient’s understanding of how to obtain and use medications correctly in an Australian context. This can be done by another member of the health team, such as the practice nurse.1
  • Explaining the need for long-term prescriptions and the concept of ‘repeat prescriptions’, which may be unfamiliar.
  • Requesting that pharmacists use phone interpreters by specifying this on scripts. For information about fee-free interpreting see Communication and interpreters.
  • Confirming the adherence to medications prescribed; this can mean needing to re-prescribe medicines.

Person-centred prescribing requires understanding about cultural practices and beliefs, values and previous experiences with medications to assess possible impacts on taking medications correctly. For example, people in refugee camps may be used to sharing medicine, and/or not taking the correct dosage because the medicine will last longer and therefore cost is reduced. Education about correct use will need to incorporate the person’s individual needs for information.

Considerations

  • Take into account a patient’s cultural or religious practices. For example, patients of Muslim faith may require halal medications.
  • PBS-listed drug and generic brands are preferable because of their lower cost.1 Consider affordability of medications, including making arrangements for asylum seekers who do not have access to Medicare/concession cards.
  • Some people use herbal or traditional medicines that have the potential to interact with prescribed medicines. Always ask about the use of other traditional and non-prescription medicines.
  • As people move to other areas, especially in the early stages of settlement, it is helpful to supply a list of current medications.
  • A Home Medicines Review for Medicare card holders at risk of medication errors may promote better understanding of medications. See Home Medicines Review.

References

  1. Kay M, Wijayanayaka S, Cook H, Hollingworth S. Understanding quality use of medicines in refugee communities in Australian primary care: a qualitative study. Br J Gen Pract. 2016;66(647):e397-e409.

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.