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 Transmissable 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.

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The Australian Refugee Health Practice Guide received funding from the Australian Government.

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.