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.
All permanent migrants to Australia, including migrants who enter through the offshore Humanitarian Programme, have a pre-migration Immigration Medical Examination (IME) within 3–12 months of departure. The IME includes:17,18
Full medical history and
Chest x-ray (CXR) in those aged 11 years and older (and in younger children if indicated).
Interferon gamma release assay (IGRA) or tuberculin skin test (TST) in children 2–10 years (if they: are applying for a Humanitarian or onshore protection visa, OR from a high tuberculosis (TB) prevalence country, OR declare previous household contact), with further investigation for TB if positive (starting in 2016).
Urinalysis in those 5 years and older (and in younger children if indicated).
Human immunodeficiency virus (HIV) testing in those 15 years and older (and in younger children if indicated), all unaccompanied humanitarian minors, or where hepatitis C virus (HCV) infection is
Hepatitis B surface antigen (HBsAg) in pregnant women, unaccompanied minors; those aged 15 years and over and intending to study or work as a doctor, dentist, nurse or paramedic; and those aged 15 years and over applying for an onshore protection
Hepatitis C antibody tests in those aged 15 years and over and intending to study or work as a doctor, dentist, nurse or paramedic; or applying for an onshore protection
Syphilis testing in those aged 15 years and older and applying for either an onshore or offshore protection
Other tests as clinically
Humanitarian entrants are also offered voluntary pre-Departure Health Checks (DHC) within 72 hours of their intended departure for Australia. Not all humanitarian entrants undergo a DHC, as it depends on the visa subtype and port of embarkation. The DHC includes:19 20
A physical
Malaria rapid diagnostic testing (RDT) on blood, and treatment if positive, generally with three days of oral artemether/lumefantrine (based on location).
Empirical treatment for intestinal helminths with a single dose of albendazole in all those aged 12 months and older (unless pregnant).
CXR in those with a history of TB or latent TB infection (LTBI) or clinical suspicion of active
Measles, mumps, and rubella (MMR) vaccination in those aged 9 months to 54 years (unless pregnant).
Yellow fever (YF) vaccine where relevant (based on location).
Polio vaccination where relevant (based on location).
Extended screening will be implemented for the Syrian cohorts, with additional review of mental health and additional immunisations (MMR, polio vaccination and diphtheria-tetanus-pertussis vaccination – in the form of hexavalent or pentavalent vaccine in children <10 years – check available paperwork).
People seeking asylum who arrive by boat generally receive a health assessment on arrival in immigration detention. The detention health services provider completes this assessment. There is no published information on the format of detention health screening; however, assessment appears to have included: CXR in those 11 years and older, and screening bloods in those aged 15 years and older (screening for syphilis, hepatitis B (HBV), HCV and HIV; and screening with full blood examination (FBE), liver function test (LFT), blood sugar level (BSL) testing, urinalysis and pregnancy testing where clinically indicated). Prior to mid-2014, children had very limited detention health screening. After this time they had health assessments similar to adolescents and adults, with the addition of ferritin, vitamin D levels, strongyloides serology, and malaria testing and schistosoma serology where clinically indicated. Clinical experience suggests the management of health conditions detected on the detention health assessments varied depending on access to healthcare in detention, or may have been deferred while awaiting transfer to community-based arrangements.
Asylum seekers arriving by plane may not have had any health screening or healthcare in Australia and will not have had a pre-departure IME.
We recommend a full health assessment be offered to all newly arrived people from refugee-like backgrounds as soon as practical after arriving in Australia (ideally within one month) to ensure early and proactive intervention.
While these recommendations are based on expert opinion and clinical evidence, screening and management of certain conditions may vary depending on particular jurisdiction requirements.
Offering newly arrived individuals a full health assessment is a positive step towards optimising health, and addresses health inequity through the provision of ‘catch up’ immunisation, as well as diagnosis and treatment of unmanaged chronic conditions.
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
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)
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.
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.
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.
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 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.
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 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.
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.
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.
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.
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 developGender 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 maturationGrowth 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 densityFurther 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.
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.
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.
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.
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.
