GPs play a critical role in ensuring refugees have access to patient-centred and culturally receptive health care.
Kathy Skantzos reports
For the thousands of refugees and humanitarian entrants who enter Australia each year, there are many health issues they may be experiencing, ranging from physical to psychological and emotional.
Recent statistics show that up until this year, 950,000 refugee and humanitarian entrants have arrived in Australia since World War II and most recently they have come from war-torn or poverty-stricken communities in countries including Afghanistan, Iran, Syria, Myanmar, Ukraine, South Sudan, Venezuela and Guatemala.
Many refugees have experienced the trauma of war, conflict, poverty, economic crisis, food insecurity, family or community separation or isolation, political unrest, persecution or torture. As a result, refugees are likely to be at higher risk of psychological disorders including depression, anxiety and post-traumatic stress disorder (PTSD).
There is also higher prevalence of unmanaged chronic health conditions, noncommunicable diseases, infectious diseases, under-immunisation, poor dental and optical health and higher rates of nutritional deficiencies among refugees.
A safe space
According to the RACGP, culturally sensitive and accessible health care that’s conscious of refugee and migrant challenges is critical for their wellbeing and safety.
Health literacy can be low among refugees, who may have had limited access to stable health care or education. Given their circumstances and diverse cultural backgrounds, refugees may have altered perceptions of abuse, trauma, nutrition, reproductive health, sexual health, chronic disease and immunisation.
Research indicates that refugees may be reluctant to share mental or physical health concerns with medical professionals for cultural or personal reasons or associated stigma.
RACGP WA chair Dr Ramya Raman says care and sensitivity is required when assessing the health of refugees, particularly with trauma-related health concerns such as domestic violence, sexual violence and PTSD.
“Dealing with health issues with these patients requires very careful inquiry and it needs to be culturally sensitive,” Dr Raman tells Medical Forum.
“It’s about understanding their cultural background, and Eastern cultural values will be very different to Western. As a treating doctor or GP, what we may recognise as a potential concern may not be a concern for the patient and we have to find a common ground.”
While GPs can reach out to the refugee health unit at their local hospital, or units within the tertiary hospitals, as well as at Perth Children’s Hospital for paediatric care, there are resources and support services at arm’s length to guide doctors through patient assessments.
HealthPathways guide
HealthPathways WA is a comprehensive resource providing guidance for clinicians to assess and manage refugee patient health through a range of primary, community and acute health assessment pathways.
Refugees and humanitarian entrants who have arrived in Australia within the past 12 months are eligible for an MBS refugee health assessment for their physical, psychological and social functioning, and whether preventive health care and education should be offered to improve their health.
RACGP’s refugee health assessment template is a useful tool to help GPs complete the MBS refugee health assessment, while also being a helpful general resource to assess the health of refugee children, adolescents and adults.
Translation and interpreting services are also available.
“Doctors should not hesitate to use an interpreter, whether face-to-face or over the phone to ensure the consultations are robust,” Dr Raman says.
While it may be convenient for a patient’s family or children to interpret for them, it is advised to use an interpreter where possible due to confidentiality in medical assessments and to take the responsibility off family members.
Support for children
Refugee children, teenagers and their primary carers can be referred to CAHS’ refugee health service (RHS), while the Humanitarian Entrant Health Service (HEHS) can link patients with community GPs.
It also provides a holistic health assessment service for refugees and humanitarian entrants who are resettled in WA under the Australian Government’s Humanitarian Program and Special Humanitarian Program.
CAHS RHS is based with WA’s community Refugee Health Team, working alongside a multidisciplinary team of medical specialists, nurses, dietitians, social workers, clinical psychologists, dentists and special needs educators at PCH, assisted by professional interpreters.
The Refugee Health Team helps young refugees and their families, who have limited English language skills, transition to mainstream health services. Patients are assessed using a family-centred, evidence-based, culturally appropriate and trauma-informed approach, incorporating a review of medical, neurodevelopmental, educational, psychological and socio-economic domains.
Preventative health for both women and men should be prioritised to prevent risk factors, such as cardiovascular disease and diabetes, while undermanaged chronic health conditions should be screened for.
GPs should also screen for cancers, such as bowel and breast cancers, and consider the patient’s family history of any other conditions and chronic diseases.
“Certain ethnic populations are at a higher risk of developing diabetes and cardiovascular risk factors and heart disease, so it needs to be addressed,” Dr Raman says.
“Also, nutritional concerns and dietary deficiencies can be present, depending on where the patients are from. In certain populations we see conditions like rickets and poor bone health in kids.”
It is common to see nutritional deficiencies such as vitamin B, vitamin D, calcium and iron. Gastrointestinal symptoms can often be present as well.
“We often check for helicobacter pylori. Certain groups of patients are at a higher risk because it is endemic in some regions, so it’s important to test and look out for symptoms,” she says.
“A lot of children and some older patients tend to complain about abdominal discomfort, so we need to think about constipation and the underlying cause of that.”
Infectious diseases, such as STIs, hepatitis B and C, HIV, syphilis, and tuberculosis, are also common.
“It’s important to think through considerations for tuberculosis and taking sexual health history and screening, of course with consent,” Dr Raman says.
Testing for parasitic infections such as malaria should also be considered, depending on the patient’s geographical risk.
Dental care, eye health, and foot care are all important to monitor as well, to ensure healthy teeth, eyes and feet, and reduce associated risks, since visual, dental and audiological issues are common and undertreated in refugee populations.
Trauma issues
Mental health and psychological distress can often be present as Dr Raman says they have most likely gone through a very traumatic time. However, there is often stigma and altered perceptions about mental health within refugee communities.
“The incidence of PTSD of survivors of torture and trauma is quite high, so it is important to think through the implications of stigma around mental illness in certain cultural communities. It’s important that it is addressed and in a sensitive matter,” Dr Raman says.
Psychological and mental health screening spans all the way from the paediatric population to the geriatric population, no matter where they are in their stage of life.
GPs can refer patients to Association for Services to Torture and Trauma Survivors (ASeTTS), a specialised service providing holistic care and counselling for survivors of torture and trauma.
A key area for GPs to be aware of and screen for with a high degree of sensitivity is domestic violence.
“Patients from migrant and refugee backgrounds can be hesitant to disclose some of the experiences of family abuse and violence,” Dr Raman says. “That could be due to cultural reasons, and it also depends on who’s at home with them, and whether they consider what is happening to be a type of family domestic violence.
“Because of their level of health literacy, they may not even realise that is what’s going on.”
Whitebook
Dr Raman points to the RACGP White Book 5th edition chapter on ‘Working with migrants and refugee communities’ to help guide clinicians to provide a safe pathway for migrants and refugees who are experiencing family or domestic violence in the home.
“It provides important and practical information for GPs and specialists in terms of managing patients from culturally and diverse backgrounds, specifically screening for possibility of domestic violence,” Dr Raman says.
“It’s been shown that it’s mostly women who have been affected from domestic violence. When we think about family domestic violence there’s physical abuse, sexual abuse, emotional abuse, and financial abuse, and there are concerns around children,” she says.
“Some people of migrant and refugee backgrounds may be quite hesitant to disclose their experiences of family abuse and domestic violence due to cultural differences or potentially language or level of health literacy.”
GPs should also consult women on their sexual and reproductive health and give them options for contraception, while being culturally sensitive of their choices.
Gynaecological issues are typically underreported in women, and female genital cutting/mutilation (FGC/M) is still prevalent in many countries of origin. The HealthPathways WA Female Genital Cutting / Mutilation (FGC/M) Pathway is available for clinical guidance.
ECU Professor Loretta Baldassar, lead researcher of BEFRIENDING with GENIE, a government-funded research project to increase social support and service access for people living with dementia and caregivers from culturally and linguistically diverse communities, says dementia is a key issue for migrant Australians, with one in three people currently living with dementia in Australia born overseas.
“People from migrant backgrounds living with dementia, and their caregivers, often have less knowledge about, access to, and uptake of medical and health services, including prevention activities that support their social interaction,” Professor Baldassar says.
“This can put them at increased risk of significantly reduced social connection and isolation, which in turn increases their risk of disease and mortality.
“Family caregivers from migrant backgrounds often have the additional care burden of managing English language and other cultural barriers to service access for themselves and their loved ones,” she adds.
Dr Raman points to the ‘Multiculturalism in aged care’ chapter in the RACGP aged care clinical guide, also known as the Silver Book, which explains that many older people from refugee backgrounds have had poor or no prior access to health care before arriving in Australia. Undiagnosed and undertreated chronic illnesses are common, such as diabetes, hypertension, osteoarthritis, chronic obstructive pulmonary disease.
High rates of PTSD are seen in those who have experienced war, imprisonment, torture and dislocation, including older refugees. However, stigma surrounding mental illness in many refugee communities may strongly affect an elderly person’s engagement with assessment and treatment, according to the Silver Book.
Health professionals should also consider social isolation among older migrants with the transition from rural, village life with close-knit communities and large families often living under one roof where elders played a central role, to a drastic social change when living in Australia.
Dr Raman says that taking time with people is key.
“The benefits of being a GP is you don’t just see that patient that single time for a single issue, you get to learn about that patient over time, whether it’s physical, mental health, their social circumstances and helping them through that, and in addition we end up seeing their family members as well,” Dr Raman says.
“It’s important to keep in mind that cultural, religion and settlement experiences influence perceptions of health care, and working together with an open mind and knowing about the services that you can call on for help if you need it.”