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Clinical guidelines

Abuse and violenceWorking with our patients in general practice

Chapter 12. Migrant and refugee communities

Key messages

  • Avoid making assumptions about a patient’s cultural beliefs. Speak to the patient as an individual while still acknowledging that their cultural background may inform their personal beliefs and expectations
  • Health practitioners need to reflect upon their personal belief systems so that they can recognise how these beliefs impact upon their consultations with others
  • Patients from migrant and refugee backgrounds who are experiencing violence may be disadvantaged by a lack of knowledge about their rights, lack of good support systems, and their social isolation.297 Patients may be experiencing abuse by multiple people, including in-laws and intimate partners298,299

Recommendations

  • In working with patients from migrant and refugee backgrounds, remember that they are likely to have similar symptoms to other victims of family violence.300 However consider that this may be in addition to trauma experienced in their country of origin, refugee camps and in transit Practice point
  • Practices need to put systems in place to ensure care is delivered in a culturally sensitive manner300 Practice point
  • Assistance and support offered in a culturally sensitive manner to migrant and refugee women helps to empower women to make positive changes in their lives. Ideally these services should be language concordant301 Practice point

Introduction

In Australia, a country rich in cultural diversity, approximately one in four people is a first generation migrant, and 60% of Australian migrants come from non-English speaking backgrounds.302 Many medical practitioners, including GPs, have a migrant or refugee background.

The measure of cultural identity may not be a spoken language, religion and/or place of birth. Cultural identity is complex and is often entangled with gender, class, socioeconomic status and other factors. The indefinable nature of culture means it is important to be aware of the potential for cultural misunderstanding in every day practice. Yet it is also important to avoid making assumptions about the individual. A person’s health beliefs and values are informed by a mix of cultural understandings, personal experiences and knowledge. Because of this, different individuals from the same culture may have very different expectations and understandings when seeking care from a GP.

Not all members of a gender, family or culture will hold the same values. The individual patient who is presenting to the doctor may be able to assist the doctor with how their cultural beliefs influence their gender roles, family roles and what constitutes abuse and violence, as well as how willing they are to disclose their concerns. However, the shame and stigma of the issue, wider family pressures, fears of ostracism or deportation297 and ignorance of the law and supports in the Australian system are powerful barriers to disclosure. GPs should be mindful of these issues.

Importantly, not only do patients bring culturally influenced values, beliefs and behaviours to clinical practice, so do GPs.114 It is necessary for GPs to identify and confront their own belief systems and values to understand how these impact upon their clinical decision making. Just as GPs develop clinical skills, they must also develop their cultural competence and sensitivity. GPs must examine their own attitudes about abuse and violence in their own and other cultures.

Prevalence

The 2011 census302 found, within the Australian population, that:

  • 27% were first generation migrants
  • 33% of migrants came from South-East Asia
  • 49% of longer-standing migrants and 67% of recent arrivals spoke a language other than English at home
  • religious affiliations were: 68% Christian, 2.5% Buddhist, 2.2% Muslim, 1.3% Hindu, 0.5% Jewish and 22.3% no religion.

Family, especially intimate partner, violence is prevalent in the home countries of migrant and refugee communities seeking a new life in Australia.303 In the Asia-Pacific region, estimates of the prevalence of women assaulted by a partner in the previous 12 months vary from 3% or less among women in Australia to 19% of currently married Bangladeshi women.9 The global estimate for intimate partner violence using the Global Burden of Disease (GBD) shows that the lifetime prevalence rate in South Asia is 41.7%.3 Intimate partner violence is more common in countries where war or other conflict or social upheaval has recently taken place. Population studies in their own countries have estimated that approximately one in three Vietnamese or Indian women report ever experiencing physical or sexual violence,304,305 and 8.5% of Vietnamese women reported abuse in the previous 12 months.

The few studies that exist in diaspora countries have found similar rates to those in the home country.298,306,307 Newer migrant communities often represent significant proportions of families with young children, and this can be a time of greater risk of violence. Women from migrant backgrounds can be over-represented in crisis services and murder statistics.40 Drug abuse, gambling and alcohol misuse are also associated with violence perpetration in migrant and refugee communities, as they are in other communities.308,105

The role of GPs

Cultural sensitivity

It is important to remember that the health effects of violence are very consistent across countries and cultures.309 However cultural taboos may surround the issue of violence in families and this may make it difficult for patients to disclose without additional encouragement, support and sensitivity. The building of a trusting therapeutic relationship is essential to facilitate this disclosure. Cultural sensitivity, but more importantly, non-judgemental and supportive practice (refer to Chapter 2) will make it ‘culturally safe’ for victims to find the appropriate moment to speak about their concerns with a GP. Consider training reception, nurse or other clinic staff so that they are culturally sensitive and act as a bridge to the community. Some practices in particular locations may employ bilingual reception and clinical staff.

Ensuring culturally sensitive care may also include:300

  • booking and using an interpreter that is not a family member (refer to Resources)
  • allowing time to establish rapport and trust
  • explaining and emphasising doctor–patient confidentiality, patient consent, choice and control
  • understanding that confidentiality and consent issues vary dramatically in different cultures, with some cultures understanding consent as a community issue not an individual issue
  • explaining procedures and being prepared to repeat information
  • providing opportunities for the patient to ask questions or seek clarification – some will have come from other cultures in which this was not encouraged
  • explaining why you are asking certain questions
  • considering gender issues – for example, male GPs may consider referring female patients to a female GP
  • establishing if there are any cultural or religious factors that need to be accommodated
  • taking into account a patient’s cultural or religious practices – for example, considering the need for halal medications for patients of Muslim faiths and issues related to times of fasting.

Assistance and support offered to migrant and refugee women that is culturally appropriate and if possible, in their own language, is extremely important in empowering women to feel that they can make changes in their lives.301 Many larger states have services specifically for migrant and refugee women that offer direct service support to women experiencing violence. Some also have links with ethno-specific men’s behaviour change programs (refer to Resources).

The ethnicity of a GP and its congruence with the practice population may impact upon the clinical consultation. GPs of a similar culture and/or ethnic background may be more aware of health disparities experienced by the community – for example, access to services. A GP who belongs to the same cultural group may understand how to address the issues of abuse more effectively within a culture, offering helpful and relevant advice, often with significant cultural authority. Conversely, a GP of a similar background to the patient may overlook the possible presence of abuse or violence or may minimise its significance or accept it as a cultural normal, rather than engage with the definition accepted by mainstream society.

Presentations in general practice

Victim presentation or symptoms and health effects do not differ across cultures. These issues have been presented in Chapter 2 and Chapter 6. WHO guidelines for GPs should guide your approach in the identification of intimate partner abuse.3

Because of the possible normalisation of abusive behaviours and cultural taboos in many migrant and refugee communities, GPs need to modify their language to speak about it. For example, the most common symptoms related to abuse, such as depression, trauma or anxiety310 are often associated with significant stigma in different communities. In some countries, there is no word equivalent to depression in the language. Symptoms are often somaticised and this can lead to over-investigation of the patient who is experiencing the effects of abuse. Careful discussion, description and recognition of the patient’s attribution of the symptoms is essential when disentangling these concepts where there is a cultural divide.

Some patients from culturally and linguistically diverse backgrounds may have their experience of abuse complicated by other issues that may add further complexity to their experience:

  • Victims may be experiencing abuse from other family members – for example, their in-laws (mother, father or brother-in-law).298,299 Questioning should elicit the full spectrum of abuse being perpetrated in the family and not only focus on intimate partner abuse.
  • Children from refugee backgrounds may have witnessed or experienced serious violence prior to their arrival, and continuing violence within the home can add to the pre-migration trauma experiences and the acculturative stress issues.
  • For younger women, especially students and migrant workers on limited visas, fears about immigration status may affect their comfort to disclose.
  • If the patient is in an abusive gay or lesbian relationship, fears about confidentiality and stigma may be very strong.
  • In all cases, reassure patients about their confidentiality within limits of legal requirements (refer to Chapter 13), explore safety and express support and offer ongoing help. If you share the same language and culture as the patient, this reassurance at the outset will be very important.

Refer to Chapter 2 for examples of how to ask patients about experiences of violence.

Alcohol and drug abuse are potential signals for perpetration in migrant communities as they are elsewhere,308 so you should be alert to asking about the effect of such substance misuse on other family members, especially children. The safety of the survivor and children needs to be paramount.

Management

Many GPs can think that their gender or ethnicity is perceived as a barrier to disclosure by a victimised patient from a migrant or refugee background. But if a patient is reassured empathically, and if they perceive their GP to be listening, trustworthy and understanding, then empathy within the therapeutic relationship can overcome stereotypes of gender and culture. Feder et al6 found near unanimity among over 800 victimised women’s views about the need for GPs to be empathic and non-judgemental in their care. When developing healing relationships with our patients, Scott et al 228 established that trust, hope and a sense of being known were the important things identified by patients.

In order to address the cultural diversity of patients who present, the GP needs to:

  • be mindful of their own personal beliefs and assumptions
  • respect and appreciate the values and beliefs of all patients
  • be informed of cultural issues relevant to their patient, including their migrant and refugee patients.

In many migrant communities, doctors are highly regarded authoritative figures. It is therefore a very powerful message for a GP to suggest that the survivor’s symptoms are related to their partner’s or other family members’ abuse. A clear message from the GP stating that the abusive behaviour is not acceptable is valuable for the patient, especially when pathways to help and support the survivors and their families are identified. Ensuring the patient understands the connection between the violence and health, including the health of their children and other family members, is important.

Assure confidentiality

It is good practice to reassure any abused patient that the consultation – subject to legal and mandatory reporting requirements – is strictly confidential, but for migrant and refugee patients it is vital to convey clearly that you will NOT reveal information gathered during the consultation to anyone else. This may be very important if you are a member of the same community and language community. It is also important to assure the patient that trained interpreters are also bound by these rules of confidentiality. Even where this information has been provided, confidentiality can be a difficult concept to relay within a cross-cultural environment and it may take some time for the patient to engage with this understanding.

The importance of culturally appropriate language

Members of many communities find that language barriers pose a significant problem in their efforts to access healthcare. When the GP and patient do not speak the same language it can lead to a loss of important information – for example, misunderstandings can occur regarding the presentation of illness and instructions for the use of medications. Abuse and violence identification and intervention can be especially difficult without proper linguistic tools. In many states, there are specific domestic violence services for migrant and refugee communities and they can provide secondary consultations and sometimes interpreting services if organised ahead of time (refer to Resources). It is important that any interpreter has been vetted for sensitivity to family or partner violence, as domestic violence services report anecdotally that interpreters from mainstream interpreting agencies may not always be confidential.

Professionally trained interpreters from mainstream agencies should always be used (refer to Resources). It is inappropriate to place children, family members or friends in the role of interpreter, particularly when abuse and violence is an issue. Table 17 outlines recommended guidelines for working with interpreters.

Table 17. Guidelines for interpreters 311
  • Use professionally trained interpreters
  • Try to talk to the interpreter before the visit, to share the agenda
  • Talk directly to the patient, not the interpreter
  • Use words, not gestures, and avoid technical terms
  • Speak slowly, and only ask one question at a time
  • Check frequently with the patient to ensure the patient is understanding
  • Ask the patient to repeat back important information to ensure that it has been understood correctly
  • Maintain eye contact with the patient by sitting in a triangular arrangement
  • Allow the interpreter to interrupt if needed
  • Repeat the phrases using different words if the message is not understood
  • Be alert to any discomfort the patient or interpreter may have with each other or the topic under discussion
  • Meet with the interpreter afterward to get their impressions of the visit and to debrief

Take a careful history

If a patient has disclosed, you need to take a careful history (refer to Chapter 2) and ask questions about:

  • all those who are abusing the patient
  • the safety and situation of the patient and any children or young people, including access to weapons. This may be more likely if the family is living in a rural area – regardless, it should always be explored (refer to Chapter 2 for questions relating to safety)
  • any pressure to maintain family harmony, irrespective of the safety of the victim and any children
  • any financial dependence, visa or migration status issues that complicate the relationship with the abuser and vulnerability of the abuser
  • other financial abuse – for example, gambling or drug abuse funding
  • religious or spiritual abuse
  • if you have the patient’s trust, consider asking about sexual abuse and coercion.

Safety planning and referral

After informing a patient that abusive behaviour is unacceptable and damaging to their health and that they are not to blame, it is appropriate to discuss:

  • what their perspective and preferences are and whether they wish to take any action
  • discuss their comfort to be referred for support – for example, to a mainstream or ethno-specific agency
  • assess their risk and safety and make a safety plan (refer to Chapter 3) that may include hiding copies of all important papers and documents, including passports, visas, birth and marriage certificates if appropriate
  • the law and rights and support services in Australia (refer to Chapter 13). For example, women from overseas who have married Australian men need to know that their visa application will be given special consideration if there has been domestic violence. The GP may be able to provide documentation that can assist this process
  • the role of police, intervention orders and courts in Australia. This may be very different to the individual’s country of origin. This can be especially important if the individual is in a rural community and the perpetrator has access to weapons.

Services for men

If the abusive partner is seen separately and will accept help, you could suggest referral or access to Mensline (www.mensline.org.au) or No to Violence (http://ntv.org.au/). As outlined in Chapter 5, it is important that the abusive male partner be seen by another GP to maintain confidentiality and safety for the victim.

Conclusion

While the health effects of violence are consistent across countries and cultures, there are a number of specific issues that GPs need to be aware of when caring for people of migrant or refugee background. Access to healthcare and specifically access to culturally sensitive services can be difficult. GPs need to understand these issues to be able to identify and support patients from migrant and refugee communities who are experiencing family violence. This chapter has detailed several ways to provide culturally sensitive care, and the Resources section provides details of additional assistance – for example, interpreters.

GPs need to be able to reflect upon how their gender, ethnicity and cultural background might impact upon a consultation with patients of migrant or refugee background. Reassuring patients by developing trust and providing an empathic culturally sensitive consultation can help to overcome many of the barriers to care.

Resources

Please refer to Tool 7 for resources nationally and in your area.

Further information

References

  1. World Health Organization. Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. Geneva: WHO, 2013.
  2. Feder GS, Hutson M, Ramsay J, et al. Women exposed to intimate partner violence: expectations and experiences when they encounter health care professionals: a meta-analysis of qualitative studies. Arch Intern Med 2006;166:22–37.
  3. Krug EG, Mercy JA, Dahlberg LL, et al. The world report on violence and health. Lancet 2002;360:1083–8.
  4. Mouzos J. Femicide: The killing of women in Australia 1989–1998. Research and Public Policy Series. Canberra: Australian Institute of Criminology, 1999.
  5. Taft A, Broom D, Legge D. General practitioner management of intimate partner abuse and the whole family: qualitative study. BMJ 2004;328:618.
  6. World Health Organization/London School of Hygiene and Tropical Medicine. Preventing intimate partner and sexual violence against women: taking action and generating evidence. Geneva: WHO, 2010.
  7. Scott JG, Cohen D, DiCicco-Bloom B, et al. Understanding healing relationships in primary care. Ann Fam Med 2008;6:315–22.
  8. Raj A, Silverman JG, McCleary-Sills J, Liu R. Immigration policies increase south Asian immigrant women’s vulnerability to intimate partner violence. J Am Med Womens Assoc 2005;60:26–32.
  9. Baba Y, Murray SB. Spousal abuse: Vietnamese reports of parental violence. J Sociol Soc Welf 2003;30:97.
  10. Khosla AH, Dua D, Devi L, Sud SS. Domestic violence in pregnancy in North Indian women. Indian J Med Sci 2005;59:195–9.
  11. The Victorian Foundation for Survivors of Torture Inc. Caring for Refugee patients in General Practice: A Desktop Guide. 4th edn. The Victorian Foundation for Survivors of Torture Inc, 2012.
  12. Echevarria A, Johar A. Beyond bitter moments: Non-English speaking women’s access to support services for survivors of domestic violence. Fairfield West: Ettinger House, 1987.
  13. Australian Bureau of Statistics. 2071.0 – Reflecting a Nation: Stories from the 2011 census, 2012–2013. Cultural Diversity in Australia. Canberra: ABS, 2012. Available at www.abs.gov.au/ ausstats/abs@.nsf/Lookup /2071.0main+features902012 -2013 [Accessed 18 October 2013].
  14. Garcia-Moreno C, Jansen HAFM, Ellsberg M, et al. Prevalence of intimate partner violence: findings from the WHO multicountry study on women’s health and domestic violence. Lancet 2006;368:1260–9.
  15. Silverman JG, Decker MR, Saggurti N, Balaiah D, Raj A. Intimate partner violence and HIV infection among married Indian women. JAMA 2008;300:703–10.
  16. Vung ND, Ostergren PO, Krantz G. Intimate partner violence against women in rural Vietnam – different socio-demographic factors are associated with different forms of violence: Need for new intervention guidelines? BMC Public Health 2008;8.
  17. Raj A, Liu R, McCleary-Sills J, Silverman JG. South Asian victims of intimate partner violence more likely than non-victims to report sexual health concerns. J Immigr Health 2005;7:85–91.
  18. Raj A, Silverman JG. Intimate partner violence against South Asian women in greater Boston. J Am Med Womens Assoc 2002;57:111–4.
  19. Abramsky T, Watts CH, Garcia-Moreno C, et al. What factors are associated with recent intimate partner violence? Findings from the WHO multi-country study on women’s health and domestic violence. BMC Public Health 2011;11.
  20. Ellsberg M, Jansen HA, Heise L, et al. Intimate partner violence and women’s physical and mental health in the WHO multi-country study on women’s health and domestic violence: an observational study. Lancet 2008;371:1165–72.
  21. Kumar S, Jeyaseelan L, Suresh S, et al. Domestic violence and its mental health correlates in Indian women. Br J Psychiatry 2005;187:62–7.
  22. Rodriguez M, Saba G. Cultural competence and intimate partner abuse: health care interventions. In: Roberts G, Hegarty K, Feder G, editors. Intimate partner abuse and health professionals: New approaches to domestic violence. London: Churchill Livingstone Elsevier, 2006. p. 179–96.
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