Mitchell M Smith
This article forms part of our ‘Access’ series for 2012, profiling organisations that provide primary healthcare to groups who are disadvantaged or have difficulty accessing mainstream services. The aim of this series is to describe the area of need, the innovative strategies that have been developed by specific organisations to address this need, and make recommendations to help GPs
improve access to disadvantaged populations in their own communities.
People of refugee background living in Australia can have significant physical and emotional healthcare needs. However, their ability to access mainstream health services, including general practitioners, may be limited by factors such as lack of familiarity with the health system, language and cultural barriers, and cost. There are a number of ways in which GPs can be involved and various sources of support available. With minor modifications to practice logistics and consultations, GPs can provide beneficial and rewarding healthcare for this disadvantaged group of families and individuals.
Each year around 14 000 people of refugee background from Africa, the Middle East and Asia are settled in Australia through the offshore and onshore components of Australia’s Refugee and Humanitarian Program.1 They have been granted permanent residency and full Medicare access. While a range of health checks are performed before migration, significant ongoing health concerns may be found in many of those who have entered Australia under the Humanitarian Migration Program.
A similar group are those seeking asylum after arrival in Australia. In addition to those in immigration detention centres, many asylum seekers live in the community under various arrangements while their application for asylum is processed. These individuals have variable access to work rights and Medicare depending on the type of visa they hold.
Many refugees and asylum seekers have experienced traumatic events such as persecution, exposure to conflict, physical deprivation, and in some cases, torture or other human rights abuses. These premigration experiences have a well documented impact on the physical and emotional health of refugees and asylum seekers. In addition, the process of settlement in a new country can be a source of ongoing hardship.
Health needs commonly identified in refugees and asylum seekers after arrival in Australia include:
- psychological issues
- nutritional deficiencies
- infectious diseases
- poor dental and optical health
- poorly managed chronic diseases
- delayed growth and development in children
- physical consequences of torture.
Some refugee women may have significant gynaecological health needs and may have undergone female genital mutilation or suffered sexual assault.2–6
In Australia, most health assessments for newly arrived refugees occur at the primary care level, either in private general practice, through state funded community health centres with salaried general practitioners or through dedicated refugee health services. The latter have been created in response to the sometimes complex health issues and barriers to accessing mainstream healthcare faced by people of refugee background and the difficulties experienced by many GPs in private practice in catering for these patients.
While those of refugee background may have significant health needs, their ability to access appropriate primary care can also be problematic. Patient factors affecting access include lack of familiarity with how our health system operates, language barriers, mistrust or anxiety and financial constraints.7,8 Provider factors may include time constraints, unfamiliarity with refugee health issues and inadequate interpreter use.8 Refugees and asylum seekers have described issues of access, consultation style and content, and a good patient-doctor relationship as important factors influencing their sense of satisfaction with their GP.9
Asylum seekers without Medicare cards experience even greater difficulty in accessing primary healthcare. Although some GPs generously provide pro bono care to these individuals, poor access to medication, pathology investigations and specialist services are ongoing issues.10 Primary healthcare is also provided by community based organisations and state funded refugee health clinics which provide their services free or at low cost.11
The NSW Refugee Health Service
The NSW Refugee Health Service is one example of a specialised unit providing dedicated refugee health services. It was established by the NSW Department of Health in 1999 in response to the significant healthcare needs of patients of refugee background living in New South Wales and the difficultiesfaced by this group in accessing mainstream healthcare. The service employs salaried, part time GPs to conduct health assessments for refugees living in the greater western area of Sydney in New South Wales. Refugee health nurses provide advice and support, and follow up clients to ensure referral services are accessed and treatment advice is followed. Interpreters are used whenever required, either onsite or over the telephone. After initial assessment and treatment, clients are referred to GPs in the community for ongoing care.
The service also has a broader role in the community providing policy and practice advice to government, health services and others; education for students, health staff, general practice trainees and GPs; and health promotion projects (eg. nutrition). The service also helps asylum seekers with their primary healthcare needs.
In other states and territories, different health service models exist for refugees, ranging from hospital based screening clinics to community based refugee health nurses.
Recent research with GPs in South Australia and New South Wales has highlighted some of the challenges faced by GPs at both an individual and structural level in providing initial care to refugees during their early settlement period.12
Recognising a refugee patient
Refugee or asylum seeker patients may present with a refugee worker or carry relevant documents. Alternatively, the type of presentation or the fact that a patient comes from a country with recent war/civil unrest or from a persecuted minority group may be clues to their refugee or asylum seeker status.
Understanding the patient’s context
Competent healthcare provision to refugees requires an understanding of the effects of cultural dislocation, persecution and trauma, and role and identity changes, and the challenges associated with re-starting life in an entirely different cultural, social and political context.5,13 Importantly, history taking, physical examination and procedures may trigger traumatic memories in refugee patients who are survivors of torture and trauma. A sensitive and gentle physical examination with explanation of investigations, empathy and interest expressed by the GP and adequate consultation time are important to accommodate a traumatised refugee patient.14
It is important to remember that psychological distress often presents as physical symptoms such as headaches, chest pains and upper gastrointestinal discomfort and not to over-medicalise these presentations. A good history, a urea breath test and some basic blood tests may be all that is needed.
Approaches to psychological problems in refugees
- Take time to build trust, and use compassionate listening
- Use ‘abstract empathic enquiry’ to gently invite revelations:15 eg. ‘I understand that your people experienced terrible hardships in your home country – was your family affected in this way?’
- Use mainstream mental health or specialised refugee trauma services
- Be alert to the risk of vicarious trauma in yourself.
Working with interpreters
General practitioners, practice nurses, reception staff and specialists in private practice have access to free telephone interpreting and limited onsite interpreters through the Translating and Interpreting Service National: 24 hours a day, 7 days a week (see Resources). General practices need to register before they can use this service. It may be helpful for practice staff to familiarise themselves with the prebooking of interpreters before performing preliminary health assessments.
Tips for working with interpreters include:
- reassure the patient about confidentiality
- maintain eye contact and speak directly to the patient (ie. ‘Do you have ...’ not ‘Does she have …’)
- use short simple sentences with frequent pauses, and avoid jargon.
Medicare item numbers
People of refugee background are linked to a GP for a health assessment soon after arrival in Australia. From 2010, the ‘refugee exclusive’ MBS Item numbers 714 and 716 were deleted and incorporated into the generic time-based assessment items (MBS Items 701, 703, 705 or 707). Refugees are entitled to a GP health assessment within their first year of arrival or within 1 year of receiving their residency. These health assessments can be linked with other Medicare items including Chronic Disease Management Plans and Team Care Arrangements.
Refugees and asylum seekers may be unable to afford private allied health or specialist care, so GPs may need to refer to public services where available (including dental care) or seek out specialists willing to bulk-bill. General practitioners may also consider referring to an optometrist before an ophthalmologist where appropriate.
Patients may have trouble booking appointments, attending on time and following management and referral advice. Help with addressing these issues may be provided by settlement service workers, refugee health nurses or Red Cross staff or family support workers. General practitioners and their staff should work closely with these services so that patients are well supported.
Screening and treatment guidelines, translated information sheets and other materials can be invaluable when caring for refugees and asylum seekers (see Resources). Immunisation advice is available from local public health offices and the Australian Immunisation Handbook.
Conflict of interest: none declared.
- Department of Immigration and Citizenship (DIAC). Fact sheet 60 –Australia’s Refugee and Humanitarian Program. Available at www.immi.gov.au/factsheets. 2011.
- Allotey P. The health of refugees: public health perspectives from crisis to settlement. Melbourne: Oxford University Press, 2003.
- Burnett A, Peel M. Health needs of asylum seekers and refugees. BMJ 2001;322:544–47.
- Aroche J, Coello M. Ethnocultural considerations in the treatment of refugees and asylum seekers. In Wilson J and Drozdek B, editors. Broken Spirits: the treatment of traumatised asylum seekers, refugees, war and torture victims. New York: Brunner-Routledge, 2004, pp. 53–80.
- Benson J, Smith M. Early health assessment for refugees. Aust Fam Physician 2007;36:41–3.
- Johnston V, Smith L, Roydhouse H. 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, 2011. Available at http://dx.doi.org/10.1071/PY11065.
- Jackson-Bowers E, Cheng I-H. Meeting the primary health care needs of refugees and asylum seekers. Primary Health Care Research Information Service. Research Round up: 2010, Issue 16.
- Finney Lamb C, Smith M. Problems refugees face when accessing heath services. NSW Public Health Bulletin 2002;13:161–3.
- Southern Academic Primary Care Research Unit. Refugee and asylum seeker experiences of general practitioner services in countries of resettlement: an international literature review. Cited in Snapshot of Australian Primary Health Care Research 2011, Primary Health Care Research and Information Service.
- Spike E, Smith M, Harris M. Access to primary health care services by community-based asylum seekers. Med J Aust 2011;195:188–91.
- Correa-Velez I, Johnston V, Kirk J, Ferdinand A. Community-based asylum seekers’ use of primary health care services in Melbourne. Med J Aust 2008;188:344–48.
- Johnson D, Ziersch A, Burgess T. ‘I don’t think general practice should be the front line’. Experiences of general practitioners working with refugees in South Australia. Australia and New Zealand Health Policy, 2008.
- Silove D. The growing challenge of asylum. In: Wilson J, Drozdek B, editor. Broken spirits: the treatment of traumatised asylum seekers, refugees, war and torture victims. New York: Brunner-Routledge, 2004; pp. 13–32.
- Gardiner J, Walker K. Compassionate listening: managing psychological trauma in refugees. Aust Fam Physician 2010;39,4:198–203.
- Managing survivors of torture and refugee trauma – guidelines for general practitioners. STARTTS, GP Unit SWSAHS, CHETRE, NSW Refugee Health Service. Sydney, 2000.