A notable proportion of new migrants to Australia are of refugee or asylum seeker backgrounds.1 The Australian government allocates approximately 13,750 places under the Humanitarian Program each year. Both of these groups are particularly vulnerable due to often substantial health inequalities as a result of their experiences before and after migration, including exposure to torture and trauma. Refugee and asylum seeker health is therefore an important area in which Australian general practitioners (GPs) have knowledge, enabling quality provision of care to these vulnerable groups to improve health outcomes. Key skills required to care for these groups are covered in the Core skills unit (CS16). The aim of this contextual unit is to emphasise the key issues and highlight important clinical skills, knowledge and attitudes that GPs should focus on in order to deliver quality care to these culturally diverse groups.
According to the United Nations Refugee Convention of 1951, refugees are individuals or families who have been found to have a:
Well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable or, owing to such fear, is unwilling to return to it."2
Asylum seekers are people who are seeking international protection and who have applied, or are in the process of applying, to be recognised as a refugee. An asylum seeker is a person whose claim has not yet been finally decided upon by the United Nations High Commissioner for Refugees (UNHCR) or authorities of the country in which he or she has requested refugee status. Not every asylum seeker will ultimately be recognised as a refugee, but every refugee is initially an asylum seeker.3
A significant portion of refugees and asylum seekers have a history of interrupted access to healthcare, clean water and nutrition. Many in these groups have been exposed to torture and trauma in their countries of origin and often during their refugee journey, and are often separated from loved ones.4 Ongoing uncertainty about settlement and the possibility of future reunion with family members, combined with cultural and linguistic differences, compound asylum seekers’ difficulties, and these issues often create complex health presentations that require respectful and supportive management.
As a signatory to the United Nations Refugee Convention,2 Australia resettles a proportion of humanitarian entrants every year. In addition, under the same convention, Australia has obligations to people who arrive in Australia and subsequently claim asylum. Both groups are likely to have significant physical and mental health problems,4 however, their care in Australia, and the ways in which GPs and other primary care providers interact with them, may differ according to their visa status. The key differences are explained below.
Refugees and humanitarian entrants
Australia currently resettles an annual quota of humanitarian entrants who are individuals deemed in need of protection by the United Nations. Once in Australia, these individuals and families may access Humanitarian Settlement Services, which entitles them to case management, basic household packages and language services.5 It is recommendedthat newly arrived humanitarian entrants see a doctor, most commonly a GP, for a refugee health assessment.6This involves a comprehensive history and physical examination, pathology screening, catch-up immunisation, further management and referrals as appropriate.7 Comprehensive primary care provides an essential first step to addressing the many immediate and long-term healthcare needs of refugees and humanitarian entrants.
According to the United Nations Refugee Convention, it is not illegal to seek asylum.2Since 1992 Australian Government policy mandates that asylum seekers who arrive by boat be held initially in immigration detention, either in offshore detention or on the Australian mainland in a variety of circumstances.8 On the mainland, asylum seekers may be in a restrictive facility, community detention or after leaving detention, living in the community on temporary visas along with asylum seekers who arrive by plane. These asylum seekers may or may not have access to Medicare, Centrelink or work rights, and they may be under the care of Federal Government-contracted services for medical support.9,10 Regional processing arrangements were put in place in 2013 in regards to asylum seekers who arrived by boat. If their arrival date was after 19 July 2013 these individuals were told that they would not be able to settle in Australia and were consequently transferred to either Nauru or Papua New Guinea.11
Asylum seekers have increased vulnerability due to the uncertainty and length of the visa determination process, the fact that many have left family members behind, and the commonality of financial hardship within this group.10 The detention of children and prolonged detention of adults has been shown to cause a range of adverse long-term physical, psychological and developmental effects.12–19 As such, detention, particularly of vulnerable groups such as children, pregnant women and survivors of torture and trauma, should be avoided if possible, and kept to a minimum for others.
he healthcare of asylum seekers in detention, whether offshore, onshore or in community detention, should be of a standard commensurate with Australian standards of health. GPs contracted to work for third parties, such as the Department of Immigration and Border Protection or private health service providers, are not absolved from their professional and ethical responsibilities to their patients. These professionals work in an environment that contributes to adverse health outcomes. This is ethically challenging and these professionals should thus be well supported and resourced.
The majority of refugees and asylum seekers come from resource-poor backgrounds with limited access to healthcare, they consequently have increased rates of infectious diseases, nutritional deficiencies and undiagnosed or undertreated chronic illnesses, and immunisation rates are generally low.20
The majority of refugees and asylum seekers have come from areas of conflict, with many experiencing traumatic events and losses, and undergoing hardship during journeys of escape. Post-migration aspects of resettlement and acculturation can be very difficult, and refugees and asylum seekers consequently often have increased rates of certain mental health conditions, such as anxiety, depression and post-traumatic stress disorders.20,21 GPs therefore need to have an understanding of disease prevalence in countries of origin and countries of transit (or know how to access this information efficiently), as well as the potential impacts of other pre-migration and post-migration factors on physical and mental wellbeing, in order to deliver holistic quality care.
It is imperative that GPs have an awareness of the potential that patients who are refugees or asylum seekers have been exposed to torture and other traumatic experiences, and are able to explore this sensitively to assess whether specialised counselling is required without unnecessarily triggering emotional responses to these experiences.20
There is a growing body of evidence identifying the specific healthcare needs of refugees and asylum seekers. However, more research is required to expand our knowledge and develop best practice primary healthcare guidelines for these vulnerable groups. GPs are in a strong position to carry out this research.
Addressing barriers to equitable healthcare access
General practices have a responsibility to address the barriers to equitable healthcare access that exist for refugees and asylum seekers, in the same way they do for other culturally and linguistically diverse (CALD) communities. In order to provide high quality general practice care, it is important for GPs to understand and address the potential linguistic, cultural or religious barriers to accessing care, as well as the cultural influences on health concepts and attitudes in line with the core skills for Australian General Practice (CS16).
Quality care provision to people of refugee and asylum seeker backgrounds also involves acknowledgement and management of the:
- impacts of the cultural lens of the GP and the patient within each consultation22
- presence of diversity within diversity, which emphasises the importance of avoiding generalisations by recognising that there are differences in ideas about health, age, gender, sexuality and social issues within cultural groups
- impact of religious beliefs on the understanding of illness, dietary habits and acceptance of medical treatments
- importance of culturally safe communication in providing care to people of all cultures, particularly to people of refugee and asylum seeker backgrounds.
Working with professional interpreters is an essential part of safe and quality healthcare practice.23 Initiatives are needed to increase GPs’ uptake of free interpreter services, as utilisation of these services in Australia is low. GPs need to readily identify the need for an interpreter in a consultation and develop skills in the effective use of interpreter services in order to provide high quality care.24
Language difficulties can negatively impact upon the care received by those from a CALD background. While the interpreter can assist in bridging the language gap, the cultural meaning embedded within language adds further complexity to cross-cultural consultations. Different cultures attach different meanings to parts of the body and types of illness, and this can impact upon the presentation of the illness, associated stigma or compliance with treatment. Linguistic difference can also reduce access to health promotion materials.
GPs are encouraged to work in collaboration with multidisciplinary teams, including refugee health nurses; settlement, humanitarian, torture and trauma services; and other agencies that are integral to facilitating the delivery of effective healthcare of refugees and asylum. People from a CALD background, particularly refugees and asylum seekers, commonly experience social discrimination in health.25 GPs are typically in a strong position to be effective advocates for their patients to ensure issues of health equity are addressed.
The material for this contextual unit was largely sourced from the RACGP Specific Interests Refugees and Asylum Seekers network’s Healthcare for refugees and asylum seekers’ position statement.