Migrant, refugee and asylum seeker health

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Instructions

This section provides a summary of the area of practice for this unit and highlights the importance of this topic to general practice and the role of the GP.

Almost one-third of Australia’s population was born overseas (29.8%).1 Each culturally and linguistically diverse (CALD) community has its own strengths and health needs, however, there may be substantial barriers to accessing, navigating, and maintaining engagement with healthcare. Individuals from CALD communities born in Australia may face similar barriers. General practitioners (GPs) can address equity barriers for all migrants, including offering professional interpreters.    

Approximately one in five households in Australia speaks a language other than English at home.2 It is estimated that one in 10 individuals presenting to GPs reported that their primary language was not English, however, 73% of GPs reported that all their consultations were conducted in English.3 Although consideration of language is essential, culturally safe care is much broader than this. Ongoing reflective practice acknowledging cultural bias and lens is essential. Showing compassion and respectful interest by undertaking a cultural assessment can provide valuable insight to inform care. This can include an exploration of beliefs and values, health literacy, traditional health practices, as well as previous access to and experiences with health services. Understanding these factors and their influences on health, presentation of illness, access to care and adherence to treatment can assist GPs in providing culturally safe care. It can also inform advocacy and improve access to appropriate health screening, culturally appropriate health information and continuity of care.

The Australian government has accepted over 80,000 humanitarian entrants since the second world war,4 and as of March 2021 there were over 90,000 people seeking asylum in Australia.5 Refugees are people who are identified as ‘unable or unwilling to return to their country of origin owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion’.6 People seeking asylum have applied for protection but have not yet been granted a humanitarian visa.2 Every refugee was once a person seeking asylum.

Refugee and asylum seeker communities are typically resilient but may carry specific vulnerabilities which are important to acknowledge.3,7-9 These include communities who originate from countries with scarcity of resources including safe drinking water, sanitation, shelter, adequate food supply, education and employment, those who have fled areas of conflict with risk of exposure to traumatic events and the associated grief that accompanies the loss of family, friends, culture and community.3,7-9 People from these backgrounds can also face continuing uncertainty which may impact their wellbeing.3,7-9 Combinations of these factors can contribute to complex health presentations that require respectful and supportive management.3

Newly arrived humanitarian entrants are recommended to undertake a comprehensive health assessment. This includes pathology screening, catch-up immunisation, management and referrals as appropriate.4,5 An understanding of disease prevalence in countries of origin and transit (or knowing how to access this information), as well as the potential impacts of other pre-migration and post-migration factors on health, is needed to deliver holistic quality care.3,4

It is important for GPs to reflect on their consultations with people who are facing significant challenges in their lives to identify and understand signs of compassion fatigue and vicarious trauma, and to ensure that they have adequate self-care and support strategies in place.

References
  1. Australian Bureau of Statistics. Migration, Australia statistics on Australia’s international migration, internal migration and the population by country of birth 2019-20 financial year. Canberra: ABS, 2021 [Accessed 2 December 2021].
  2. The United Nations High Commissioner for Refugees. Asylum-Seekers. Geneva: UNHCR, [date unknown] [Accessed 5 October 2021].
  3. The Victorian Foundation for Survivors of Torture Inc. Why focus on refugee health? A resource of the Australian Refugee Health Practice Guide. Brunswick, Vic: Foundation House, 2018 [Accessed 2 December 2021].
  4. The Victorian Foundation for Survivors of Torture Inc. Australian Refugee Health Practice Guide. Brunswick, Vic: Foundation House, 2018 [Accessed 5 October 2021].
  5. Australian Government Department of Health. Medicare Benefits Schedule (MBS) Health assessment for refugees and other humanitarian entrants. Canberra: Department of Health, 2018 [Accessed 5 October 2021].
  6. The United Nations High Commissioner for Refugees. Convention and Protocol relating to the status of refugees. Geneva: UNHCR, 1951 [Accessed 2 December 2021].
  7. Ahpra Medical Board. Good medical practice: A code of conduct for doctors in Australia. Melbourne: Ahpra, 2020 [Accessed 5 October 2021].
  8. Bayram C, Ryan R, Harrison C, et al. Consultations conducted in languages other than English in Australian general practice. Aust Fam Physician 2016;45(1–2):9–13 [Accessed 2 December 2021].
  9. Huang YT, Phillips C. Telephone interpreters in general practice - Bridging the barriers to their use. Aust Fam Physician 2009;38(6):443–46.

Instructions

This section lists the knowledge, skills and attitudes that are expected of a GP for this contextual unit. These are expressed as measurable learning outcomes, listed in the left column. These learning outcomes align to the core competency outcomes of the seven core units, which are listed in the column on the right.

Communication and the patient–doctor relationship
Learning outcomes Related core competency outcomes
The GP is able to:   
  • effectively use professional interpreters in consultations with people who speak little or no English, or English as a subsequent language
1.1.6, 1.4.1
  • demonstrate the use of culturally safe and responsive communication in consultations
1.1.3, 1.1.6, 1.3.1, 1.3.2
Applied knowledge and skills
Learning outcomes Related core competency outcomes
The GP is able to:   
  • conduct respectful health assessments that consider the migration experience, culture and health literacy of the person
2.1.1, 2.1.2, 2.1.5, 2.1.6, 2.1.7
  • provide trauma-informed care through establishing a safe, therapeutic relationship that acknowledges power differentials and potential impacts of previous traumatic experiences
2.1.8, 2.2.2, 2.3.1, 2.3.2
  • collaborate with multidisciplinary teams to provide culturally safe care to migrants, refugees and asylum seekers
2.3.1, 2.3.2, 2.3.4
Population health and the context of general practice
Learning outcomes Related core competency outcomes
The GP is able to:   
  • consider patterns of disease commonly experienced by migrants, refugees and asylum seekers and provide appropriate recommendations, including vaccinations and access to screening
3.1.1, 3.1.3, 3.1.4, 3.2.3
  • advocate for the removal of barriers to health equity regarding the care of migrants, refugees and asylum seekers
3.2.1, 3.2.2, 3.2.3, 3.2.4
Professional and ethical role
Learning outcomes Related core competency outcomes
The GP is able to:   
  • explore and identify own cultural lens and bias and reflect on how these impact provision of care for migrants, refugees and asylum seekers
4.2.1, 4.2.2, 4.2.4
Organisational and legal dimensions
Learning outcomes Related core competency outcomes
The GP is able to:   
  • demonstrate familiarity of the evidence-based recommendations, guidelines and relevant MBS items for health assessments for refugees and other humanitarian entrants
5.2.1, 5.2.3, 5.2.5

Instructions

This section includes tips related to this unit from experienced GPs. This list is in no way exhaustive but gives you tips to consider applying to your practice.

Extension exercise: Speak to your study group or colleagues to see if they have further tips to add to the list.

  1. Australian society is rich with cultural and linguistic diversity. Developing therapeutic relationships with patients from culturally and linguistically diverse communities is an essential and rewarding part of general practice in Australia. Continuously reflecting on your own cultural beliefs and cultural lens and how they impact your consultations and therapeutic relationships is essential in building trust and rapport with patients from all cultural backgrounds.
  2. To provide effective care, ensure there is adequate time during consultations to explore cultural differences with respect and humility. It is important to remember that each patient is unique and has unique needs, and not to make assumptions based on stereotypes. Take the time to reflect on your cultural lens.
  3. Consistently offer professional interpreters for consultations and develop strategies to use interpreters effectively. Keep the interpreting service phone number and your access code accessible in your consultation room.
  4. Identify your local referral pathways and find suitable patient information resources in languages used in your community, recognising that patients may not be able to read the language they speak and that resources that present information visually may be most suitable.
  5. Asking your patients about their country of origin and migration story in a culturally sensitive, trauma-informed way can help establish rapport, help you understand their health risks and protective factors, and inform your screening and clinical decision-making.
  6. Many patients who have travelled to Australia as refugees or asylum seekers are likely to have experienced trauma. It is rarely necessary to ask in detail about a patient’s trauma history and it is important to consider the potential for triggering a trauma response. It is also important to be aware of the potential role that trauma might be playing in a patient’s health. A trauma-informed approach to care is essential.

Instructions

  1. Read this example of a common case consultation for this unit in general practice.
  2. Thinking about the case example, reflect on and answer the questions in the table below.

You can do this either on your own or with a study partner or supervisor.

The questions in the table below are ordered according to the RACGP clinical exam assessment areas and domains, to prompt you to think about different aspects of the case example.

Note that these are examples only of questions that may be asked in your assessments.

Extension exercise: Create your own questions or develop a new case to further your learning.

Migrant, refugee and asylum seeker health

Jamil is a 40-year-old Kurdish man from Iran who presents to your reception desk quite distressed, asking to see a doctor as he needs medicine to help him sleep. Jamil is new to your clinic. He tells the receptionist he has no money to pay for the visit or any medicine. When you call him in from the waiting room you notice that he is standing by the front door of the clinic and he appears anxious and uncomfortable.

Questions for you to consider Clinical exam assessment area Domains

How would you determine if an interpreter should be used in this consultation?

If Jamil attended with his brother who speaks English, would it be reasonable to ask him to interpret for Jamil in the consultation?

How would you organise to use an interpreter?

What questions might you ask when doing a cultural assessment?

Would you approach this consultation differently if Jamil was female? How would you ask about her preference to be seen by a doctor of a particular gender? How might you explore concerns about risk of family violence or previous sexual trauma in a trauma-informed way?

What non-verbal cues have you noticed already?

  1. Communication and consultation skills
1,2,5

How would you identify if Jamil is a refugee or seeking asylum?

Identify the key aspects of taking a trauma-informed history to explore Jamil’s sleep difficulties.

How might you explore whether Jamil has experienced trauma to determine if this is contributing to his presentation?

  1. Clinical information gathering and interpretation
2   

What symptoms would make you consider a diagnosis of post-traumatic stress disorder?

If this was an 11-year-old child with sleep difficulties who had spent time in immigration detention, how would you approach this consultation?

If Jamil presented with a history of fever and a cough, what differential diagnoses would you consider?

  1. Making a diagnosis, decision making and reasoning
2

What resources could you use to give Jamil information about sleep hygiene in his language?

How would you approach his request for medicine to help him sleep?

What would you need to consider if this was a 26-year-old woman from Ethiopia who has had genital cutting or circumcision and presents at 22 weeks of pregnancy?

What local services are available to support people from culturally and linguistically diverse communities with mental health concerns?

  1. Clinical management and therapeutic reasoning
2   

If Jamil had recently arrived in Australia, what health screening might you consider?

What resources could you use to ensure a rational approach to screening investigations?

How would you identify what community resources might be available to support Jamil?

  1. Preventive and population health 
1,2,3

Use reflective practice to assess how you feel about this consultation. Do you have any learning needs arising from it?

If this was a Muslim woman in a burqa, how would you reflect on your own cultural lens to minimise impacts on the consultation?

  1. Professionalism
4   

At your practice, how do you record a patient’s preferred language, ethnicity, and need for an interpreter?

Would you have any legal obligations to consider if Jamil presented with psychotic symptoms and was the sole carer of his seven-year-old son?

What is your approach to patients who can’t afford to pay for healthcare?

  1. General practice systems and regulatory requirement
5   

If you were concerned that Jamil had a metabolic cause for his agitation and insomnia, how would you gain informed consent for blood tests?

  1. Procedural skills
2   

How would you address Jamil’s concerns about destitution?

How would you manage Jamil if you could not exclude a mental health cause for his symptoms?

  1. Managing uncertainty
2   

If Jamil spoke limited English and presented with chest pain, how would you approach the consultation?

If you were concerned that Jamil was at risk of suicide, how would you assess his risk and manage this?

  1. Identifying and managing the significantly ill patient
2

Instructions

This section has some suggestions for how you can learn this unit. These learning suggestions will help you apply your knowledge to your clinical practice and build your skills and confidence in all of the broader competencies required of a GP.

There are suggestions for activities to do:

  • on your own
  • with a supervisor or other colleague
  • in a small group
  • with a non-medical person, such as a friend or family member.

Within each learning strategy is a hint about how to self-evaluate your learning in this core unit.

On your own

Identify three of your patients from a culturally and linguistically diverse community. Check if interpreters were offered and used in recent consultations.

  • What are the main culturally and linguistically diverse populations in your community?
  • If interpreters were not offered or used, were there any barriers for you and/or the patient? If interpreters were used, what strategies did you use to communicate effectively? What resources are available to improve your skills in using interpreters in consultations?
  • Get feedback from interpreters and patients at the end of consultations about what worked well and what could be improved.

Using practice software, do an audit of your patients who have migrated from a refugee source country and reflect on strategies that you could use to ensure a culturally safe and trauma-informed approach to consultations.

  • What questions did you ask to explore whether the person was a refugee or seeking asylum, or whether they had experienced trauma? If they were a refugee, seeking asylum or had experienced trauma, did you use a trauma-informed approach?
  • What aspects of culturally safe care did you integrate into the consultations? What could you improve on?
  • If the person had spent time in Australian immigration detention or in a refugee camp, how might this impact their health?
With a supervisor

Present case studies of a few patients from culturally and linguistically diverse communities across the lifespan, including infants and children. Discuss how your cultural lens impacted these consultations.

  • Do you routinely reflect on your cultural lens?
  • Did your cultural bias impact clinical decision-making or management decisions in these consultations? How?
  • Did health beliefs or concerns about stigma seem to impact the patients’ perceptions of symptoms or treatment?
  • What is your supervisor’s experience with patients from these communities? What tips or tricks did they suggest to overcome any difficulties that you may have had?

Choose one of your patients (or your supervisor’s patients) from a culturally and linguistically diverse community. Discuss the local referral pathways and resources that are available to improve health and reduce barriers to care.

  • Do you consider culture and language when referring and linking patients with community resources?
  • What online multilingual and culturally appropriate patient information resources are there? How can you easily access this information? Are there resources for children and adolescents? Are there any visual aids to help patients comply with treatment for common conditions?

Review five of your patients (children and adults) from culturally and linguistically diverse communities. With your supervisor, discuss your approach to prevention (through screening and management) of conditions that the patient may have risk or protective factors for that are related to ethnicity, culture, religion and/or migration experience (eg thalassaemia, developmental delay, diabetes, vitamin D, iron or B12 deficiency, hepatitis B or C, latent tuberculosis, female genital cutting or circumcision).  

  • Are there guidelines to support your approach or to use as a resource?
  • How would your supervisor have managed these patients?
  • What strategies did you use to do cultural assessments to understand how culture may impact health or access to care? How did you explore migration experience and/or whether the patient had experienced trauma? Did you consider whether gender-specific care was relevant?
  • Ask your supervisor to observe some of your consultations to give feedback on your strengths and areas for further learning.
In a small group

Role-play a consultation with a patient who is a refugee who presents with chronic pain. Consider the potential impacts of trauma on presentation and options for management. Discuss some strategies to sensitively raise the topic of previous torture and trauma with patients. Discuss how experiences of trauma can affect physical and mental health.

  • What trauma-informed consultation strategies can you use to explore the effects of trauma on physical and mental health?
  • How can the relationship between trauma and physical symptoms be explained to patients?
  • What local services and resources are available to provide quality care to patients who have experienced trauma? What if you are based in a rural or remote area – are there any telehealth or online resources available?
  • How do you incorporate questions about cultural health beliefs and/or stigma into consultations?

Present a case study about a patient who has recently migrated to Australia and outline how you do an evidence-based health assessment. Discuss how your approach incorporates an understanding of their ethnic and sociocultural background and migration experience. Discuss each other’s experiences and share resources.

  • What resources support evidence-based screening for various culturally and linguistically diverse communities? What factors are important to consider in providing screening?
  • Does age-based screening for non-communicable diseases vary for some culturally and linguistically diverse populations?
  • Which conditions of public health importance should be incorporated into routine screening of people who migrate to Australia? Do these vary depending on the country of origin?
  • How would you undertake catch-up vaccination, if required?
  • What resources are available to support decision-making?
With a friend or family member

Ask a friend or family member who has either migrated to Australia or is part of a culturally and linguistically diverse community about any barriers they have experienced in accessing healthcare.

  • Were you surprised by any of the issues identified?
  • How could you as a GP address any barriers to healthcare access?

Ask a friend or family member to select a region of the world, and then tell them about any specific health screening considerations for that region.

  • What resources can help you make decisions about screening?
  • What are some common communicable diseases that may be prevalent in this region? Are there any non-communicable diseases that may be more common in this region than in Australia, or present at younger ages? Are there any other factors that may impact the physical or mental health of people migrating from this region?

Instructions

These are examples of topic areas for this unit that can be used to help guide your study.

Note that this is not a complete or exhaustive list, but rather a starting point for your learning.

Provide culturally safe and trauma-informed care
  • Identify the need for professional interpreters and use them effectively, including for patients who are more comfortable discussing health issues in their primary language.
  • Identify useful resources, including multilingual patient information, online explanatory videos, and visual aids to assist in communication about health issues and management.
  • Provide culturally safe care, including undertaking a cultural assessment, and understand:
    • the meaning of culturally safe care and the skills and knowledge required to support this
    • the role of a cultural assessment in establishing rapport and informing future shared decision-making and improved communication
    • the barriers to care for people from culturally and linguistically diverse communities and specifically for those who have had refugee experiences or are seeking asylum.
  • Understand the terms ‘cultural bias’ and ‘cultural lens’ and be able to reflect on own cultural lens and bias and how these affect consultations.
  • Identify and respond to a disclosure of torture or trauma.
  • Use reflective practice to identify when you have found a consultation challenging; seek help from colleagues and practise self-care.
Provide preventive care and conduct screening
  • Consider risk factors and screen for high prevalence communicable diseases common in particular geographical regions:
    • hepatitis B
    • hepatitis C
    • helicobacter pylori
    • human immunodeficiency virus (HIV) and other sexually transmissible infections
    • tuberculosis
    • intestinal parasites.
  • Consider risk factors and conduct age-based screening for high prevalence non-communicable conditions common in countries of origin:
    • vitamin D deficiency
    • age and ethnicity-appropriate cardiovascular, type 2 diabetes, and renal disease risk assessment
    • dental disease.
  • Identify common health conditions and understand referral pathways, if required:
    • nutritional disorders (eg iron, B12 and folate deficiencies)
    • inherited anaemias (eg thalassaemia, G6PD deficiency, haemoglobinopathies)
    • mental health conditions (eg post-traumatic stress disorder, somatisation, complicated grief)
    • female genital cutting or circumcision, particularly in prenatal and antenatal settings
    • visual and hearing assessments
    • low immunisation rate/catch-up immunisation
    • in children and adolescents consider impacts of disrupted schooling, assessment of developmental delay and lead exposure, where appropriate.
Identify and address barriers to care
  • Identify Medicare item numbers that may assist in provision of holistic care to people from culturally and linguistically diverse communities (eg refugee health assessment).
  • Identify online multilingual resources and local community referral pathways that might be appropriate for your patients from culturally and linguistically diverse communities and/or who have had refugee-like experiences.
  • Identify whether your practice demonstrates that it is ‘migrant, refugee and asylum seeker friendly’; for example, through displaying posters about availability of interpreters and provision of multilingual resources.

Instructions

The following list of resources is provided as a starting point to help guide your learning only and is not an exhaustive list of all resources. It is your responsibility as an independent learner to identify further resources suited to your learning needs, and to ensure that you refer to the most up-to-date guidelines on a particular topic area, noting that any assessments will utilise current guidelines.

Online resources
A large collection of regularly updated external resources, research papers and guidelines to support provision of care to people from culturally and linguistically diverse communities. An excellent evidence-based resource focused on primary care provision to refugees and people seeking asylum. National, state and territory-based referral pathways for refugees and people seeking asylum. An evidence-based resource focussing on screening for and presentations of the common conditions and health issues affecting refugees, including communicable and non-communicable conditions across the lifespan. A comprehensive range of clinical guidelines and useful resources that is regularly updated. An excellent RACGP-endorsed resource with helpful tips on using interpreters effectively. Health and wellbeing resources in over 100 languages, searchable by language and topic. A very useful visual prescribing aid.

Regularly updated vaccine catch-up for adults and children.

Information for health professionals about female genital cutting or circumcision.  
Learning activities
A useful overview of refugee health.
  • The Royal Australian College of General Practitioners. gplearning:
    • Refugee health
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Printed from the RACGP website at https://www.racgp.org.au/education/education-providers/curriculum/curriculum-and-syllabus/units/migrant-refugee-and-asylum-seeker-health 23/05/2022