Providing Refugees with Comprehensive Health Assessments in General Practice

GP Connect Clinical Feature by Dr Zoe Smythe, Senior Medical Advisor, Humanitarian Entrant Health Service FRACGP DCH DRCOG MPH&TM.

Seeing patients who have recently arrived in Australia as refugees or humanitarian entrants is an interesting, challenging and professionally rewarding part of general practice. The number of new arrivals into Western Australia has rapidly increased to pre-COVID levels, with countries of origin including Afghanistan, Iran, Syria, Ukraine, Myanmar, Eritrea, Venezuela and Guatemala.

Many refugees have been exposed to war, torture, repression, prolonged family separation, extreme poverty and food insecurity whilst experiencing poor access to health care and education, impacting on social, psychological and physical wellbeing.

The Humanitarian Entrant Health Service (HEHS) has a clinical team of nurses, GPs and a nurse practitioner providing comprehensive, voluntary health screening for newly arrived humanitarian entrants. A key objective is linking clients with community GPs; discharge letters provide GPs with details of screening, treatments and referrals along with suggestions for further management and follow up.

Patients under 18 years of age are offered referral to the Child and Adolescent Health Service (CAHS) Refugee Health Service (RHS) after initial screening.

The RHS provides a holistic health care approach to all children and their families from refugee-like backgrounds who have resettled in the last five years. It is a multidisciplinary service consisting of paediatric health professionals (medical, nursing, social work, dietetics, dentistry, mental health, education and neurosciences in-reach) providing coordination and management of the medical, developmental, educational and psychosocial domains of care using a culturally sensitive and trauma-informed approach.

Refugees and humanitarian entrants are eligible for an MBS Health Assessment within 12 months of arrival in Australia or grant of an eligible visa. Of note, asylum seekers and those in community detention or on temporary bridging visas are not routinely seen by HEHS and opportunistic health assessment with a GP is invaluable. The HealthPathways WA ‘Refugee Health Assessment Pathway‘ has been recently reviewed and is a comprehensive resource to guide this. An assessment may require two or more visits. The use of professional interpreters, ideally in-person for long and complex consultations, is vital for safe and effective care.

A trauma-informed approach recognises that previous traumas may impact on a refugee’s experience of receiving health care, aiming to minimise the risk of re-traumatising individuals. An assessment of emotional wellbeing should be performed as part of a comprehensive health assessment, however it is generally not advisable to ask specifically about experience of torture and trauma at an initial consultation. GPs can refer patients to Association for Services to Torture and Trauma Survivors (ASeTTS), a specialised service providing holistic care, including counselling, for survivors of torture and trauma. Children and adolescents with psychological symptoms should be referred to CAHS RHS.

Vitamin D deficiency and nutritional deficiencies such as B12 and iron deficiency are common. Deficiencies can occur in the context of growth faltering in children, however older children and adults may have high BMIs alongside nutritional deficiencies, reflecting food insecurity limiting access to meat and other iron and protein-rich foods. Many refugees come from higher-risk ethnic groups and have limited opportunities to make healthy lifestyle choices resulting in higher rates of diabetes, hyperlipidaemia and hypertension. Refugees are also typically under-immunised and under-screened and may require catch-up vaccinations as well as CSTs, mammograms and bowel cancer screening. Significant visual, dental and audiological issues are common and undertreated; with most children and adolescents missing early intervention checks (birth, school and community).

Given a high burden of infectious diseases, screening for Hepatitis B and C, HIV, syphilis and other STIs should be offered where appropriate, as should testing for parasitic infections such as strongyloidiasis, schistosomiasis and malaria (depending on geographical risk).

Proactive identification and treatment of these conditions will reduce the risk of long-term complications. History and examination should also focus on potential exposures and symptoms and signs of pulmonary and non-pulmonary TB. QuantiFERON, though not subsidised by Medicare, is advised given high rates of latent TB infection. Any child or adult identified with malaria is treated as an emergency and contact should be made with the Perth Children’s Hospital or tertiary adult hospital infectious diseases consultant on call.

Many female refugees have unaddressed gynaecological issues or a history of complications in pregnancy and childbirth. Many are keen to explore contraceptive options, whilst others may benefit from preconception counselling including haemoglobinopathy screening where appropriate. Female genital cutting/mutilation (FGC/M) is still prevalent in many countries of origin, with the HealthPathways WA Female Genital Cutting / Mutilation (FGC/M) Pathway available for clinical guidance. A high degree of sensitivity is also required when exploring potential experiences of domestic and family violence, and gender-based violence.

Beyond the provision of initial health screening, GPs have a vital role in ensuring that refugees have equitable access to health care that is responsive and culturally sensitive. This will contribute to successful re-settlement, enabling individuals and families to build fulfilling lives within their new communities.

For further support in managing refugee health issues:

The HealthPathways WA Refugee Health Assessment Pathway provides guidance and resources to assess and manage refugee health in your practice.