Research Commentary [16] March 2018

Mar 1, 2018

This review focuses on primary healthcare for refugees. 

General practices are a major provider of refugee health care in New Zealand. Following on-arrival health assessment at the Refugee Health Screening Service at the Mangere Refugee Resettlement Centre, people from refugee backgrounds need access to ongoing care in a primary healthcare setting. Refugees experience unique health problems which can be met by primary health care services. Australian, North American and British studies have evaluated models of primary health care delivery to refugee communities. Much of the literature focuses on describing the health problems or access barriers experienced by refugees. Importantly, this group of studies identifies some specific strategies required to provide accessible and well-coordinated care for refugees, such as case management, use of specialised staff, interpreters and outreach. 

Commentary provided by Dr Annette Mortensen, eCALD® Services Project Manager: Research and Development 

The following articles are reviewed:

Article 1: Engaging and support in general practice in refugee health

General practices are a major provider of refugee health care in New Zealand. Following on arrival health assessment at the Refugee Health Screening Service at the Mangere Refugee Resettlement Centre, people from refugee backgrounds need access to ongoing care in a primary healthcare setting. 

The primary aim of this study conducted in Victoria, Australia was to better understand and then develop and document effective approaches to engaging and supporting general practice to deliver services to refugee-background populations. The three key domains identified for action are clinical care, communication, and coordination and management.  

Importantly, a suite of very practical resources is the result. A web resource is provided for general practices to access on:   http://refugeehealthnetwork.org.au/resources-for-engaging-and-supporting-general-practice/ which includes resources for clinical and non-clinical staff. Suggestions for implementation include: how to use interpreting services; easidose, a prescribing aid addressing language and literacy barriers. Easidose uses colour coding for medications, and picture based instructions for dose, frequency, duration and special conditions; a website with links to additional resources, such as refugee settlement support services; tip sheets for coordination and management; and up-to-date clinical recommendations.

The findings in this report suggest general practice engagement should be practical, flexible and based on the needs, priorities and resources of the practice. While general practice engagement is seen as a part of many people’s roles in the refugee health and social sectors, there are specific and unique skills, and supports required to do this effectively. This project offers practical guidance for general practices engaged in the delivery of care to people from refugee backgrounds.

Authors: Furneaux, S., Duell-Piening, P., Christensen, S., Jaraba, S.,Loupetis, M. & Varenica R.

Citation: Furneaux, S., Duell-Piening, P., Christensen, S., Jaraba, S., Loupetis, M. & Varenica, R. (2016). Engaging and supporting general practice in refugee health. Melbourne, Australia: Victorian Refugee Health Network, EACH Social and Community Health Service and ISIS Primary Care. 

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Article 2: A narrative synthesis of the impact of primary health care delivery models for refugees in resettlement countries on access, quality and coordination.

This systematic review of the literature, aims to identify the components of primary health care service delivery models for refugee populations in resettlement countries which have been effective in improving access, quality and the coordination of care. The study found that the elements of models most frequently associated with these components were case management, use of specialist refugee health workers, interpreters and bilingual staff. Unfortunately no published evaluation studies have been conducted in New Zealand. 

Integration between the different health care services and services responding to the social needs of clients was most frequently addressed by a case management approach conducted by a refugee health nurse or other health professional and often involving home visiting refugee clients in their homes.  Interpreters, bilingual staff, and staff training in cross-cultural management were also used to facilitate access to and quality of health and social care.

All primary care services need to be prepared to deliver health care to refugees in their local area and some services should develop models of care specifically addressing the needs of refugees because of the demographics of their local communities. The models of accessibility in the review included: 

  • Increasing awareness and health literacy in using health services with interventions involving media
  • and health education.
  • Outreach to facilitate registration or clinic attendance.
  • Improving acceptability and appropriateness through the use of interpreters and bilingual workers.
  • -Coordinating service networks (often facilitated by refugee health nurses) to improve access to a range of services and to transport.

The review found that coordination of care was largely focused on integrating care across the number of health and non-health services that might be involved. The two main coordination models were case management and team coordination, and these were associated with improved communication and coordination between service providers. Good patient–provider communication is of paramount importance to quality of care. Patient dissatisfaction arises more frequently from poor communication than from medical errors, and language barriers degrade the quality of care, resulting in poorer health outcomes.  Several studies in the review evaluated impacts on quality of care. These service models included use of interpreters, bilingual staff, cross-cultural training of staff and specialised refugee health nurses, and engagement with the community. They were associated with improvements in staff confidence, detection of problems at assessment, clients’ assessment of the quality of communication and interpersonal care. These measures are broadly consistent with international policy.

Authors: Joshi et al.

Citation: Joshi et al., (2013). A narrative synthesis of the impact of primary health care delivery models for refugees in resettlement countries on access, quality and coordination. International Journal for Equity in Health, 12, 88.

Publication 

Article 3: Working together to improve health literacy of women from refugee backgrounds.

This project aimed to develop and trial an effective and sustainable health literacy programme/tool suitable for women from refugee backgrounds living in Victoria. Many of the findings of the study conducted with Syrian, Karen, Afghan, Iranian, Sierra Leonean, and Sudanese refugee communities are directly applicable to health services and refugee communities in New Zealand.  

Participants said that staying healthy depended on many factors including establishing effective communication with health professionals, particularly through interpreter mediated appointments or doctors who spoke their language. Understanding how the health system works (including making general practice appointments, the role of pharmacies and referral systems to specialists). Also, knowledge about how to take medications and follow regimes correctly, the role of preventative screening and care including healthy eating, and support for raising children were also viewed as areas of need. 

Engagement in meaningful activity including in the workforce was viewed as vital for maintaining health. For instance men facing unemployment often experienced deterioration of their mental health and wellbeing. Supporting families and resolving intergenerational conflict was also viewed as important for staying healthy. Shifting power dynamics as children more readily adapt to the new environment, culture and language than their parents results in conflict between generations. Support with mental health and addressing the issue of stigma and lack of knowledge about the effects of trauma on physical and mental health were also viewed as being pivotal for keeping healthy.   

The best ways to distribute this information was through face to face sessions and group encounters and through the Internet and social media. Other distribution channels suggested included community settings such as churches, mosques and temples, schools community groups, sport groups, Neighbourhood Houses, cafes, GP clinics, Maternal and Child Health services, councils and Refugee and Migrant Resource Centres.  

Authors: Victorian Refugee Health Network, Health Issues Centre.

Citation: Victorian Refugee Health Network (2016). Working together to improve health literacy of women from refugee backgrounds. Victoria: Australia: Victorian Refugee Health Network, Health Issues Centre. 

Publication 

Article 4: A Rohingya refugee’s journey in Australia and thebarriers to accessing healthcare.

Refugees may minimise the severity of chronic health conditions such as diabetes, as they are not perceived as emergencies and are therefore unlikely to supersede the basic needs of food, housing and employment. This case report follows the medical journey of KB, a 38-year-old Rohingya refugee diagnosed with type 2 diabetes mellitus—the crux of all her health issues. KB, was referred by her general practitioner to the Endocrine Department at a tertiary hospital in Brisbane. This was a follow-up appointment for her diabetes management, for which she was recently commenced on insulin. However, during this consultation KB was unaware of what diabetes was, and of the chronicity associated with the condition although explained in previous appointments because the interpreter provided spoke a different dialect from her, causing a near fatal hypoglycaemic event.  

KB’s primary healthcare concern was infertility, while she believed that the doctors were more interested in her diabetes and the main reason for her attendance at medical appointments was because she believed diabetes to be a hindrance to her conception. Pregnancy was of such crucial importance to her that she sought medical advice, on other ways to increase her chances of falling pregnant. KB had a limited understanding of the medication prescribed given its scarcity while living in Bangladeshi refugee camps. The utility of subcutaneous insulin pens was a form of medication that did not fit into her ‘concept’ of medicine, which historically and culturally was always administered orally.  

The learning points in this case highlight: the discordance between the patient’s and the physician’s goals of treatment; the importance of a cultural assessment in patient history taking; the importance of cross-cultural training for health professionals, particularly the use of interpreters (and taking dialects into consideration when booking an interpreter); and that miscommunication can result in life-threatening consequences. 

Authors: Jiwrajka, M., Mahmoud, A. & Uppal, M.

Citation: Jiwrajka, M., Mahmoud, A. & Uppal, M. (2017). A Rohingya refugee’s journey in Australia and the barriers to accessing healthcare. BMJ Case Rep 2017. doi:10.1136/bcr-2017-219674. 

Publication 

Article 5: Common mental health problems in immigrants and refugees: general approach in primary care.

Refugees who have had severe exposure to violence often have higher rates of trauma-related disorders, including post-traumatic stress disorder and chronic pain or other somatic syndromes. Assessment of risk for mental health problems includes consideration of premigration exposures, stresses and uncertainty during migration, and postmigration resettlement experiences that influence adaptation and health outcomes. Clinical assessment and treatment effectiveness can be improved with the use of trained interpreters and cultural brokers when linguistic and cultural differences impede communication and mutual understanding.  

In general, the same methods that are effective in diagnosing and treating common mental health problems in primary care for the general population can be extended to refugees.  However, for maximum effectiveness, attention must be given to various contextual and practical issues that influence illness behaviour, patient–physician communication and intercultural understanding. Specific challenges in refugee mental health include communication, cultural shaping of symptoms and illness behaviour, the effect of family structure and process on acculturation and intergenerational conflict, and the receiving society’s facilitation of or impedance of adaptation and social integration. There is limited but consistent evidence from qualitative studies and clinical experience in intercultural primary care that these challenges can be addressed through specific enquiry into social and cultural context, the use of interpreters and culture brokers, meetings with families and consultation with community organisations. 

The outline for cultural formulation in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, provides a basic set of considerations that can be incorporated into assessment of patients to explore clinically relevant aspects of their identity, illness explanations, psychosocial environment and expectations for patient–physician relationships.

Author: Kirmayer et al.

Citation: Kirmayer et al. (2011). Common mental health problems in immigrants and refugees: general approach in primary care. Canadian Guidelines for Immigrant Health. CMAJ, 183(12),e959-967. DOI:10.1503/cmaj.090292.

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