Dr Lucy Hanington and Dr Rachel Birch, Medico-Legal Consultants at Medical Protection, outline some practical steps GP practices can take to try to break down some of the barriers refugees face when trying to access healthcare.
It is estimated that there are currently over 9,000 refugees in Ireland. Many will have fled from war or imprisonment, and may have experienced physical or sexual abuse. In recent months, due to the Russian invasion of Ukraine, more than 7.4 million Ukrainian citizens have fled their homes and over 30,000 are believed to have sought refuge in Ireland.
Many refugees will have been separated from loved ones, either as a result of death, war or geography. For doctors, caring for this vulnerable group of people presents a number of unique challenges.
Refugees may speak little or no English and, on occasions, it may be difficult even to determine what language they are speaking. Practices may wish to make use of the HSE’s multilingual aid, a resource intended to assist health staff to communicate more effectively with patients whilst awaiting the services of an interpreter. It is currently available in 18 languages.
Although a family member may be on hand to assist with translation, there are several risks associated with this arrangement. For example, a patient may not feel comfortable discussing sensitive topics in front of a relative, or the relative may present their own version of events rather than directly translating what the patient says, which could lead to confusion and result in a complaint later on. In addition, there may be occasions where the patient expects their child to translate a conversation, and clearly there will be occasions when this is unsuitable, such as discussions around violence or sexual abuse.
It is therefore best to access professional translators where possible and local refugee organisations or the HSE may be able to suggest appropriate individuals or services, which may be in person, but might also involve telephone translation services. Double appointments are advisable if translation is required, as the consultation will inevitably be more time-consuming. Depending on the local population, it may be helpful to provide patient information leaflets and appointment booking forms in relevant languages.
The HSE has published a guide to the Irish health service, available in 17 different languages, detailing how to access different types of healthcare, and what to do in an emergency. Practices may wish to have copies of these available for patients.
Educating staff and patients
There may be anxiety about whether a refugee is entitled to register with a practice. It is important to ensure that reception staff have a basic understanding of the support that the Irish State provides for refugees and asylum seekers. Broadly speaking, patients claiming asylum are entitled to benefit from what is known as “direct provision”, and can have a medical card and therefore access to GP appointments free of charge.
The healthcare system in the patient’s country of origin may be very different to that in Ireland. At the initial consultation, it is helpful to have a discussion about the role of the GP and how to access care. An awareness of local refugee groups and support services can aid in signposting patients to alternative sources of help. Not all refugees’ needs will be medical and they may look to their GP, as a trusted member of society, for guidance.
Cultural awareness and other factors
Refugees form a culturally diverse group. People from different backgrounds react to stress in different ways, and there may be variation in the way in which particular conditions present. For example, multiple somatic symptoms may be a manifestation of depression. Some patients may find certain investigations unacceptable; others may hold a belief that it is best to actively forget bad experiences rather than to seek treatment, such as counselling. Some may ask to see a clinician of a particular gender, due either to their culture or past events. If it is not possible to arrange for this, an explanation should be given, and it may be helpful to arrange to have a chaperone of the preferred gender present during the consultation.
Continuity of care can be particularly important for refugees. A trusting relationship with a GP can be key to enabling disclosure of torture or rape, for example. Seeing the same individual over time can also mean that a distressing event does not need to be recounted at each appointment.
Refugees may present with a range of physical health problems. Many of these will be familiar to the GP; however, certain diseases may occur more commonly. For example, there may be a higher prevalence of infectious diseases, such as tuberculosis and human immunodeficiency virus in the patient’s country of origin. In the absence of a detailed past medical history, it may be necessary to do some epidemiological fact-finding.
Conditions during travel to Ireland may have been crowded and lacking in sanitation, leading to problems, such as scabies and gastroenteritis. Refugees may be living with the physical consequences of torture, such as post-traumatic head injury and brachial plexus injury as a result of suspension, malnutrition, and damage to eyes and ears. In women of child-bearing age, it is important to consider sexual health and family planning, as well as the possibility of unwanted pregnancy. Depending on the country of origin, female genital mutilation may have occurred.
Refugees are in a uniquely vulnerable position. Having often lived through traumatic experiences in their own country, they are then required to adapt to a new life in a different country, often without their usual support network. Unusual behaviour may be due to an acute stress reaction, but mental illnesses such as depression or psychosis, should also be considered and indeed are more prevalent in this population. GPs should be alert to the possibility of post-traumatic stress disorder, which is commonly seen in victims of torture. Symptoms can include flashbacks, avoidance and emotional numbing, and referral of these patients to a specialist psychiatric service is likely to be necessary.
Other roles for GPs
Outside primary care, doctors can play a valuable role in organisations supporting refugees, signposting individuals to medical services, or providing treatment. If you are involved in such work, it is important to inform your medical defence organisation to ensure you are appropriately indemnified.
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