Health service delivery for newly arrived refugee children: A framework for good practice
Conflict of Interest Notification: None.
Ms Lisa Anne Woodland, Multicultural Health Service, Level 1, McNevin Dickson Building, Randwick NSW 2031 Australia. Fax: +612 9382 3353; email: email@example.com
Aim: To propose a framework for good practice to promote improved access, equity and quality of care in service delivery for newly arrived refugee children.
Methods: Development of a framework based on national and international literature and current service models in Australian paediatric refugee health.
Results: Ten elements of a framework for good practice were identified: comprehensive health screening; coordination of initial and ongoing health care; integration of physical, developmental and psychological health care; consumer participation; culturally and linguistically appropriate service provision; inter-sectoral collaboration; accessible and affordable services and treatments; data collection and evaluation to inform evidence-based practice; capacity building and sustainability; and advocacy.
Conclusions: High-quality care can be achieved through a range of service models. The elements identified provide a framework for evaluating current services and for planning future service development. The framework for good practice can be applied to facilitate improvements in refugee health care and to reduce the gap between health needs and currently available services.
Australia accepts around 13 500 refugees per year under the Humanitarian Program, of whom 40–50% are children and adolescents.1 In keeping with the United Nations High Commissioner for Refugees and Commonwealth government priorities, there has been a shift in the regions of origin of the Humanitarian program in recent years, with increasing numbers from Africa and South East Asia regions. The term ‘refugee’ is used hereafter to refer to people arriving via the Humanitarian Program (including those sponsored by family or community groups), people seeking refugee status through the Onshore Protection Program (asylum seekers) and people of refugee-like backgrounds arriving via the Family Reunion Program.1
Refugees are a highly vulnerable and often traumatised population.2,3 Despite this, many of their health conditions are amenable to intervention, and comprehensive health assessment following resettlement improves short- and longer-term health outcomes.4–6 Particular issues for refugee children are immunisation coverage (which is universally incomplete compared with the Australian immunisation schedule), nutritional deficiencies, growth and developmental issues, poor dental health and often asymptomatic but clinically significant communicable diseases, including tuberculosis, hepatitis B and parasitic infections.4,7 Refugee children have often had interrupted education and multiple language transitions associated with migration, further affecting their development and learning. Mental health conditions such as post-traumatic stress disorder (PTSD), anxiety and depression are believed to be prevalent.8
A wide range of service models for refugee child health are currently in place in Australia (Table 1). Early refugee health assessments are often delivered in refugee specific services, such as those provided through community or hospital-based family clinics, paediatric screening clinics and/or torture and trauma services. In general, there is a separation of physical and mental health screening; only the Australian Capital Territory and South Australia have models providing co-located services. Ongoing health care for refugees is predominantly delivered within the mainstream health system, where multiple barriers to access have been documented.9–11
Table 1. Models of care for providing comprehensive health assessment on arrival to refugee children and their families In Australia
|General practitioners (GPs) in private practice with support from public health services||• Refugee Health Nurse Program, Victoria|
• GP–Hospital Collaborative Care Model, South Eastern Sydney Illawarra Health, New South Wales (NSW)
• Refugee Health Nurse Program, New England, NSW
• Screening programs in primary care settings are being developed in Queensland (QLD) and South Australia (SA)
|• Refugees linked with ongoing primary health provider|
• GPs able to offer care to whole family
• Often located in close proximity to where refugees are living
• Close links between primary care providers and hospital services
|• Ongoing recruitment of GPs interested and available to work with refugees|
• Coordination of care for children/families with multiple or complex health problems
• Some health issues not frequently seen in primary care setting
• Access to Mantoux testing and some treatments
• Different access pathways dependent on visa type
• Access to public health or bulk billing specialists
• High burden of pathology
|Specialised paediatric screening and/or referral clinics in hospital settings||• Royal Children's Hospital, Melbourne, Victoria|
• Health Assessment for Refugee Kids (HARK) Clinic, Children's Hospital Westmead, NSW
• Refugee Health Service, Princess Margaret Hospital for Children, Western Australia (WA)
• Refugee Child Health Clinic, Sydney Children's Hospital, NSW
• Liverpool Paediatric Clinic, Liverpool Hospital, NSW
|• Able to coordinate subspecialties required for children with multiple or complex health problems|
• Access to pathology, radiology, immunisation and pharmacy services
|• Unable to offer care to adult members of the family|
• Difficulties in transferring care to community GPs
• Often located some distance from where refugees are living
|Specialised family screening clinics in hospital or community settings||• Migrant Health Unit, WA|
• Migrant Health Service, SA
• Hobart Hospital, Tasmania
• Darwin Hospital, Northern Territory (NT)
• Newcastle Clinic, Hunter New England Health, NSW
• NSW Refugee Health Service Clinics, NSW
• Launceston Migrant Resource Centre, Tasmania
• Companion House, Australian Capital Territory (ACT)
• Centralised screening services, such as those in NT, ACT and Tasmania achieve 80–100% screening coverage
|• Able to offer care to whole family|
• Access to pathology, radiology, immunisation and pharmacy services
• Some community-based clinics located in close proximity to where refugees are living
|• Difficulties in transferring care to community GPs|
• Often located some distance from where refugees are living
• Some community-based clinics have difficulties with access to public health or bulk billing specialists, pathology, radiology and pharmacy services
• Only short-term care provided, except in the case of Companion House, which provides medium term GP services
Improved models of service provision are required to address the health needs of refugees and asylum seekers and to close the gap between identified needs and currently available services.12–14 While ongoing quality improvement, equity and public health frameworks are clearly central to refugee health provision, a specific framework informed by the relevant literature and the experience of existing services would facilitate more specific interventions and service developments. Service models differ with jurisdictions, but the generic elements of good practice are relevant for all service models and for future service development (Table 2). Furthermore, a national refugee health policy would assist in developing standardised high quality services across the country.
Table 2. Framework for good practice in health service delivery for newly arrived refugee children
|Framework for good practice|
| 1 Routine comprehensive health screening|
| 2 Co-ordination of initial and ongoing health care|
| 3 Integration of physical, developmental and psychological health care|
| 4 Consumer participation|
| 5 Culturally and linguistically appropriate service provision|
| 6 Inter-sectoral collaboration|
| 7 Accessible and affordable services and treatments|
| 8 Data collection and evaluation to inform evidence-based practice|
| 9 Capacity building and sustainability|
|10 Advocacy |
The proposed framework could be used by established services to develop local priorities by reviewing what is already in place and identifying service gaps and opportunities. The elements are illustrated with a range of practice examples from across Australia (Table 3).
Table 3. Practice Examples (Reformatted 23 May 2010)
|The Immigrant Health Service, Royal Children's Hospital, Victoria |
The service provides a multidisciplinary assessment for children/young people of a refugee background. The clinic has strong links with primary care providers performs initial health screening when required or act as a consultation service for issues arising in primary care.
|Comprehensive screening and coordination of care |
The service provides health and developmental assessment, dental review, full catch-up immunisations, and Mantoux testing. Pathology, radiology and pharmacy are all on site. All medications are supplied free of charge. Latent TB infection, TB disease, hepatitis B and other parasitic infections are all managed within the service, with input from relevant specialist units as required. Ophthalmology and Audiology appointments are coordinated with clinic times. Existing pathology and immunisation records are sourced from primary care providers and ACIR is checked. A detailed management plan is supplied to the primary care provider and the family.
|Companion House, Australian Capital Territory |
Companion House is an integrated service model which offers specialist counselling services for children and adults, community development, training programs and a medical service.
|Integration of physical, developmental and psychological health care |
All newly-arrived refugees in the ACT attend the medical service, where the counsellor and the GP work jointly with refugee families to undertake screening, assessment and advocacy. Refugee families have multiple routes into Companion House's services through its children's holiday program, community development activities and outreach to schools.
Companion House is a community-run not-for-profit non-government organisation directed by a community board, which includes refugees. The service has regular community consultation sessions for all programs and has the flexibility to reconfigure its service mix rapidly to meet emerging needs.
|Refugee Health Program, Victoria |
In 2005, the Refugee Health Nurse Program was established as the centre-piece of the Victorian Refugee Health and Wellbeing Action Plan 2005–08.22
|Culturally and linguistically appropriate service provision |
The refugee health nurse in the Western Region Health Centre in Footscray works alongside, access workers, a Dinka/Arabic interpreter and community development workers to provide culturally appropriate clinical services and health promotion programs. The latter include exercise groups, nutrition education, refugee men's cooking classes and chronic disease self management classes.
The refugee health nurse at Greater Dandenong Community Health Service has developed strong links with local community based organisations, This intersectoral collaboration has led to monthly cross agency planning and education meetings (including GPs, specialists, Divisions of General Practice, youth and settlement services), a drop-in service at the community health centre and a multi-agency refugee and asylum seeker health assessment clinic at Dandenong Hospital.
|The Paediatric Refugee Service, Princess Margaret Hospital for Children, WA |
Approximately 90% of refugee children are referred to the tertiary paediatric clinic at WA's tertiary children's hospital (Princess Margaret Hospital) with a defined medical issue identified on initial health assessment. The clinic has a holistic approach, with paediatricians, dietician, social worker, refugee community nurse and a refugee liaison nurse on staff.
|Accessible and affordable treatments |
Assistance with transport may be provided on the first visit and the clinic is located close to free public transport. The clinic dispenses frequently required medication and undertakes catch-up immunisations.
Data collection, monitoring and evaluation
Standardised clinical, laboratory and demographic data are routinely collected for all new patients. With appropriate ethical approvals and consents, both retrospective audits and prospective research has been conducted, aiming to develop an evidence base to guide ongoing clinical practice.
|GP-Hospital Collaborative Care Model, South Eastern Sydney Illawarra Health, NSW |
In 2007, Sydney Children's Hospital (SCH) implemented a collaborative care model in partnership with The Wollongong Hospital, the Area Multicultural Health Service and the Illawarra Division of General Practice. The model placed a network of refugee-friendly GPs in private practice at the centre of care for newly arrived refugee children and their families. GPs provide both routine comprehensive health assessment on arrival and ongoing care for families and are supported by specialists at SCH and TWH as well as a Refugee Health Nurse.
|Capacity building and sustainability |
The GP-Hospital collaborative care model was developed with the support of a number of small project grants which focused on developing the capacity of the health system to provide accessible and equitable care to newly arrived refugee children and their families. Strategies included development of partnerships with key service providers and the provision of education and training, clinical guidelines, referral pathways and other resources to GPs and service providers. Sustainability of the model has been ensured through successfully advocating for recurrent funding for a Refugee Health Nurse to provide support to refugees to access care, and the development of a refugee health portfolio within the MHS to provide organisational and research support.
What is already known on this topic
- 1Refugee children are a highly vulnerable group with specific health needs related to their background and experiences.
- 2Refugee families face multiple barriers in accessing appropriate care within the mainstream health system.
- 3There are significant complexities associated with the delivery of comprehensive, effective health care to refugee populations in Australia.
What this paper adds
- 1The ten elements identified provide a practical framework for improving access, equity and quality of care in service delivery for newly arrived refugee children.
Element 1: Routine Comprehensive Health Screening
Currently, there is no nationwide, coordinated system in place to support routine comprehensive health assessment for refugee children despite the Royal Australian College of Physicians' specific recommendation on this issue.9 Some states, territories and/or local area health services have implemented systems to capture refugees, but significant gaps remain, notably for families seeking asylum or those entering on sponsored or family reunion visas.
Many health conditions prevalent in refugee children have long-term individual health implications and to a lesser extent, public health implications if untreated. Lack of post-arrival health assessment represents a missed opportunity to improve the health status of refugee children. Only one in five refugee children arriving in New South Wales are assessed by specialised refugee services, and therefore, the challenge remains to establish adequate systems to ensure full capture.14 Furthermore, there are cost benefits associated with providing catch-up immunisation and the early detection and treatment of conditions such as malaria, tuberculosis and hepatitis B.5,6
Irrespective of jurisdiction or service model, comprehensive health assessment on arrival, guided by recent nationally agreed protocols, is fundamental to effective paediatric refugee health care.15–19 Refugee children and their families should be systematically linked to refugee health nurses, specialised assessment services and/or experienced and willing mainstream health providers. This requires inter-sectoral collaboration as well as capacity building within the health sector; the exact mechanisms will depend on local conditions and existing services.
Element 2: Coordination of Initial and Ongoing Health Care
Provision of accessible, equitable and quality care to newly arrived refugee children and their families requires coordination of care across screening providers and medical specialists in the initial period, and routine transfer to primary care for ongoing management. There is ongoing debate over whether general practitioners (GPs) in private practice in the community are able to overcome the multiple challenges in providing care to newly arrived refugees, or whether initial care should be provided by specialised refugee health services.20 There are advantages to both approaches.
GPs are well placed to provide holistic family-centred long-term care to refugees and are encouraged, through the Medicare item numbers 714 and 716, to play a central role in comprehensive health assessment for new arrivals. However, uptake of the item numbers has varied across states and territories and has been very limited for children.21 It is argued that it does not adequately remunerate GPs.20 In addition, many jurisdictions have limited systems in place to connect newly arrived refugees with GPs with the necessary interest and expertise in refugee health screening. Furthermore, considerable investment is required to develop specific expertise in refugee health.
Coordination of care across multiple services and specialties has been identified as a key challenge for GPs, especially in rural and regional settings where access to specialised training and support may be limited.20,21 Other issues identified by GPs include language and communication, social and cultural aspects of care and information regarding investigation and management of common refugee health conditions.15 Some of these issues can be readily overcome by linking GPs with refugee health services. Support by refugee health nurses has been shown to be effective in coordination of care across primary and tertiary settings.23 Specialist clinics linking multiple sub-specialists may also be beneficial in supporting GPs to provide continuity of care and in managing integrated health-care plans.
Specialised refugee services
Specialised refugee services (hospital-based paediatric clinics and community-based family clinics) provide comprehensive screening and mostly short-term follow-up to new arrivals. Staff may include sessional GPs, paediatricians, infectious diseases physicians, refugee or community health nurses, allied health professionals and/or bicultural workers. Significant issues faced by specialised clinics are avoiding duplication of pathology testing and immunisation and linking families with primary care providers.
Family-based services, where parents and children are seen in the same setting, are most convenient for refugees and may increase efficiency. However, significant challenges exist in providing the required blend of generalists and specialists, overcoming institutional barriers for adult physicians practising in paediatric settings and ensuring child-friendly practices in adult settings.
GP-run refugee-specific family clinics may more readily provide the range of initial screening and allied health services, but specialist referral is required for managing a significant proportion of patients. Referral rates to specialists vary across models and jurisdictions, ranging from 30% to 80%, presenting a significant burden of co-ordination to primary care providers and the expectation on families to attend multiple appointments.
While there has been much discussion as to whether refugee-specific services or mainstream health services are best placed to offer initial health assessments for refugees, there is general consensus that one of the goals of specialised services is to integrate refugees into mainstream health services for ongoing care.9,11,13,20
Element 3: Integration of Physical, Developmental and Psychological Health Care
Current screening guidelines tend to focus on physical health, but the high prevalence of co-morbidity suggests that screening for developmental and psychological conditions in refugee children may also be indicated.4 Given the history of trauma, dislocation and disadvantage, a holistic family-centred approach is warranted. At a practical level, this necessitates comprehensive assessment for physical, developmental and psychological conditions and reduced fragmentation of services across providers of physical health, child development, mental health and torture and trauma services.
Refugee children have significantly higher rates of PTSD (7–17%), childhood depression (4–47%), anxiety (11–23%) and behavioural difficulties compared with their non-refugee counterparts.8,24–26 Factors such as pre-migration exposure to torture and trauma, loss of family members, family separation, processes of seeking asylum, including periods in detention and post-migration social support, are significant predictors.8,26 While many refugee children display remarkable resilience and adaptability, mental health problems are often persistent.26–29
Refugee children are also reported to be at higher risk of experiencing developmental delay and learning problems; in practice, development is not fully assessed routinely, either prior to departure or on arrival in Australia.4,30 Given the likely inter-relationships in producing good health outcomes, further research is required to determine whether developmental and psychological screening is of benefit and the most appropriate timing, instruments and interventions.
Element 4: Consumer Participation
Active consumer involvement in health services is an integral component of improving the quality, accessibility and effectiveness of health services, yet this has been inadequately addressed in Australia.31 When involving refugees in consumer participation, careful consideration must be given to appropriate ways of identifying refugees and consulting with individuals of diverse gender, ethnicity, cultural background and religion, especially in the face of a dynamic demographic. Representation and the mandate to speak on behalf of the whole refugee community cannot be assumed, especially where various refugee communities may be settling within a given geographical area and ethnic groups may have a past history of conflict in their countries of origin or transit.
The development of strategies for culturally competent consumer participation is an important aspect of addressing inequities in health for refugee communities.32 Respectful and sensitive mechanisms need to be developed for recruiting, training, supporting and remunerating consumer or community representatives on health service committees and/or in support roles within the health system. A focus on those refugees who have direct experience with the health services may lead to practical strategies for service development and improving access.
Element 5: Culturally and Linguistically Appropriate Service Provision
Health services sensitive to their clients' cultural and linguistic backgrounds are more likely to improve access and equity, health literacy, communication, patient safety and quality of service provision.33 Health assessments conducted with an appreciation of clients' culture can provide clinically useful insight into the cultural/religious practices, dietary practices and health beliefs. This assists the clinician to tailor information regarding diagnosis and treatment and thus, to maximise the families' understanding and adherence. Refugee families may have limited experience or understanding of preventative health care or the management of asymptomatic conditions.
The use of professional interpreters for newly arrived refugees from non-English speaking backgrounds is a cornerstone of good clinical practice. Adequate conversational English may not be sufficient to comprehend health/medical issues including medical terminology. Professional interpreters, who are not family members or friends and who adhere to the principle of patient confidentiality, promote informed consent and enhanced client understanding. The use of telephone interpreters may be more appropriate for clients from small and emerging communities where concerns about confidentiality are magnified.
The use of patient education materials to support clinical interactions is well–established; however, generic resources may not be useful in that content may be inappropriate for the target group (such as common mechanisms of transmission of hepatitis B differing between developed and developing countries) and literacy levels may be lower than required. Refugee health networks can facilitate the sharing of appropriate resources.
Element 6: Inter-sectoral Collaboration
Collaboration within and between agencies and sectors is essential to improve health outcomes of refugee children. Collaboration with Department of Immigration and Citizenship (DIAC) and Integrated Humanitarian Settlement Strategy (IHSS) providers can identify newly arrived refugees in a given geographical area. Refugee children and their families can then be channelled systematically through to refugee screening services and/or linked with mainstream health providers equipped to provide comprehensive assessment. Provision of health manifests by DIAC and IHSS providers to medical practitioners, detailing pre-departure medical checks and treatments, provide useful information but does not reduce the need for a comprehensive post-arrival health assessment. Collaboration between local settlement services and health services is essential in ensuring that refugees are supported to attend health-care appointments and to track refugee arrivals, who frequently change address within the initial settlement period. A national refugee health policy that addressed other determinants of health, such as education, housing and employment, may also improve long-term health outcomes, social–emotional adjustment and educational achievement for refugee children.
Element 7: Accessible and Affordable Services and Treatments
Differential access to health services based on visa category and asylum seeker status (including those held in immigration detention) has varied significantly across Australia and the need for coordinated policy development across states and territories has been highlighted.10 The Pharmaceutical Benefits Scheme (PBS), the Commonwealth government's national drug subsidy system, has addressed the costs of some commonly prescribed medications for refugee families. However, even for non-prescription medication, such as vitamin D, the cost to refugee families may be prohibitive.17 Financial constraints, together with lack of transport, are major barriers for refugees accessing health services.11 Many services invest considerable resources in reducing these barriers.
Element 8: Data Collection, Monitoring and Evaluation
Routine standardised data collection, service evaluation and clinically relevant, culturally appropriate research are required in order to develop the evidence base to inform optimal care and service development.
Data on the long-term health of refugee children and their families settling in Australia are limited, as are those relating to health service utilisation and the long-term sequelae of common chronic conditions (such as hepatitis B, vitamin D deficiency, latent TB infection, Helicobacter pylori infection). The Longitudinal Survey of Immigrants to Australia indicated that a higher proportion of humanitarian entrants compared with other visa streams rated their health as ‘fair to poor’ and had higher levels of health-care utilisation 3.5 years post-arrival.34 Standardised and consistent data collection across health services, which requires specific funding support, would allow monitoring of the health of refugee children at a population level and would serve to guide service provision.35
Element 9: Capacity Building and Sustainability
Building health service and system capacity is required in order to meet the special and diverse needs of disadvantaged groups, including refugees and asylum seekers. The key challenges are the provision of both routine comprehensive initial assessment (often requiring specialist skills) and accessible, ongoing care that is universally available to all refugees settling in Australia. Special consideration is needed for refugees settling in rural locations where critical health infrastructure, primary care services and networks may be underdeveloped.36
Strengthening mainstream health services to enhance access and quality of care for refugees requires multiple strategies.13,37 These include the following: developing expertise and cultural competence within the workforce; providing resources to address the additional time and costs required to provide comprehensive care; incorporating use of interpreters as routine practice for non-English-speaking clients; building linkages between primary care and specialist services to deliver well-coordinated care; developing policies, protocols and organisational culture that is responsive to the needs of refugees; and developing cross-agency collaborations to address key determinants of health such as education and housing.16,37
Element 10: Advocacy
A number of professional bodies and advocacy groups have called for asylum seekers and refugees to have access to basic health care including Medicare, torture and trauma services, PBS medications and professional interpreters for dental, pharmaceutical and allied health services.9,10 Australian provision of health care does not fully comply with the United Nations Convention on the Rights of the Child, which promotes children's rights to optimal survival, development, health and access to health care without discrimination on any grounds and states that in all actions affecting children, their best interests must be a primary consideration.37 Considerable success has been achieved in advocating for the health needs of children in detention given the well-documented negative health and developmental outcomes.38–42 Key issues for continuing advocacy are summarised in Table 4.
Table 4. Key issues for continuing advocacy
|• Development of a comprehensive national health policy for refugees and asylum seekers|
|• Increasing availability of comprehensive health assessments for all refugee arrivals, irrespective of visa type|
|• Improving access to mainstream health services for non-acute conditions, including dental and allied health services|
|• Mechanisms to increase the use of professional interpreters (such as those provided through the Translation and Interpreting Service's Doctors' Priority Line)|
|• Developing a national approach to the routine collection and collation of data on access to care, epidemiology of health issues and long term outcomes|
|• Increasing allocation of resources to provide appropriate support to refugee families with complex needs|
|• Ongoing support for training positions in refugee health to increase the capacity of the workforce in this area |
The delivery of comprehensive and effective health care to refugee populations in Australia is complex but not insurmountable. These issues are evident at the clinical, health service delivery and systems levels. The Australian health care system must develop a capacity to consistently meet the complex needs of newly arrived refugee children. A national refugee health policy outlining minimum standards of care across all Australian health-care settings is a good place to start.
Different models have evolved in response to local needs and service environments. The elements within the proposed framework can assist in service development and evaluation by highlighting priorities for action in improving access, equity and quality of care for refugee children. Sustainable health solutions require an approach that integrates strategies and action at a range of levels including local, State and Commonwealth government.
The challenges in optimising physical, developmental and mental health outcomes for refugee children and their families are not unique. This framework may be informative to working with other disadvantaged groups. This review has been limited by the lack of readily available information about the long-term health and well-being of refugee children and their families settling in Australia and the paucity of data relating to health service utilisation by this group. Standardised data collection, service evaluation and clinically relevant, culturally appropriate research are required in order to systematically inform optimal care and service development.