Community-based asylum seekers' use of primary health care services in Melbourne

Self-harm in the Australian asylum seeker population: A national records-based study

Background

Systematic research into self-harm in the Australian asylum seeker population is scarce, largely due to the lack of accessible data. The aim of this study was to examine the incidence and characteristics of self-harm across the Australian asylum seeker population, and to ascertain whether self-harm rates and characteristics vary by processing arrangements (i.e. community-based arrangements, community detention, onshore detention, offshore detention (Nauru), and offshore detention (Manus Island)), and gender.

Methods

Data relating to the incidence of self-harm, method(s) used to self-harm, processing arrangements, and gender were extracted from all self-harm incidents recorded as occurring among the Australian asylum seeker population between 1st August 2014 and 31st July 2015. Self-harm episode rates were calculated using the average estimated adult population figures for the 12-month period for each asylum seeker population.

Results

949 self-harm episodes were included in the analyses. Rates ranged from 5 per 1000 asylum seekers in community-based arrangements to 260 per 1000 asylum seekers in offshore detention in Nauru. Rates were highest among asylum seekers in offshore and onshore detention facilities, and lowest among asylum seekers in community-based arrangements and community detention. The most common methods of self-harm were cutting (37%), self-battery (26%), and attempted hanging (11%), with asylum seekers in held detention using a wider variety of methods than those in community-based arrangements and community detention.

Conclusions

Our findings highlight the exceptionally high rates of self-harm among detained asylum seekers compared to rates observed in the general Australian population, and among asylum seekers in community-based settings. These findings point clearly to the deleterious impact of immigration detention, and warrant urgent attention.

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Rates of self-harm among asylum seekers were exceptionally high.

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Rates were highest in held detention, lowest in community-based settings.

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High rates of hanging were observed for both women and men.

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Asylum seekers in held detention used a wide variety of self-harm methods.

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Findings point to the deleterious impact of immigration detention.

The OPTIMISE project: protocol for a mixed methods, pragmatic, quasi-experimental trial to improve primary care delivery to refugees in Australia

BACKGROUND

Australia is one of many nations struggling with the challenges of delivering quality primary health care (PHC) to increasing numbers of refugees. The OPTIMISE project represents a collaboration between 12 organisations to generate a model of integrated refugee PHC suitable for uptake throughout Australia. This paper describes the methodology of one component; an outreach practice facilitation intervention, directed towards improving the quality of PHC received by refugees in Australian general practices.

METHODS

Our mixed methods study will use a cluster stepped wedge randomised controlled trial design set in 3 urban regions of high refugee resettlement in Australia. The intervention was build upon regional partnerships of policy advisors, clinicians, academics and health service managers. Following a regional needs assessment, the partnerships reached consensus on four core areas for intervention in general practice (GP): recording of refugee status; using interpreters; conducting comprehensive health assessments; and referring to refugee specialised services. Refugee health staff trained in outreach practice facilitation techniques will work with GP clinics to modify practice routines relating to the four core areas. 36 general practice clinics with no prior involvement in a refugee health focused practice facilitation will be randomly allocated into early and late intervention groups. The primary outcome will be changes in number of claims for Medical Benefit Service reimbursed comprehensive health assessments among patients identified as being from a refugee background. Changes in practice performance for this and 3 secondary outcomes will be evaluated using multilevel mixed effects models. Baseline data collection will comprise (i) pre-intervention provider survey; (ii) two surveys documenting each practices' structure and approaches to delivery of care to refugees. De-identified medical record data will be collected at baseline, at the end of the intervention and 6 and 12 months following completion.

DISCUSSION

OPTIMISE will test whether a regionally oriented practice facilitation initiative can improve the quality of PHC delivered to refugees. Findings have the potential to influence policy and practice in broader primary care settings.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12618001970235 , 05/12/2018, Retrospectively registered. Protocol Version 1, 21/08/2017.

The Asylum Seeker Integrated Healthcare Pathway: a collaborative approach to improving access to primary health care in South Eastern Melbourne, Victoria, Australia

It is important to address the health needs of asylum seekers within the early stages of their arrival in Australia, as this impacts all aspects of their resettlement. However, asylum seekers face a range of barriers to accessing timely and appropriate health care in the community. In 2012, the increasing number of asylum seekers in Australia placed additional demand on health and social services in high-settlement regions. Health providers experienced a substantial increase in Medicare ineligible clients and avoidable presentations to Emergency Departments, and the health needs of new asylum seeker arrivals were not being fully addressed. In response, South Eastern Melbourne Medicare Local, Monash Health, the Australian Red Cross and local settlement support agencies collaborated to develop an integrated healthcare pathway in South Eastern Melbourne to facilitate healthcare access for asylum seekers released from detention. From September 2012 to December 2014, a total of 951 asylum seekers transitioned through the pathway. Seventy-eight percent required primary healthcare assistance, and were provided with a service appointment within 3 weeks of their arrival in Melbourne. This initiative has demonstrated the value of partnership and collaboration when responding to emergent asylum seeker health needs.

The need for a rights-based public health approach to Australian asylum seeker health

Public health professionals have a responsibility to protect and promote the right to health amongst populations, especially vulnerable and disenfranchised groups, such as people seeking asylum and whose health care is frequently compromised. As at 31 March 2016, there was a total of 3707 people (including 384 children) in immigration detention facilities or community detention in Australia, with 431 of them detained for more than 2 years. The Public Health Association of Australia and the Australian Medical Association assert that people seeking asylum in Australia have a right to health in the same way as Australian citizens, and they denounce detention of such people in government facilities for prolonged and indeterminate periods of time. The position of these two professional organisations is consistent with the compelling body of evidence demonstrating the negative impact detention has on health. Yet in recent years, both the Labour and Liberal parties-when at the helm of Australia's Federal Government-have implemented a suite of regressive policies toward individuals seeking asylum. This has involved enforced legal restrictions on dissenting voices of those working with these populations, including health professionals. This paper outlines Australia's contemporary offshore immigration detention policy and practices. It summarises evidence on asylum seeker health in detention centres and describes the government's practice of purposeful silencing of health professionals. The authors examine how Australia's treatment of asylum seekers violates their health rights. Based on these analyses, the authors call for concrete action to translate the overwhelming body of evidence on the deleterious impacts of immigration detention into ethical policy and pragmatic interventions. To this end, they provide four recommendations for action.

Unemployment in Iraqi refugees: The interaction of pre and post-displacement trauma

Previous refugee research has been unable to link pre-displacement trauma with unemployment in the host country. The current study assessed the role of pre-displacement trauma, post-displacement trauma, and the interaction of both trauma types to prospectively examine unemployment in a random sample of newly-arrived Iraqi refugees. Participants (N = 286) were interviewed three times over the first two years post-arrival. Refugees were assessed for pre-displacement trauma exposure, post-displacement trauma exposure, a history of unemployment in the country of origin and host country, and symptoms of posttraumatic stress disorder (PTSD) and depression. Analyses found that neither pre-displacement nor post-displacement trauma independently predicted unemployment 2 years post-arrival; however, the interaction of pre and post-displacement trauma predicted 2-year unemployment. Refugees with high levels of both pre and post-displacement trauma had a 91% predicted probability of unemployment, whereas those with low levels of both traumas had a 20% predicted probability. This interaction remained significant after controlling for sociodemographic variables and mental health upon arrival to the US. Resettlement agencies and community organizations should consider the interactive effect of encountering additional trauma after escaping the hardships of the refugee's country of origin.

Social factors ameliorate psychiatric disorders in community-based asylum seekers independent of visa status

The impact of industrialised host nations' deterrent immigration policies on the mental health of forced migrants has not been well characterised. The present study investigated the impact of Australia's refugee determination process (RDP) on psychiatric morbidity in community-based asylum-seekers (AS) and refugees. Psychiatric morbidity was predicted to be greater in AS than refugees, and to persist or increase as a function of time in the RDP. The effect on mental health of demographic and socio-political factors such as health cover and work rights were also investigated. Psychiatric morbidity was measured prospectively on five mental health indices at baseline (T1, n=131) and an average of 15.7 months later (T2, n=56). Psychiatric morbidity in AS significantly decreased between time points such that it was no longer greater than that of refugees at T2. Caseness of PTSD and demoralisation reduced in AS who gained protection; however, those who maintained asylum-seeker status at T2 also had a significant reduction in PTS and depression symptom severity. Reduced PTS and demoralisation symptoms were associated with securing work rights and health cover. Living in the community with work rights and access to health cover significantly improves psychiatric symptoms in forced migrants irrespective of their protection status.

Noncommunicable diseases among urban refugees and asylum-seekers in developing countries: a neglected health care need

With the increasing trend in refugee urbanisation, growing numbers of refugees are diagnosed with chronic noncommunicable diseases (NCDs). However, with few exceptions, the local and international communities prioritise communicable diseases. The aim of this study is to review the literature to determine the prevalence and distribution of chronic NCDs among urban refugees living in developing countries, to report refugee access to health care for NCDs and to compare the prevalence of NCDs among urban refugees with the prevalence in their home countries. Major search engines and refugee agency websites were systematically searched between June and July 2012 for articles and reports on NCD prevalence among urban refugees. Most studies were conducted in the Middle East and indicated a high prevalence of NCDs among urban refugees in this region, but in general, the prevalence varied by refugees’ region or country of origin. Hypertension, musculoskeletal disease, diabetes and chronic respiratory disease were the major diseases observed. In general, most urban refugees in developing countries have adequate access to primary health care services. Further investigations are needed to document the burden of NCDs among urban refugees and to identify their need for health care in developing countries.

Mental health research and evaluation in multicultural Australia: developing a culture of inclusion

INTRODUCTION

Cultural and linguistic diversity is a core feature of the Australian population and a valued element of national identity. The proportion of the population that will be overseas-born is projected to be 32% by 2050. While a very active process of mental health system reform has been occurring for more than two decades - at national and state and territory levels - the challenges presented by cultural and linguistic diversity have not been effectively met. A key area in which this is particularly an issue is in the collection, analysis and reporting of mental health data that reflect the reality of population diversity. The purpose of this study was to examine: what is known about the mental health of immigrant and refugee communities in Australia; whether Australian mental health research pays adequate attention to the fact of cultural and linguistic diversity in the Australian population; and whether national mental health data collections support evidence-informed mental health policy and practice and mental health reform in multicultural Australia.

METHODS

The study consisted of three components - a brief review of what is known about mental health in, and mental health service use by, immigrant and refugee communities; an examination of national data collections to determine the extent to which relevant cultural variables are included in the collections; and an examination of Australian research to determine the extent to which immigrant and refugee communities are included as participants in such research.

RESULTS

The review of Australian research on mental health of immigrant and refugee communities and their patterns of mental health service use generated findings that are highly variable. The work is fragmented and usually small-scale. There are multiple studies of some immigrant and refugee communities and there are no studies of others. Although there is a broadly consistent pattern of lower rates of utilisation of specialist public mental health services by immigrants and refugees the absence of adequate population epidemiological data prevents judgments about whether the observed patterns constitute under-utilisation. There are virtually no data on quality of service outcomes. The examination of national data collections revealed multiple gaps in these data collections. The review of papers published in four key Australian journals to determine whether immigrants and refugees are included in mental health research studies revealed a high rate (9.1%) of specific exclusion from studies (usually due to low English fluency) and a much higher rate of general neglect of the issue of population diversity in study design and reporting.

CONCLUSIONS

While there are many positive statements of policy intent in relation to immigrant and refugee communities in national mental health policies and strategies there is virtually no reporting by Commonwealth or State and Territory governments of whether policies that are relevant to immigrant and refugee communities are effectively implemented. It is not possible, on the basis of the data collected, to determine whether immigrant and refugee communities are benefiting from the mental health system reforms that are being actively carried out. The majority of Australian mental health research does not adequately include immigrant and refugee samples. On the basis of the findings of this study eight strategies have been recommended that will contribute to the development of a culture of inclusion of all Australians in the national mental health research enterprise.

Access to primary health care services by community-based asylum seekers

OBJECTIVES

To determine whether community-based asylum seekers experience difficulty in gaining access to primary health care services, and to determine the impact of any difficulties described.

DESIGN, SETTING AND PARTICIPANTS

Qualitative study using semi-structured interviews between September and November 2010. Participants were community-based asylum seekers who attended the Asylum Seekers Centre of New South Wales, and health care practitioners and staff from the Asylum Seekers Centre and the NSW Refugee Health Service.

RESULTS

We interviewed 12 asylum seekers, three nurses, one general practitioner and one manager. Asylum seekers' responses revealed that their access to primary health care was limited by a range of barriers including Medicare ineligibility, health care costs and the effects of social, financial and psychological stress. Limited access contributed to physical suffering and stress in affected asylum seekers. Participants providing care noted some improvement in access after recent government policy changes. However, they noted inadequate access to general practitioners, and dental, mental health and maternity care, and had difficulty negotiating pro-bono services. Both groups commented on the low availability of interpreters.

CONCLUSIONS

Access to primary health care in Australia for community-based asylum seekers remains limited, and this has a negative effect on their physical and mental health. Further action is needed to improve the affordability of health care and to increase the provision of support services to community-based asylum seekers; extending Medicare eligibility would be one way of achieving this.

Representations and coverage of non-English-speaking immigrants and multicultural issues in three major Australian health care publications

BACKGROUND

No recent Australian studies or literature, provide evidence of the extent of coverage of multicultural health issues in Australian healthcare research. A series of systematic literature reviews in three major Australian healthcare journals were undertaken to discover the level, content, coverage and overall quality of research on multicultural health. Australian healthcare journals selected for the study were The Medical Journal of Australia (MJA), The Australian Health Review (AHR), and The Australian and New Zealand Journal of Public Health (ANZPH). Reviews were undertaken of the last twelve (12) years (1996-August 2008) of journal articles using six standard search terms: 'non-English-speaking', 'ethnic', 'migrant', 'immigrant', 'refugee' and 'multicultural'.

RESULTS

In total there were 4,146 articles published in these journals over the 12-year period. A total of 90 or 2.2% of the total articles were articles primarily based on multicultural issues. A further 62 articles contained a major or a moderate level of consideration of multicultural issues, and 107 had a minor mention.

CONCLUSIONS

The quantum and range of multicultural health research and evidence required for equity in policy, services, interventions and implementation is limited and uneven. Most of the original multicultural health research articles focused on newly arrived refugees, asylum seekers, Vietnamese or South East Asian communities. While there is some seminal research in respect of these represented groups, there are other communities and health issues that are essentially invisible or unrepresented in research. The limited coverage and representation of multicultural populations in research studies has implications for evidence-based health and human services policy.

Australian asylum policies: have they violated the right to health of asylum seekers?

OBJECTIVES

Notwithstanding recent migration policy amendments, there is concern that Australian asylum policies have disproportionately burdened the health and wellbeing of onshore asylum seekers. There may be a case to be made that Australian governments have been in violation of the right to health of this population. The objective of this paper is to critically examine these issues and assess the implications for public health practice.

METHODS

The author undertook a review of the recent empirical literature on the health effects of post-migration stressors arising from Australian policies of immigration detention, temporary protection and the restriction of Medicare to some asylum seekers. This evidence was examined within the context of Australia's international law obligations.

RESULTS

Findings reveal that Australian asylum policies of detention, temporary protection and the exclusion of some asylum seekers from Medicare rights have been associated with adverse mental health outcomes for this population. This is attributable to the impact of these policies on accessing health care and the underlying determinants of health for asylum seekers.

CONCLUSION

It is arguable that Australian Governments have been discriminating against asylum seekers by withholding access on the grounds of their migration status, to health care and to the core determinants of health in this context. In so doing, Australia may have been in violation of its obligation to respect the right to health of this population.

IMPLICATIONS

While the 'right to health' framework has much to offer public health, it is an undervalued and poorly understood discipline. The author argues for more education, research and advocacy around the intersection between heath and human rights.