Refugee health for healthcare providers

For health providers, it is very important to understand the very different backgrounds and health needs of refugees as most are at risk of significant health issues. Specific focus on refugee health is required to ensure this vulnerable population receives optimal care and support. Refugee families also need additional support and guidance as they learn to navigate a health system that's often very different to healthcare in their homeland and previous experiences in refugee camps or countries. 

Any person who, owing to a well founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his/her nationality and is unable, or owing to such fear, is unwilling to avail himself/herself of the protection of that country.  1951 Refugee Convention.(external link)

Refugees are at much higher risk of a number of physical and mental health issues. These include: 

• Body modification
• Lifestyle changes after adopting western lifestyles of smoking, alcohol use, physical inactivity etc. 
• Circumcision (male)
• Dental disease
• Failure to thrive in children under two years
• Haemoglobinopathies
• Infectious diseases eg Hepatitis B and C, HIV, AIDs, and tuberculosis
• Parasitic diseases
• Nutritional deficiencies eg Vitamin A and D deficiencies
• Trauma and infections from rape and sexual assault.
• Chronic lung disease (COPD) from indoor cooking fires, smoking etc
• Sexual and reproductive health issues 
• Female genital mutilation

Common mental health issues in children, young people and adults such as: 

• Anxiety and depression
• Eating disorders
• Grief and loss
• Post-traumatic stress disorder
• Psychosomatic disorders
• Substance abuse
• Torture and trauma experiences

Higher rates of special health and disability needs:

• club feet
• untreated cerebral palsy
• blindness and hearing impairment 

These issues can be further compounded by differing health beliefs, cultural practices and high use of complementary therapies. 

Other areas to consider: 

• Immunisation
• Understanding of medications and how to take correctly 
• Ensure access to good nutrition and dietary information
• Catch up with usual screening programmes, breast screening, cervical screening, heart and diabetes checks.
• Contraception and antenatal care

For more information about each of these areas and a medical examination guide, refer to the Refugee Health Care: A handbook for health professionals, 2012.(external link) 

As explained in the 2012 Refugee Handbook(external link), the ‘refugee experience’ refers to the physical, psychological and social experiences of refugees as they flee conflict and persecution and seek safety.

“Refugee experiences are diverse. Some refugees, such as those from Southern Sudan, have endured years of warfare. Others, such as the Hazara from Afghanistan, have suffered internal displacement or repression within their own countries for long periods. Still others have been subjected to siege conditions in their home towns and cities, as in Burma, or have lived through the terror of total anarchy, as in Somalia. Many have survived detention, physical violence, rape and perilous journeys to countries of asylum, only to endure a hand-to-mouth existence in dangerous overcrowded camps or urban refugee environments.”

• Re-migration experiences may lead to high health needs on arrival.
• Very few refugees have emerged from their experiences without having endured or witnessed some form of physical or psychological trauma.
• Approximately 40 percent of refugees have experienced severe trauma, such as witnessing killings – often of their own family members.
• Long-term physical and psychological suffering are a common feature of the ‘refugee experience’.

After living in New Zealand for a number of years, additional health problems can arise which are associated with lifestyle changes which can result in adverse health patterns eg mental health conditions, uptake of tobacco smoking, increasing obesity, and reduced physical activity.

Refugee groups require tailored and targeted health interventions. In particular, health services which are culturally and linguistically responsive to the refugee groups that they serve will improve access, provide early intervention and reduce avoidable hospitalisations.

Culturally appropriate and safe care may include consideration of a broad range of areas including language, migration history, religious beliefs, cultural values, health beliefs, health seeking behaviours, and non-western models of health more generally. Additionally, the unique ways in which these intersect with other identities such as age, gender, sexual orientation, socioeconomic position, and visa status, require attention.

There are 3 ways in which refugees arrive in New Zealand:

1. Under the United Nations High Commissioner for Refugees (UNHCR) mandated quota system (‘quota refugees’)

• The quota for UNHCR-mandated refugees to enter New Zealand is set annually by Cabinet.
• Currently the quota is set at 1500 per year. Read more here.(external link)
• On arrival, quota refugees spend a 5-week orientation period in the Te Āhuru Mōwai o Aotearoa(external link) (Mangere Refugee Resettlement Centre).
• During the 5-week orientation period health screening, assessment and treatment is provided by Te Whatu Ora Counties Manukau's Mangere Refugee Health Service (MRHS) which operates as their primary care practice. Once they are settled in new regions, their notes will be sent to receiving practices. 

2. As refugee family-sponsored migrants under the Refugee Family Support Category – RFSC (‘family reunification’)

• Those entering the country under this category are relatives of refugees already living in New Zealand.
• The objective of the RFSC is to help refugees living in New Zealand to settle by allowing the sponsorship of family members for residence in New Zealand who do not qualify for residence under any other immigration policy.
• The sponsored relatives may be refugees, but this is not a requirement of the policy.
• The application costs and the air travel are generally met by relatives who are themselves often struggling with their own resettlement costs and challenges.
• There are 600 residence places available under the RFSC annually. Read more here.(external link)

3. As spontaneous refugees (‘asylum seekers’)

• Asylum seekers usually seek refugee status on arrival at our borders, or when their temporary visa or permit expires.
• Claims for refugee status are confirmed or rejected by Immigration New Zealand depending on whether their circumstances meet the criteria set out in the UN Convention Relating to the Status of Refugees.
• Those who are successful are then eligible to apply for permanent residence and later, New Zealand citizenship.

In the last 2 decades the largest groups of refugees to New Zealand have come from:

• Vietnam
• Laos
• Cambodia
• Burma
• Iran
• Iraq
• Afghanistan.

Refugees have also come from:

Tunisia, Palestine, Syria, Kuwait, Algeria, China, Sri Lanka, Bosnia, former Yugoslavia, Somalia, Djibouti, Eritrea, the Sudan, Ethiopia, Burundi, Rwanda, the Democratic Republic of Congo (DRC), Republic of Congo (Congo-Brazzaville), Sierra Leone, and Colombia. More recently, NZ has accepted refugees from Ukraine. 

Studies have shown the use of professional interpreters is an important safety and cultural factor for refugee health. Most regions now have access to interpreter services. Contact your local hospital or read more in the languages section. 

Migrant and refugee health overview