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Meeting the needs of refugees

Those fleeing war and repression present a new set of challenges for health services, writes Alex Turnbull.

The British government has pledged to accept 20,000 asylum seekers from refugee camps in Syria by 2020.1

This means that the NHS will see an influx of people with complex physical and mental health conditions requiring treatment. The variety of conditions means nurses will often require specialist knowledge to provide refugees and asylum seekers with the care they require. ‘Treating refugees really needs to be seen as a specialism,’ says Dr Jane Gray, a former practice nurse and director of Leicester’s ASSIST practice, which specialises in the treatment of refugees and asylum seekers. ‘Their needs are incredibly different [to a typical member of the general public] and complex, and nurses must understand that.’

The former Health Secretary Jeremy Hunt previously stated that the treatment of foreign nationals costs the NHS approximately £200 million each year, or 0.2% of its budget. However, it could be argued that the complexities present in this population requires more funding.

There also is not a national strategy for treating asylum seekers and refugees. This has led to some areas, typically urban localities with a diverse population, offering specialist services for refugees and asylum seekers, while other areas lack any specialist services.

A report by the Faculty of Public Health2 identified four major categories of healthcare that commonly arose among asylum seeker and refugee populations, including long-term conditions, sexual health, communicable disease, and the consequences of injury and torture, while the mental health of refugees and asylum seekers has also been cited as an issue to recognise (See Box). Nurses should also be aware that a large proportion of those with asylum seeker status come from regions where female genital mutilation is prevalent,3 which may lead to
a rise in the number of cases found in their settings.

Nurses can learn about infectious diseases that may not be common in the UK, from guidance published by the Department of Health (DH).4 The guidance states that symptoms in migrants should be assessed as for non-migrant patients; however, where infectious disease is suspected the differential diagnosis should not only include infections commonly acquired in the UK, but also those that may occur in their country of origin. ‘Healthcare practitioners should remain vigilant for this and investigate and manage appropriately,’ it states.

Refugees and asylum seekers will often have endured unimaginably traumatic situations in their countries of origin and in transit to the UK. Many refugees report being subjected to torture, rape and other acts of brutality.

Dr Gray says: ‘When people arrive in this country, they are often in a state of total distress. The traumas of their journey can severely affect their mental health. Many have been tortured, incarcerated, beaten to the point of disability, and raped. Nurses need to understand this, and it is crucial that they know where people who have suffered these experiences can be referred to for support.’

A report by mental health charity Mind5 found that traumatic situations in their country of origin, and during the journey to the UK, the effects of UK government legislation, and cultural barriers can contribute to the development of mental health conditions.

Other research2 has found that conditions such as depression and anxiety are common in refugees and asylum seekers, but post-traumatic stress disorder is ‘greatly underestimated and underdiagnosed’ and may be contested by healthcare professionals. The research states that children are particularly neglected in this area and that there is shortage of mental health services tailored to the needs of asylum seekers.

Research has found that the experience of asylum seekers when they reach the UK can also have a detrimental impact on mental and physical health. The authors of a BMJ study which looked at the specific health needs of asylum seekers and refugees in the UK commented that they ‘face the effects of poverty, dependence, and lack of cohesive social support. All these factors undermine both physical and mental health. Additionally, racial discrimination can result in inequalities in health and negatively impact on opportunities and quality of life’.6

Long-term conditions
Syrians have left a country where much of the health infrastructure has been shattered by nearly five years of civil war. This is typical of many refugees and asylum seekers who arrive from countries where healthcare services are unavailable or inaccessible due to an unstable political situation. This means when refugees and asylum seekers arrive in the UK, they may not be fully vaccinated, and often have undiagnosed conditions such as COPD, hypertension, and diabetes.

‘It is common to see conditions such as diabetes undiagnosed when refugees reach the UK,’ Dr Gray says. ‘When an asylum seeker first accesses primary care, nurses should make sure they test for common conditions which may have remained undiagnosed in their home countries.’

The lack of available healthcare in many countries mean that asylum seekers and refugees may not know how to support their own health. For example, uptake rates for cervical and breast cancer screening are typically poor in comparison with the general population.2

‘It is so important for patients to understand their conditions,’ Yvonne Keene, the refugee nurse from Guy’s and St Thomas’ NHS Foundation Trust’s community inclusion team, says. ‘It is a matter of reminding them that they should attend check ups and screenings. It is also important to educate patients on self-care of conditions they have.’

This wide range of issues has led to the development of specialist teams in certain local authorities with a large migrant population. Ms Keene highlighted the varied nature of the provision of these services, saying that while most boroughs in inner London had teams specifically for refugee, asylum seekers, and other vulnerable groups, many regions outside metropolitan areas did not. As asylum seekers and refugees can be dispersed to any part of the UK, the lack of a specialist services in some counties is problematic.

‘We run a specialist service for asylum seekers and refugees, as well as other vulnerable groups.’ Ms Keene says. ‘You tend to see teams in inner-city areas. However, the outer areas might not have these services.’

Cultural factors
Very few countries in the developing world have a universal free health service such as the NHS7, and the concept of free healthcare may not be immediately recognisable for many people who come from those countries. ‘A lot of patients do not understand that healthcare in this country is free’ says Dr Gray. ‘It is vital that nurses explain to them that the only thing that it will cost them to attend check-ups, screenings and vaccinations is their time.’

Nurses must take the fact that many asylum seekers and refugees are recent arrivals to the UK, and may not speak any English into consideration. Many will require the use of interpretation services, either with a face-to-face interpreter or the Language Line service. Ms Keene, however, says that patients with limited English skills often want a relative to translate for them, frequently using a child.

Ms Keene says: ‘We absolutely discourage this. A child may not understand the condition they are talking about, and patients may be unwilling to speak frankly to a healthcare professional through a child. It’s also important for receptionists to be clear on this.’

There are a variety of resources available for nurses to overcome this. Alongside translation services, the DH has produced information for patients in various languages such as Urdu, Somali, and Polish to improve the public health knowledge of migrant patients. These are designed to educate patients on issues such as immunisation and conditions such as measles and rubella. Ms Keene also advocates targeting media such as newspapers and television programmes made for specific communities with public health campaigns.

With no sign of the humanitarian crises ravaging countries such as Syria, South Sudan, and Eritrea abating in the near future, it’s likely that the UK will continue to see an increase in the number of refugees and asylum seekers. The unique needs of these vulnerable people will continue to represent a challenge to nurses and other healthcare professionals. ‘People seeking humanitarian protection can suffer extreme poverty, isolation, loneliness and vulnerability’ says David Parker-Radford, director of the homeless health project at the QNI.

‘For people who have left unimaginably traumatic circumstances, nurses and other health professionals offer empathy, hope, care and compassion. Nurses use and develop their knowledge and skills to help these people connect to their strength and ensure they have access to all the care they need.’

1. Public Health England. Migrant health guide.

2. Public Health England. Immunisation: why our children must be protected (DVD). 2015.

1. UNCHR. The facts: Asylum in the UK.

2. Faculty of Public Health. The health needs of asylum seekers.

3. Refugee Legal Aid. Female genital mutilation: Grounds for seeking asylum.

4. Public Health England. Migrant health guide.

5. Mind. Improving mental health support for refugee communities –an advocacy approach.

6. Burnett A and Peel M. Health needs of asylum seekers and refugees. BMJ. 2001 Mar 3; 322(7285): 544–547.

7.Wikipedia. Universal health coverage by country.