Mar 01, 2016
By Laura Eggertson

Focused on helping move refugees forward

New guidelines and health-care professionals promote advocacy, empathy and support as critical components of caring for refugees

When nurse practitioner Vanessa Wright began working with refugees at the Crossroads Clinic at Toronto’s Women’s College Hospital in 2011, she braced herself for the difficult stories she thought patients would disclose about their journeys and the trauma that precipitated their flights.

But instead of traumatic disclosures, what Wright and fellow NP Roseanne Hickey initially encounter are a variety of health-care needs and questions about the way life in Canada works.

“What I hear more about is people striving to acculturate,” says Wright. The 10 to 12 patients each NP sees on a typical day are focused on adjusting to their new reality. They want to know how to enrol their children in school, to understand how public transit and the health-care system work, and where to look for jobs.

“Our job is to keep them moving forward,” says Hickey.

That experience of helping refugees with their health-care needs, from vaccinations to contraception, and of supporting and advocating for them in the community is exactly what health-care providers treating newly arrived Syrian refugees should do, according to guidelines published in January in CMAJ.

It is understandable that some health-care professionals might think they will be concentrating on mental health needs and possible post-traumatic stress disorder (PTSD), given media coverage of the war in Syria and images of starving children in Madaya that have circulated on Facebook and Twitter.

While mental health issues are a concern and may emerge in a proportion of the Syrian refugee population, the new guidelines caution against routinely screening for PTSD or trauma. That could potentially re-traumatize patients, says the lead author of the guidelines. Dr. Kevin Pottie is associate professor of family medicine, epidemiology and community medicine at the University of Ottawa’s Bruyère Research Institute.

“We don’t want to overreact to the fact that there has been trauma. We don’t want practitioners to overscreen. But when symptoms appear, we want people to be aware of them.”

Establishing supportive relationships and getting to know patients is the goal, Pottie says. If symptoms such as anxiety, depression and insomnia emerge, treatment or referral to specialists can be provided.

Pottie and four colleagues offered to prepare “Caring for a Newly Arrived Syrian Refugee Family” in response to concerns from many care provider groups, particularly about the scale of the migration to Canada. At the time, he was already drafting evidence-based guidelines on migrant care for the European Union and felt it was important that Canadian practitioners have an authoritative source to consult.

Pottie was also a lead author of comprehensive guidelines developed in 2011 for treating all refugee groups. In developing the new document, the authors used updated data on Syrian refugees in Turkey, Jordan and Lebanon and considered emerging diseases in the refugees arriving in Europe.

Because Syria had a well-regarded health and education system prior to the war, Pottie expects its refugees to adapt well to life in Canada. “In some ways, they may have fewer health problems overall than some of the other refugee populations we’re seeing,” he says.

Wright and Hickey are familiar with both guideline documents and encourage nurses, in all practice settings, to read them.

At Crossroads, they work with refugees for up to two years before transitioning them to primary care providers in the community. Refugees usually begin to disclose their stories only after that trusting relationship is strong, says Hickey.

“A lot of people do quite well, even with horrendous trauma history, after they are settled and are supported here and through other organizations.”

In the initial appointments they have had with Syrian families so far, Wright and Hickey say they have been struck by their patience and level of engagement and by the number of children. One family they saw recently has eight children. The NPs have made referrals for dental care and for long-standing injuries and begun to address chronic health conditions. In the next visits, they will move on to discuss cervical cancer screening, contraception, immunizations, mental health and nutrition.

One issue the guidelines don’t discuss in detail is the challenge of working with interpreters. Patients will sometimes arrive at appointments with an interpreter, but it may be up to the health-care provider to facilitate phone access to interpreters, say the NPs. Either way, they try to schedule extra time for appointments as a result.

As the guidelines emphasize, advocacy, empathy and support are critical factors in ensuring the refugees will successfully transition to life in Canada. That support may include helping with such basic needs as how to fill a prescription, which can be daunting for refugees who aren’t accustomed to taking a slip of paper to a pharmacy for their medication.

“The support we give as case managers and patient advocates is as important as our clinical interventions,” says Wright. “Writing letters for patients for a refugee hearing, connecting them with specialists in child health, counselling and social work, and helping them navigate health insurance are all in a day’s work for us.”

Of course, the most critical tool to employ is kindness, which helps reassure the refugees as they begin to navigate the health-care system. “A smile goes a long way. People are people. They’ve been through a lot of difficulty, but when you see them with their children, you realize they’re the same as you and me.”

Summary of clinical recommendations for the care of Syrian refugees

  • Should not routinely screen for trauma but should remain alert for impairment of social functioning or high levels of suffering that may be related to posttraumatic stress disorder, depression or anxiety disorders, or exposure to war-related violence, and should refer patients to the appropriate services for assessment and follow-up.
  • Should vaccinate all children and adults without a record of complete vaccination. Depending on age, these may include measles, mumps, rubella, diphtheria, tetanus, pertussis, Haemophilus influenzae B and polio.
  • Should not offer testing for latent tuberculosis (TB) because the incidence of active TB in the Middle East region remains low.
  • Should screen all children and adults for chronic hepatitis B virus infection and prior immunity, and vaccinate those who are susceptible.
  • Should consider serologic testing for varicella in refugees 13 years of age and older and vaccinate those who are susceptible; many Syrians are likely immune.
  • Should consider screening for hepatitis C virus infection; prevalence of this infection in Syrian refugees is currently uncertain, but war may have increased its prevalence.
  • Should consider serologic testing for the intestinal parasite Strongyloides stercoralis but should not collect stool samples in asymptomatic patients.

From “Caring for a Newly Arrived Syrian Refugee Family,” by K. Pottie, C. Greenaway, G. Hassan, C. Hui, and L. J. Kirmayer, 2016, CMAJ. Reprinted with permission.

Also recommended by Wright and Hickey

Laura Eggertson is a freelance journalist in Ottawa.

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