CLINICAL PRACTICE Refugee health Health care of refugee women series BACKGROUND Women refugees have endured major discrimination and poverty in their countries of origin or countries of displacement. This has had a major impact on their physical and psychological health. The experience of resettlement places a further burden on their health. Daniela Costa OBJECTIVE MBBS, FRACGP, FPFA, is senior This article aims to provide a simple approach to the health assessment and management of women refugees, taking medical practitioner, Womens into account specific issues related to migration and resettlement. Health Statewide, North Adelaide, and visiting senior DISCUSSION medical practitioner, Migrant Because of the complexities of their realities related to gender, social and economic status, and premigration and Health Service, Adelaide, resettlement experiences, women refugees need a multiplicity of health interventions. The identification of the major South Australia. danielac@ physical and psychological health issues with consideration of gender issues and premigration and resettlement chariot.net.au experiences, represents more adequate basis for the assessment and management of the health care of women refugees. The complex experiences of women refugees in their Health issues – physical countries of origin and in refugee settings have a • Chronic diseases including diabetes, hypertension major impact on their health. In recent years, primary and heart disease health care services in Australia and other countries of • Infectious and parasitic diseases such as hepatitis B resettlement have addressed the specific health care and C, tuberculosis, malaria and schistosomiasis needs of women refugees. The aspects of assessment • Nutritional deficiencies such as folate, iron and and management described in this article are based vitamin D deficiency on the experience of these services including the • Anaemia – which threatens women more than experience of a state funded medical service for men because of chronic malnutrition and endemic women refugees in South Australia.1–5 deprivation. Common causes are: – iron deficiency due to chronic blood loss caused This article incorporates some of the procedures by intestinal parasitic infections, menstruation, developed by the service, a collaborative initiative malabsorption, multiple pregnancies close together between Women’s Health Statewide and the Migrant and concurrent, prolonged breastfeeding Health Service, started in 1994. – folate deficiency – hemoglobinopathies, commonly thalassaemias and Health issues sickle cell anaemia During life in their country of displacement, and in refugee • Reproductive health issues12,13 camps where they may have spent protracted periods, – high rates of poor pregnancy outcomes (miscarriage, women refugees have been routinely exposed to violence preterm labour, low birth weight babies), unsafe and extreme poverty. Furthermore, access to basic needs abortions such as adequate food and water, education, and income – complications from gynaecological surgery generating and resettlement opportunities would have – complications of female genital circumcision including been limited. These factors, together with the relative lack vulval scarring and chronic vulva and pelvic pain, of gender specific health care, have had a major impact on urinary tract infection, menstrual problems and their physical and psychological health.6–10 complications during pregnancy and childbirth At their point of entry in countries of resettlement • Sequelae of gender based violence women, like men, are likely to experience a large number – physical effects – mutilation and deformities leading 11 of acute and chronic health problems. to chronic musculoskeletal problems, sexually Reprinted from Australian Family Physician Vol. 36, No. 3, March 2007 151 CLINICAL PRACTICE Health care of refugee women transmitted infections (STIs), notably HIV, interpreter and adequate allocation of • Mental health history including: chlamydia, syphilis and gonorrhoea. time. The interpreter’s role as the woman’s – details of experience of PTSD, anxiety, – psychological effects – post-traumatic ‘voice’, in the background, and bound, depression, grief and loss and somatic stress disorder (PTSD), anxiety, depression, like the practitioner, by absolute respect of symptoms (see Case study 2). low self esteem, relationship difficulties; confidentiality must be stressed. The constant Physical examination somatic symptoms of fatigue, headaches, focus of the consultation must be between insomnia, generalised pain and anorexia the practitioner and the woman. The request to It is important to consider that many women • General conditions including dental involve a family member, in particular a spouse, are unfamiliar with their anatomy, in particular problems and incomplete immunisation. often presents a cultural challenge. While sometimes it may be appropriate initially Health issues – mental Case study 1 to do so, it is important to point out that Mrs B migrated to Australia with Resettlement stress arises from dealing with accurate diagnosis and management her husband and five children pressing needs such as housing, transport, require the language skills of a qualified after having spent 4 years in a refugee camp in Guinea. They finances, social security and immigration. interpreter who should be booked for lived in Liberia until the war broke Increasingly, women head many newly arrived future consultations. out in 1996. She was assaulted African families. Adjusting to a new culture Time has a cultural meaning. The time to and sustained major injuries to brings about change in roles and the dynamic greet, smile and involve family members can the pelvis and legs. Her son and of relationships within the family, which open new paths in developing trust and rapport. brother were killed. The family was taken to the Ivory Coast by can often become strained. As a result History taking peacekeeping forces. In 2002, many women become more vulnerable to when another war erupted, while family violence. • History of health problems and treatment fleeing to Guinea, they become Grief is experienced because of the loss of before migration separated from the two older children. Soon after their arrival to or traumatic separation from their loved ones • Migration and resettlement history Australia, the Red Cross located whose whereabouts are often unknown. Women detailing life in country of origin, country of the children in a refugee camp may also be in constant fear for the safety of their displacement other host countries, or time in Kenya. With the support of the relatives left behind in the countries still stricken spent in refugee camps. Australian Refugee Association, she applies for a resident visa for by conflict, or in refugee camps. As a result the It is also important to enquire about the her children and patiently engages memories of past trauma are kept alive.5,14 woman's circumstances of seeking refuge with the immigration department. and with whom she migrated, time separated Health assessment from family, family left behind and if she is in Assessment and management require touch with them, the current composition of Case study 2 understanding of the impact of culture and her family, relationships and adjustment, how Mrs D and her two teenage of migration and resettlement on the health she deals with multiple resettlement demands, daughters are refugees from of women refugees. The explanatory model and links with her own community and support Afghanistan. The Talibans killed approach proposed by Kleinman has provided agencies (see Case study 1). her husband 7 years ago. For the past 12 months she has a suitable framework to establish a culturally • Reproductive health history including: been suffering from constant sensitive therapeutic relationship.15 – obstetric and gynaecological history with headaches, generalised body The model emphasises a patient centred specific attention to complications during aches, intermittent episodes of left approach to explore the influence of culture on pregnancy, delivery, abortion and menstrual sided chest pain, palpitations and shortness of breath. Apart from health, on the perceived causes of illness and on problems mild hypertension, no causes are therapeutic relationships. Therefore, by following – contraceptive history found for her symptoms. Since the woman’s narrative of her presenting – sexual history including past history of coming to Australia, her appetite problem, the practitioner gains insight into how STIs and level of awareness of safer sexual and sleep have been poor. She constantly thinks about her two the woman ‘understands, feels, perceives, practices sons left behind in Pakistan and and responds’ to the problem and also what – female genital circumcision and related spends most of her time at home, is at stake for her family and community. The complications. As many women may not as she has stopped attending model also provides the practitioner with self find it appropriate to talk directly about this English classes because of monitoring tools to critically reflect on the issue, it is useful to start by enquiring about difficulties with concentration. Above all, she fears that if she dies impact of his/her belief system and practices. cultural/family practices. This issue may be suddenly there will be no-one to Important elements of the therapeutic further addressed as part of the preventive look after her daughters. encounter are the use of a