Initial Medical History in Refugee Patients

INITIAL MEDICAL HISTORY IN REFUGEE PATIENTS

As for any new patient accepted in a family physician's practice, a complete medical history should be performed for new refugee patients. However, some specific elements should be included in their initial medical history. Most of the following recommendations are based on the CMAJ Evidence-based clinical guidelines for immigrants and refugees (Pottie et al., 2011).

General Interview
LANGUAGE BARRIERS

This is a very common issue with newly arrived refugees or refugee claimants, but it should never prevent these people from accessing quality healthcare. A professional phone or in-person interpreter should be used. Family members should only be used to interpret as a last resort. LanguageLine Solutions provides professional interpreting services over the phone and is available at all Alberta Health Services (AHS) and Mosaic Primary Care Network clinics.

CONFIDENTIALITY

At the start of the intial visit, we usually inform refugee patients about the confifentiality of medical appointments and medical records. This usually helps building a relationship of trust with these patients. This is especially true for refugee claimants who have to be reassured that the information they share with their family physician will not affect their refugee claim in any way.
GEOGRAPHIC HISTORY

It is essential to know in which countries patients have lived in (and when) during their lives. This will have an impact on the screening tests that should be ordered for these patients and on the differential diagnoses of some clinical presentations (e.g. fever). Often, refugees and refugee claimants will have transitioned through different countries before arriving in Canada. It is also important to ask patients if they have stayed in a refugee camp, since this can be a risk factor for multiple conditions (e.g. gastrointestinal parasites).
Infectious Diseases
HISTORY OF INFECTIOUS DISEASES

Specifically inquire about any history of hepatitis, HIV, Tuberculosis, and malaria (especially recent malaria episodes).

PREVIOUS LATENT TUBERCULOSIS SCREENING

While most refugees and refugee claimants will have had a chest X-ray done as part of their routine Immigration Medical Examination, this is only done to screen for active tuberculosis and most patients will have never been tested for latent tuberculosis. It is still important to ask if a tuberculin skin test was already performed to prevent repeating the test needlessly. Patients who have gone through the USA or another Canadian province will often have been screened already. See the Recommended Initial Screening Tests section for the indications of latent TB screening.
VACCINATION HISTORY

Even if patients remember being vaccinated, they should not be considered immunized unless they have appropriate immunization records. While some refugees have pre-departure immunization records from the International Organization for Migration (IOM), most refugees and refugee claimants do not possess proof of vaccination. 

The CMAJ guidelines recommend adults to have had at least 1 MMR dose, a complete diphtheria/tetanus/pertussis/polio series (3 doses) and serologic proof of immunization against hepatitis B and varicella to be conidered adequately immunized. Vaccination against human papillomavirus is also recommended for female patients between the age of 9 and 26 years old. Adults who do not have records showing the above immunizations, and all pre-school age children should be referred to a local vaccination clinic for age-appropriate vaccination. In Canada, school-age children should be routinely vaccinated through school by a public health nurse (the immunization schedule may vary depending on the province).
Women's Health
CONTRACEPTION

Using a culturally sensitive approach, all refugee women of reproductive age should be asked about their contraception history and desire for a contraception method. This should preferably be discussed with the patient alone in the room. While all the usual contraception methods are valid options, we usually prefer intra-uterine devices and medroxyprogesterone acetate injections at the Calgary Refugee Health Program. This is because the methods present less risk of non-adherance (compared to oral combined contraceptive pill for example), which is a common issue in refugee patients. However, we have found that some refugee women prefer to continue having their monthly period. Patients should thus be counselled about this before being prescribed a birth control method. 
CERVICAL CANCER SCREENING

Most of our newly arrived female refugee patients have never been screened for cervical cancer. It is thus important to ask about previous Pap tests and discuss the importance of this screening program. Screening recommendations for refugee women are that same as for the rest of the population (every 3 years between the ages 25-69). While we rarely perform a Pap test on the first visit (remember that this is an invasive procedure), we recommend discussing it as soon as possible. If a patient is not comfortable having a Pap test done by a male physician, she should be offered a referral to a female practitioner.
Mental Health
DEPRESSION

While we do not recommend routinely screening for depression, physicians should pay special attention to potential depressive symptoms. This is a very common issue in the refugee population and patients will often present with somatic symptoms (non-specific headaches, abdominal pain, fatigue, dizziness, etc.). If symptoms of depression or any other mental illness do become apparent or if the patient raises concerns about their mental health, appropriate counselling and/or referral should then be offered. 
POST-TRAUMATIC STRESS DISORDER (PTSD)

Do not routinely screen for a history of traumatic events. This can actually cause harm in well-functioning individuals. Remember that not all refugees who have experienced traumatic events will develop PTSD. However, since PTSD is more common in refugees than in the general Canadian population, physicians should pay close attention to potential PTSD symptoms. Again, somatic symptoms are very frequent in this population. It is important to note that post-migration mental health is largely dependent on how well refugees are able to resettle. The post-migration experience plays a significant role in PTSD (Kirmayer et al., 2011). Therefore, it is essential to ensure good socioecominic support and refer to a social worker if any social issue is identified.
Social History
SOCIAL SITUATION

The patient should be asked about his/her current family and housing situation. Newly arrived refugees and refugee claimants often have socioeconomic concerns (financial problems, food insecurity, poor housing, etc.), but will not always spontaneously mention them.
INTIMATE PARTNER VIOLENCE AND CHILD ABUSE

In the 2011 CMAJ guidelines, Pottie et al. recommended to not routinely screen for intimate partner violence (IPV) or child abuse. The current evidence at the time did not demonstrate clear benefits and showed that screening could even cause harm. In contrast, in a recent review (Curry et al., 2018), the U.S. Preventive Services Task Force now recommends that clinicians should screen for IPV in women of reproductive age. This recommendation is however not specific to refugee patients. Our consensus at the Calgary Refugee Health Program is to at least screen all our prenatal refugee patients for IPV. We do not perform routine screening for child abuse. Even if routine screening for IPV or child abuse is not performed, physicians should always be alert to any sign or symptom that could be related to these issues.

In Calgary, the Calgary Catholic Immigration Society (CCIS) usually educates government-assisted refugees about Canadian laws regarding intimate partner violence and child maltreatment.
Oral and Vision Health
DENTAL PAIN

We recommend inquiring about dental pain in all new patients. Patients with dental pain or any obvious caries (See Specificities of the Initial Physical Exam in Refugee Patients) should be referred to a dentist. It is also reasonable to offer a routine dentist referral to all new refugee patients (especially children) even if they are asymptomatic. The Interim Federal Health Program (IFHP)* will cover oral exams (one emergency examination per 6 months) as well as basic treatment for caries, trauma and dental pain. Routine care such as teeth cleaning is not covered. 

Refer to the IFHP Dental Benefit Grid table for more information. 



VISION

We usually refer all school-aged children, as well as adults with vision complaints to the optometrist. Other refugees can also be screened for visual impairment using a Snellen chart. The IFHP covers one complete eye exam by an optometrist per year.




*See Appendix A1 for a list of optometry and dental clinics in Calgary accepting IFHP coverage.
The key elements of the initial medical history in refugee patients are summarized below:

General Interview
  • Use a professional phone or in-person interpreter if required

  • Inform patients about confidentiality of medical appointments/records

  • Ask about country of origin and transition countries, as well as any refugee camp history
Infectious Diseases
  • History of hepatitis, HIV, TB, or recent malaria episode?

  • Previous latent TB screening?
    • especially if came from USA or another Canadian province

  • Any immunization records from the IOM
    • need at least 1 MMR, 3 DTaP-IPV doses and serologic proof for hepatitis B and varicella to be considered adequately immunized
Women's Health
  • Ask about contraceptive history and desire for a contraceptive method
    • with patient alone in the room

  • Offer cervical cancer screening if indicated
Mental Health
  • Do not routinely screen for child abuse, and only screen for intimate partner violence in prenatal patients
    • be alert however for any potentially associated symptoms
Social History
  • Do not routinely screen for child abuse, and only screen for intimate partner violence in prenatal patients
    • be alert however for any symptoms/signs of IPV or child abuse in all refugee patients

  • Inquire about current family and housing situation
Oral and Vision Health
  • Inquire about dental pain, and refer patients with dental pain or obvious caries to a dentist

  • Refer all school-age children and adults with vision complaints to an optometrist

Also refer to the following links for additional resources to help facilitate the interview process:
Share by: