Primary Care for Refugees: Challenges and Opportunities

 

Am Fam Physician. 2017 Jul 15;96(2):112-120.

  Related editorial: Refugee Mental Health: A Primary Care Approach.

  Related article in the July/August 2017 issue of Family Practice Management: Building Capacity to Care for Refugees

Author disclosure: No relevant financial affiliations.

Since 1975, more than 3 million refugees have settled in the United States, fleeing unrest, conflict, and persecution. Refugees represent diverse ethnic, cultural, religious, socioeconomic, and educational backgrounds. Despite this heterogeneity, there are commonalities in the refugee experience. Before resettlement, all refugees must undergo an overseas medical screening to detect conditions that pose a potential health threat in the United States. On arrival, they should undergo an examination to detect diseases with high prevalence in their country of origin or departure. Refugees have higher rates of chronic pain compared with the general population, and their mental health and well-being are strongly influenced by their migration history. Refugees have higher rates of mood disorders, posttraumatic stress disorder, and anxiety than the general population. Some refugees have been tortured, which contributes to poorer health. Chronic noncommunicable diseases, such as diabetes mellitus and hypertension, are also prevalent among refugees. Many refugees may be missing routine immunizations and screenings for cancer and chronic diseases. Attention to reproductive health, oral health, and vision care will help identify and address previously unmet needs. Refugees face barriers to care as a result of cultural, language, and socioeconomic factors.

More than 65 million persons worldwide were forcibly displaced in 2015, a figure that the United Nations says is the highest level ever recorded and is likely to increase 1,2  (Table 1,3 and Figure 1 3). The United Nations defines a refugee as someone 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 nationality, and is unable to, or owing to such fear, is unwilling to avail himself of the protection of that country.” 4

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

All refugees should have a medical screening examination within 30 days of arrival in the United States.

C

11

Physicians should consider whether refugees need assistance in overcoming barriers to health care.

C

2931, 33

All refugee patients should be provided with a trained professional interpreter during physician visits, if necessary.

C

11, 37

Malaria should be considered in refugees from endemic regions who present with fever.

C

11

Physicians should assess for reactivation of latent tuberculosis in refugees who present with suggestive signs and symptoms, particularly in the first five years after resettlement.

C

11, 27

All refugees should be screened for depression, anxiety, and posttraumatic stress disorder.

C

15

Refugees should be screened for anemia, hypertension, impaired fasting glucose levels, micronutrient deficiencies, chronic pulmonary disease, and overweight or obesity.

C

11-13, 16, 6366

Refugees without vaccine documentation should receive routine vaccinations except for varicella and hepatitis B, for which serologic testing is recommended or more cost-effective.

C

11, 16


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

All refugees should have a medical screening examination within 30 days of arrival in the United States.

C

11

Physicians should consider whether refugees need assistance in overcoming barriers to health care.

C

2931, 33

All refugee patients should be provided with a trained professional interpreter during physician visits, if necessary.

C

11, 37

Malaria should be considered in refugees from endemic regions who present with fever.

C

11

Physicians should assess for reactivation of latent tuberculosis in refugees who present with suggestive signs and symptoms, particularly in the first five years after resettlement.

C

11, 27

All refugees should be screened for depression, anxiety, and posttraumatic stress disorder.

C

15

Refugees should be screened for anemia, hypertension, impaired fasting glucose levels, micronutrient deficiencies, chronic pulmonary disease, and overweight or obesity.

C

11-13, 16, 6366

Refugees without vaccine documentation should receive routine vaccinations except for varicella and hepatitis B, for which serologic testing is recommended or more cost-effective.

C

11, 16


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

The Authors

show all author info

RANIT MISHORI, MD, MHS, is a professor and director of global health initiatives in the Department of Family Medicine at Georgetown University School of Medicine, Washington, D.C....

SHOSHANA ALEINIKOFF, MD, is a physician at HealthPoint Midway Medical, Des Moines, Wash., and clinical faculty at the Wright Center National Family Medicine Residency at HealthPoint, Auburn, Wash.

DAWN DAVIS, MD, MPH, is an assistant professor in the Department of Family and Community Medicine at Saint Louis (Mo.) University School of Medicine.

Address correspondence to Ranit Mishori, MD, MHS, Georgetown University School of Medicine, 3900 Reservoir Rd. NW, Washington, DC 20007 (e-mail: mishorir@georgetown.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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show all references

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