Improving the management and care of refugees in Australian hospitals: a descriptive study.

Objectives The aim of the present study was to investigate healthcare provider perceptions of the impact of refugee patients at two public hospitals, one rural and one urban, in designated refugee resettlement areas. Healthcare professionals' views regarding improvements that could be made in this area were also sought. Methods Two-page anonymous questionnaires containing demographic, quantitative and open-ended questions were distributed to 150 healthcare providers at each research site. Results Response rates at the rural and urban sites were 50% and 49%, respectively. Refugees were seen at least monthly by 40% of respondents. Additional support was requested by 70% of respondents. Confidence was associated with being born overseas (P=0.029) and increased time working with refugees (rs=0.418, P<0.001). Only 47% of respondents felt confident managing social and psychological needs of refugees. Midwives saw refugees more than nursing and allied healthcare staff combined, and this was significant at the rural hospital (P<0.001). Rural respondents reported that working with refugees enhanced their practice (P=0.025), although felt significantly less confident (P<0.001) than urban respondents. Themes that arose regarding barriers to care included language and cultural barriers, paucity of knowledge and issues accessing available services, including appropriate interpreters, Medicare eligibility and patient factors, including lack of patient trust in government systems. Desire for support was more pronounced in the rural setting (P=0.001). Conclusions Refugees were seen frequently in both settings and most respondents requested additional support, highlighting that caring for refugees in Australian hospitals is a significant challenge. Additional support and education should be targeted to those caring for refugees most frequently, particularly midwifery services, to reduce barriers to care. What is known about the topic? Refugees are a vulnerable group, often with complex health needs. These needs are often unmet because of issues including language and cultural barriers. What does this paper add? Refugees were seen frequently in the two public hospital settings involved in the present study and most often by midwifery services. Healthcare professionals require more support, more information about available services and better access to interpreter services. These issues were more pronounced in the rural setting where very limited research exists. What are the implications for practitioners? Implementing additional support and education regarding refugee health needs could increase knowledge and confidence when managing refugees, reducing barriers to care and improving quality of care.

Kuskokwim syndrome, a recessive congenital contracture disorder, extends the phenotype of FKBP10 mutations.

Recessive mutations in FKBP10 at 17q21.2, encoding FKBP65, cause both osteogenesis imperfecta (OI) and Bruck syndrome (OI plus congenital contractures). Contractures are a variable manifestation of null/missense FKBP10 mutations. Kuskokwim syndrome (KS) is an autosomal recessive congenital contracture disorder found among Yup'ik Eskimos. Linkage mapping of KS to chromosome 17q21, together with contractures as a feature of FKBP10 mutations, made FKBP10 a candidate gene. We identified a homozygous three-nucleotide deletion in FKBP10 (c.877_879delTAC) in multiple Kuskokwim pedigrees; 3% of regional controls are carriers. The mutation deletes the highly conserved p.Tyr293 residue in FKBP65's third peptidyl-prolyl cis-trans isomerase domain. FKBP10 transcripts are normal, but mutant FKBP65 is destabilized to a residual 5%. Collagen synthesized by KS fibroblasts has substantially decreased hydroxylation of the telopeptide lysine crucial for collagen cross-linking, with 2%-10% hydroxylation in probands versus 60% in controls. Matrix deposited by KS fibroblasts has marked reduction in maturely cross-linked collagen. KS collagen is disorganized in matrix, and fibrils formed in vitro had subtle loosening of monomer packing. Our results imply that FKBP10 mutations affect collagen indirectly, by ablating FKBP65 support for collagen telopeptide hydroxylation by lysyl hydroxylase 2, thus decreasing collagen cross-links in tendon and bone matrix. FKBP10 mutations may also underlie other arthrogryposis syndromes.

GP and registrar involvement in refugee health - a needs assessment.

BACKGROUND: General practitioners play a crucial role in understanding the specific health and social issues of refugees, as they are often the first contact that refugees have with the healthcare system. Providing equitable access to healthcare services presents considerable challenges, particularly in regional areas. METHODS: A purposive sample of GP supervisors and general practice registrars was selected from a regional area of southern New South Wales and the Australian Capital Territory. General practitioners were surveyed to assess their needs and attitudes in treating refugees, and the perceived impact of refugees in practice. RESULTS: There were significant differences between GP groups, between domestic and internationally trained medical graduates, and between genders in their needs and attitudes relating to refugee health. DISCUSSION: There is a strong sense that there are benefits in dealing with refugee health. More research is needed to identify the supports and education required to be able to effectively help refugees.

Parkinson's disease in regional Australia.

INTRODUCTION: Parkinson's disease (PD) incidence and prevalence, particularly in Western countries, is greater in rural areas. Despite several epidemiological studies on PD in Australia, there are few publications addressing specific issues facing people with Parkinson's disease (PWP) in regional, rural and remote areas. This study looked at the dynamics of healthcare delivery to PWP and their carers in and around a regional New South Wales centre. METHODS: Qualitative analysis of rural and regional healthcare delivery to PWP involved five participant groups. Literature searches via electronic and medical databases were performed to provide a foundation for focus group questions, semi-structured interviews and questionnaires. Volunteers from five groups: PWP, carers, allied health professionals (AHP), GPs and neurologists participated after recruitment via pamphlets, newsletters, postal invitation, public advertisements and preliminary talks. RESULTS: Data analysis highlighted a lack of relevant facilities, funding, available health staff and awareness of information regarding beneficial services for PWP and their carers. With few available neurologists, the roles of GP and AHP were emphasized in consumer focus groups as being most significant in a regional and rural setting. Transport, and geographical and financial issues were also significant in these areas. Psychological issues, dementia and memory loss were considered to be as debilitating as the overt motor symptoms of PD. CONCLUSIONS: The study found that the management of PD in regional NSW was highly variable, depending on geographical location and liaison among GPs, neurologists, AHPs, carers and PWP. Enhanced communication is recommended among PD stakeholders in regional NSW. This study provided a microcosmic view of the issues revealed by the very limited literature available on Australia's rural and regional healthcare delivery to PWP and their carers. It highlighted the lack of health staff, funding and information for relevant stakeholders, as well as PWP's desire for increased input from medical practitioners and the ancillary sectors. While this study did not directly compare rural with metropolitan PD services, it was inferred from all participant groups that regional and rural areas are disadvantaged in terms of medical staff and facilities, hindering timely diagnosis, management and treatment. The findings have implications for all stakeholders in the care of rural patients with PD.

Working with refugees--a manual for caseworkers and volunteers.

INTRODUCTION: The Australian Government encourages the regional settlement of refugees and it is expected that 45% of refugees to Australia be regionally located. Wagga Wagga, an inland regional city in New South Wales (NSW), a destination for both primary and secondary migration, offers settlement for refugees under the Australian Integrated Humanitarian Settlement Strategy (IHSS) and the Settlement Grants Program. Refugees currently represent 1% of Wagga Wagga's 60 000 population. For people previously living in cities or crowded camps with a background of disruption, torture and trauma, relocation to rural areas of Australia is confronting, and they require dedication and effort from those supporting resettlement. Currently, caseworkers working for settlement agencies do not have formal training. Volunteers are offered induction days and information sessions but have training needs beyond this. METHODS: Two projects were undertaken during 2007 and 2008. Refugee services in regional and rural NSW and their efficacy were reviewed, exploring models of care in four NSW locations and clarifying needs via a literature search. Training and resources available to caseworkers and volunteers were also investigated. The objective was to design and construct a basic manual addressing the needs of this workforce informed by a literature search and consultation with key stakeholders in refugee resettlement. Literature searches of electronic databases, relevant websites and journals informed the questions for participants of focus groups and semi-structured interviews. Additional data were obtained via self-report questionnaires from caseworkers, volunteers and mainstream agencies. Information was also disseminated to refugees, inviting community to participate in focus groups. RESULTS: Our study supported others noting difficulties associated with the settlement of refugees in regional Australia, and recommendations of improvements were developed using the social determinants of health. The supporting workforce encounters a multitude of issues when working with newly arrived refugees, including language barriers, client expectations and challenges in developing living skills. Workers reported that accessing refugees' information is time-consuming, and that available resources are fragmented. Refugees expressed frustration at being categorised but acknowledged the efforts of volunteers and caseworkers. CONCLUSION: Findings and feedback from the literature review, focus groups, consultations with resettlement stakeholders and interviews supported the concept of developing a basic manual and conversation-starter flashcards. The limitations of the developed manual are acknowledged, as is a need for agency specific information on common topics for volunteers, caseworkers and clients, is suggested. Volunteer and caseworker training should be expanded.

Acceptability of an adjunct equine-assisted activities and therapies program for veterans with posttraumatic stress disorder and/or traumatic brain injury.

OBJECTIVE: Equine-assisted activities and therapies (EAATs) have been a growing adjunctive integrative health modality, as they allow participants to practice mindfulness, emotional regulation, and self-mastery or self-esteem building skills. Preliminary evidence suggests that these programs may be helpful in reducing posttraumatic stress disorder (PTSD), anxiety, and depressive symptoms. The current study examines the acceptability of integrating an EAAT program as part of a two-week, intensive clinical program for veterans with PTSD and/or traumatic brain injury (TBI). METHODS: A family member or support person could accompany veterans and participate in the program. One hundred and six participants (veteran n = 62, family n = 44) left the urban environment in an intensive outpatient program (IOP) to attend a two-day, weekend EAAT in rural New Hampshire. Satisfaction surveys were conducted on the last day of the program and examined using thematic analysis. RESULTS: The following themes were reported in the surveys: ability of horses to catalyze emotional rehabilitation, effectiveness of immersion in equine-assisted activities, program's ability to foster interpersonal relationships and necessity of education about PTSD for staff. Participants also reported enjoying the program as highlighted by qualitative feedback, a mean score of 9.76 (standard deviation [SD] = 0.61) as reported by veterans and a mean score of 9.91 (SD = 0.29) as reported by family members on a 10-point visual analog scale with higher scores indicating a greater overall experience. CONCLUSION: These data offer preliminary evidence that an adjunct EAAT program is acceptable for veterans with PTSD and/or TBI participating in an IOP.

General practitioner and registrar involvement in refugee health: exploring needs and perceptions.

Objective Despite the recognition that refugees should have equitable access to healthcare services, this presents considerable challenges, particularly in rural and regional areas. Because general practitioners (GPs) are critical to resettlement for refugees and play a crucial role in understanding their specific health and social issues, it is important to know more about the needs of GPs. Methods In-depth interviews were conducted with 14 GPs and GP registrars who trained with a New South Wales regional training provider with the aim of assessing the needs and attitudes of GPs in treating refugees and the perceived effect that refugees have on their practice. Results The interviews, while acknowledging well-recognised issues such as language and culture, also highlighted particular issues for rural and regional areas, such as employment and community support. International medical graduates identified with resettlement problems faced by refugees and are a potential resource for these patients. A need for greater information for GPs regarding services available to help manage refugees in rural and regional areas and greater access to those services was demonstrated. Conclusions Issues such as time, costs, language and culture were recognised as challenges in providing services for refugees. GPs highlighted particular issues for rural and regional areas in addressing refugee health, such as finding jobs, problems with isolation and the effect of lack of anonymity in such communities. These social factors have implications for the health of the refugees, especially psychological health, which is also challenged by poor resources. What is known about the topic? Providing refugees equitable access to healthcare services presents considerable challenges, particularly in rural and regional areas. Time, language and culture are commonly reported barriers in providing services for this population group. What does this paper add? There are particular issues for rural and regional areas in addressing refugee health, including finding jobs, problems with isolation and the effect of lack of anonymity in rural communities. These social factors have implications for the health of refugees, especially psychological health, which is also challenged by a paucity of services. The findings of this study suggest that international medical graduate doctors identified with resettlement problems faced by refugees and may be an important resource for these patients. This study highlights the awareness, empathy and positive attitudes of GPs in regional and rural areas in their approach to treating patients with a refugee background. What are the implications for practitioners? International medical graduates often identify with resettlement problems faced by refugees and are an important resource for these patients. A need for greater information for GPs regarding services available to help manage refugees in rural and regional areas and greater access to those services was demonstrated.

Accuracy of Screening Tools for Pap Smears in General Practice.

BACKGROUND: Data extraction tools (DETs) are increasingly being used for research and audit of general practice, despite their limitations.Objective This study explores the accuracy of Pap smear rates obtained with a DET compared to that of the Pap smear rate obtained with a manual file audit. METHOD: A widely available DET was used to establish the rate of Pap smears in a large multi-general practice (multi-GP) in regional New South Wales followed by a manual audit of patient files. The main outcome measure was identification of possible discrepancies between the rates established. RESULTS: The DET used significantly underestimated the level of cervical screening compared to the manual audit. In some instances, the patient file contained phone/specialist record of Pap smear conducted elsewhere, which accounted for the failure of the DET to detect some smears. Those patients who had Pap smears whose pathology codes differed between time intervals, i.e. from different pathology providers or from within the same provider but using a different code, were less likely to have had their most recent Pap smear detected by the DET (p < 0.001). CONCLUSION: Data obtained from DETs should be used with caution as they may not accurately reflect the rate of Pap smears from electronic medical records.How this fits in DETs are increasingly being used for research and audit of general practice. This study explores the accuracy of Pap smear rates obtained with a DET compared to that of the Pap smear rate obtained with a manual file audit The DET tested significantly underestimated the level of cervical screening compared to manual screening. Data obtained from DETs should be used with caution as they may not accurately reflect the rate of Pap smears from electronic medical records.

Cultural and communication awareness for general practice registrars who are international medical graduates: a project of CoastCityCountry Training.

OBJECTIVE: (1) To generate discussion about Australian culture and language with GP registrars using the medium of poetry; and (2) to introduce discussion about language and communication skills in a role-play format that GP registrars would embrace as part of their clinical training. DESIGN: (1) A variety of Australian poems was selected to reflect six themes: men, women, the Bush, ANZACS, Aboriginal Australia and migrants, which would provide a basis for discussion on a range of cultural issues to aid a medical professional trained overseas in developing further understanding of aspects of Australian culture. (2) A series of role plays was developed to reflect the clinical themes of each Day Release education program. These were enacted in a small group setting by preselected GP registrars with feedback from a medical educator and an English as a Second Language teacher. SETTING: The Riverina/Murrumbidgee area of New South Wales, one of the three local training groups of CoastCityCountryTraining. PARTICIPANTS: GP registrars attached to the Riverina/Murrumbidgee Local Training Group. MAIN OUTCOME MEASURES: To show that discussion of poetry and participation in role plays are active language- and cultural-learning environments capable of enhancing understanding of a range of issues about Australia that are relevant to a GP registrar. RESULTS: There was increased participation by GP registrars in accessing the set material prior to each session. It was noted that there was also increased active involvement of all registrars in discussion within the group throughout the year. Discussion allowed clarification of aspects of Australian culture to participants with different international medical backgrounds, as well as providing an opportunity for GP registrars to share their own experiences.

Issues for clinicians training international medical graduates: a systematic review.

OBJECTIVE: To ascertain the specialised communication issues clinicians need to understand when preparing international medical graduates (IMGs) for clinical practice in Australia. STUDY DESIGN: Systematic review. DATA SOURCES: A series of searches using MEDLINE (1990-2006) was conducted with relevant keywords. Literature from countries with experience in the integration of IMGs into their medical workforces was included. All except four articles were published between 1997 and 2006. STUDY SELECTION: The initial search identified 748 articles, which reduced to 234 evidence-based English language articles for review. Of these, only articles relating to postgraduate medical training and overseas trained doctors were selected for inclusion. DATA EXTRACTION: Titles and abstracts were independently reviewed by two reviewers, with a concordance rate of 0.9. Articles were included if they addressed communication needs of IMGs in training. Any disparities between reviewers about which articles to include were discussed and resolved by consensus. DATA SYNTHESIS: Key issues that emerged were the need for IMGs to adjust to a change in status; the need for clinicians to understand the high level of English language proficiency required by IMGs; the need for clinicians to develop IMGs' skills in communicating with patients; the need for clinicians to understand IMGs' expectations about teaching and learning; and the need for IMGs to be able to interact effectively with a range of people. CONCLUSION: Training organisations need to ensure that clinicians are aware of the communication issues facing IMGs and equip them with the skills and tools to deal with the problems that may arise.