MU15 Multicultural health

Transcription

1 MU15 Multicultural health Rationale and general practice context 1. Australia s society is linguistically and culturally diverse, consisting of about 2.5% of Australians being of Aboriginal and Torres Strait Islander origin 2, while 97% have settled or are descendants of settlers over the past 200 years.. 2. Since 1945, 7 million people have migrated to Australia and 1 in 4 of Australia s 22 million people were born overseas. Australians speak over 260 languages and identify with more than 270 ancestries 3 3. Multicultural diversity in Australia is increasing. In 2011, 26% of people living in Australia were born overseas 3 compared to 14.35% in Over recent years, migrants have been coming from increasingly diverse About one in six Australians speak a language other than English at home and about 17% of this group are not proficient in English The concept of multiculturalism in Australia is based on the principles of pluralism, which values the benefits of cultural diversity, is committed to a just, inclusive and cohesive society, respecting the rights of all Australians to celebrate, practice and maintain their cultural heritage, traditions and language within the law and free from discrimination Issues in multicultural health in Australian general practice are complex and exist at every level of the health system, community and individual social environments. These issues include: Access to healthcare patients from a culturally and background may find they have specific problems accessing healthcare. Poverty, poor education, reduced opportunities for employment and difficulty with transport are likely to impact health opportunities for those from a culturally and In addition to these well documented social determinants of health, those from a culturally and background may not be aware of the care available in the community and may not be able to access what is readily available because of language, religion or other cultural barriers. Healthcare professionals need to recognise this potential and be prepared to advocate for their patients when necessary to ensure issues of equity are addressed. Social discrimination in health is commonly experienced by people from a culturally and Language difficulties can negatively impact upon the care received by those from a culturally and While the interpreter can assist in bridging the language gap, the cultural meaning embedded within language adds further complexity to cross-cultural consultations. Different cultures attach different meanings to parts of the body and types of illness, and this can impact upon the presentation of the illness or compliance with treatment. Linguistic difference can also reduce access to health promotion materials. Culture encompasses many issues. There are significant cultural differences even between people who speak the same language or come from the same country. Cultural issues that need to be considered are: cultural lens: each person, including health professionals, needs to recognise that they have their own unique personal worldview influenced by the cultures that nurtured them. This cultural lens may influence the way a health professional may judge and make assumptions about patients from a different background, and recognising this cultural bias is a necessary step for clinical effectiveness. A patient s cultural lens shapes beliefs about illness causation, the nature of a particular illness, and the appropriate treatment and expected outcome 1

2 diversity within diversity: within each culture group there may be differences in ideas about age, gender, sexuality and social issues. General practice care needs to acknowledge this diversity in its provision of healthcare religious issues: can alter the management of a patient. Religion can determine the patient s and healthcare provider s worldview and has a major influence over a person s life, lifestyle and understanding of illness. It may affect diet and use of medications. All major religions are represented in Australia. 6. Multicultural health in general practice involves tackling health inequalities and reducing barriers to accessing general practice care. The GP also has a role to play in breaking down cultural stereotypes through the provision of high quality care for all people from culturally and GPs are in a strong position to be advocates for the improvement of the health of people from culturally and Related curriculum areas 7. Most other curricula are also relevant to Multicultural Health. References 1. Department of Social Services. The People of Australia. Australia s Multicultural Policy; Australian Government Available at: 2. Australian Bureau of Statistics Census of Population and Housing: Characteristics of Aboriginal and Torres Strait Islander Australians, Available at: 3. Australian Bureau of Statistics Reflecting a Nation: Stories from the 2011 Census, Available at: 4. Klein, HA. Cognition in natural settings: The cultural lens model. Cultural Ergonomics: Advances in Human Performance and Cognitive Engineering Research. 2004; 4: Kleinman A. Anthropology in the Clinic: The Problem of Cultural Competency and How to Fix It. PLoS Medicine (10): United Nations High Commissioner for Refugees - Convention and Protocol relating to the Status of Refugees and Available at: 7. United Nations High Commissioner for Refugees (2002) Refugee resettlement: an international handbook to guide reception and integration. UNHCR: Geneva. Available at: 8. Department of Immigration and Border Patrol. Fact Sheet 60 - Australia s Refugee and Humanitarian Programme. Available at: 9. Smith M, Lo W, Bindra J. Prescribing for refugees. Australian Prescriber 2013; 36(5): Farley Rebecca, Askew Deborah, Kay Margaret. Caring for refugees in general practice: perspectives from the coalface. Australian Journal of Primary Health 2014; 20(1):

3 11. Sheikh M, Pal A, Wang S, MacIntyre C, Wood N, Isaacs D, Gunasekera H, Raman S, Hale K, Howell A The epidemiology of health conditions of newly arrived refugee children: a review of patients attending a specialist health clinic in Sydney. Journal of Paediatrics and Child Health 2009; 45: Sheikh-Mohammed M, MacIntyre C, Wood N, Leask J, Isaacs D. Barriers to access to health care for newly resettled sub-saharan refugees in Australia. The Medical Journal of Australia , Benson J, Smith M (2007) Early health assessment of refugees. Australian Family Physician 36, Victorian Foundation for Survivors of Torture. Caring for refugee patients in general practice: a desk-top guide th ed. Victorian Foundation for Survivors of Torture: Melbourne. Available at: Victorian Foundation for Survivors of Torture. Promoting Refugee Health: A guide for doctors, nurses and other health care providers caring for people of refugee rd ed. Victorian Foundation for Survivors of Torture: Melbourne. Available at: Royal Australian College of General Practitioners. Resources in Refugee and Migrant health Available at: Johnston V, Smith L, Roydhouse H. The health of newly arrived refugees to the Top End of Australia: results of a clinical audit at the Darwin Refugee Health Service. Australian Journal of Primary Health. 2012; 18(3) Huang Y, Phillips C. Telephone interpreters in general practice. Bridging the barriers to their use. Australian Family Physician. 2009; 38(6): Henderson S, Kendall E, See L. The effectiveness of culturally appropriate interventions to manage or prevent chronic disease in culturally and communities: a systematic literature review. Health Soc Care Community. 2011; 19(3):

4 Learning outcomes and criteria Domain 1 Communication and the doctor-patient relationship Learning outcomes General practice lifelong learning MU1.1 Demonstrate effective, respectful and sensitive crosscultural communication. MU1.1.1a Describe common challenges that the doctor may face when communicating in a cross-cultural consultation. MU1.1.2a Describe common challenges that the patient may face when communicating in a cross-cultural consultation. MU1.1.3a Outline the importance of curiosity, empathy and respect in crosscultural patient care MU1.1.4a Describe the role of the interpreter in the medical interview. MU1.1.5a List the key steps for the effective use on an interpreter when communicating with a patient. MU1.1.6a Describe how to access an interpreter for a medical consultation in general practice. MU1.1.7a Discuss the pros and cons of using an on-site (faceto-face) interpreter compared to a telephone interpreter for a consultation. MU1.1.1b Discuss how cultural and linguistic difference can impact upon treatment concordance. MU1.1.2b Discuss the rationale for using gender concordant interpreters. MU1.1.3b Apply models of effective cross cultural communication in consultations. MU1.1.4b Modify communication with patients from cross-cultural MU1.1.5b Describe how the cultural context can alter the inherent power imbalance between doctor and patient within the clinical encounter. MU1.1.6b Use interpreters when required. MU1.1.7b Share decision-making with patients from a culturally and linguistically different background to that of the doctor. MU1.1.8b Outline how issues of trust that may arise in a crosscultural consultation can be managed. MU1.1.1c Review processes to ensure that culturally sensitive care is enhanced through communication within the consultation MU1.1.2c Critically analyse whether cultural issues impact upon the delivery of care provided in the practice that uses the Western biomedical model. MU1.1.3c Develop strategies for demonstrating respect for a patient s cultural background and health beliefs. MU1.1.4c Evaluate and enhance your knowledge and skills for communicating effectively with people from culturally and MU1.1.9b Recognise and manage the impact of cultural bias upon the medical consultation. 4

5 Learning outcomes General practice lifelong learning MU1.2 Integrate a cultural assessment into patient assessment to effectively identify potential cultural needs of your patient. MU1.2.1a Describe the process of a cultural assessment. MU1.2.2a Discuss how a cultural assessment can enhance your communication with your patient. MU1.2.3a Discuss the concept of diversity within diversity. MU1.2.1b Identify when a cultural assessment can impact (positively and negatively) upon the process of health care delivery. MU1.2.2b Critically analyse how the cross-cultural issues can impact upon the presentation of an illness. MU1.2.1c Review the positive and negative impacts of cultural diversity upon the delivery of care. MU1.2.2c Develop strategies to reduce the negative impact of cross-cultural issues upon a consultation. MU1.2.3b Describe strategies for collaborating with culturally and communities to eliminate stereotyping and other bias from healthcare. MU1.3 Deliver holistic care to people from culturally and MU1.3.1a Describe how people from culturally and communities may experience health issues differently. MU1.3.2a Explain how a patient s health beliefs may facilitate or impede the doctor s engagement with a patient from a culturally and MU1.3.1b Deliver patientcentred care in the crosscultural consultation. MU1.3.2b Evaluate the role of relevant individual and community support in facilitating the delivery of holistic care in a therapeutic consultation. MU1.3.3b Critically analyse how a patients health beliefs and explanatory models of illness can impact upon their perception of care they receive. MU1.3.1c Develop strategies designed to foster the delivery of holistic care to a patient from a different 5

6 Domain 2 Applied professional knowledge and skills Learning outcomes General practice lifelong learning MU2.1 Examine and treat people from culturally and backgrounds in a culturally appropriate manner. MU2.1.1a Discuss specific physical examination practices that may need to be modified for patients from a culturally and MU2.1.2a Describe how global health issues may be relevant to the consultation with a patient from a culturally and MU2.1.3a Detail the potential influence of family and community upon the decision to comply with treatment recommendations. MU2.1.1b Identify and implement strategies to ensure that patient care is not compromised when physical examination is limited by cultural considerations. MU2.1.2b Sensitively manage women who present with complications from genital mutilation. MU2.1.3b Modify clinical practice to ensure cultural expectations including gender issues and the need for genderconcordant care are addressed. MU2.1.4b Evaluate the impact of cultural concepts upon women s health issues. MU2.1.1c Identify and implement processes to support patients from diverse backgrounds receive optimal healthcare in the practice. MU2.1.2c Provide community education related to culturally specific practices that impact on health. MU2.1.3c Develop strategies to assist the presentation of the biomedical evidence based approach to treatment to patients who have very different health belief systems. MU2.1.7b Discuss the potential impact of cultural and religious beliefs on specific medications and medication regimens. MU2.1.8c Use strategies to identifying how a patient s health belief system can impact upon shared decisions and treatment concordance. 6

7 Learning outcomes General practice lifelong learning MU2.2 Assess and manage newly arrived refugees. MU2.2.1a Discuss the rationale for a health assessment for all refugees who have recently arrived in their host country. MU2.2.2a Compare presentations of infectious disease in people of refugee background with those of travellers. MU2.2.3a Discuss why specific populations are at risk of nutritional deficiency after arrival from overseas. MU2.2.4a Discuss the costbenefits of managing nutritional deficiencies in diverse communities. MU2.2.1b Practice strategies to ensure a comprehensive history and examination of the refugee patient is conducted. MU2.2.2b Use an integrated approach that addresses the requirements of the Medicare guidelines to cover the clinical needs of refugees. MU2.2.3b Identify and manage infectious diseases commonly experienced by newly-arrived refugees. MU2.2.4b Identify and manage health risks associated with immunocompromised refugees. MU2.2.5b Identify and manage nutritional diseases commonly experienced by newly-arrived refugees. MU2.2.1c Develop strategies to address the complexities of the refugee health assessment. MU2.2.2c Critically evaluate the refugee health template used by the practice to ensure it adequately records the demographics, history, medications, examination and management plan. MU2.2.3c Develop practice protocols for managing follow-up of common infectious diseases experienced by patients of refugee MU2.2.4c Develop practice protocols for managing common nutritional diseases experienced by patients of refugee MU2.2.5c Develop protocols for identifying children and adults at risk of nutritional deficiency. MU2.3 Effectively assess and manage mental health conditions in patients from culturally and MU2.3.1a List the mental health problems commonly experienced by refugees that could interfere with the communication between doctor and patient. MU2.3.2a Identify options for mental health care available to people of culturally and MU2.3.3a List the mental health issues commonly identified in refugees who have experienced detention, specifically considering the impact of detention on children s mental health MU2.3.1b Discuss how the social, linguistic and cultural isolation commonly experienced by patients from culturally and background has the potential to escalate mental health issues. MU2.3.2b Identify and address barriers when caring for patients from culturally and backgrounds with mental health problems. MU2.3.3b Incorporate into treatment and management options the experiences of loss, torture and trauma and the impact they may upon the health of the patient of refugee MU2.3.1c Develop strategies for engaging patients from culturally and backgrounds in management of their mental health issues. MU2.3.2c Engage with individuals and communities to reduce the stigma around mental health issues that can complicate the management of a patient from a culturally and 7

8 Domain 3 Population health and the context of general practice Learning outcomes General practice lifelong learning MU3.1 Manage patients from culturally and backgrounds taking into account the epidemiology of significant population health issues for the cohort. MU3.1.1a Compile a list of illnesses that are more commonly found in patients from specific cultural MU3.1.2a Discuss how the global distribution of vaccinepreventable diseases relates to the health needs of people from culturally and MU3.1.3a Describe how to identify the immunisation needs of patients from diverse MU3.1.4a Discuss why some cultural groups are at higher risk of vaccine-preventable diseases than others. MU3.1.1b Manage serious health issues found in specific communities, related to their ethnicity and to their occupational and environmental risks MU3.1.2b Determine how to identify the vaccines a refugee has had prior to arrival in Australia and produce an immunisation schedule for the refugee patient soon after arrival. MU3.1.3b Access vaccinations for people of refugee MU3.1.4b Manage vaccinepreventable diseases in people of specific cultural backgrounds living in Australia. MU3.1.1c Maximise immunisation rates within people from culturally and MU3.1.2c Manage patients at risk of under-immunisation within the practice focusing on the recall of the patient from a diverse MU3.1.3c Engage with public health organisations to enable immunisation of local community groups who are identified as being at risk of under-immunisation. MU3.2 Reduce the barriers to appropriate healthcare by people from culturally and MU3.2.1a Discuss the barriers that are commonly experienced by people from a diverse MU3.2.2a Discuss the barriers that are commonly experienced by people of refugee MU3.2.3a Describe how health access barriers can result from the loss of trust in the benevolent nature of the health system. MU3.2.4a Describe how the variation in access to Medicare and Social Security payments for asylum seekers and humanitarian entrants complicates the social determinants of health and health access. MU3.2.1b Analyse how previous experiences of health care in the person s country of origin can impact on health access in Australia. MU3.2.2b Facilitate access to specific health services as required by refugees and people from diverse MU3.2.3b Identify the expectations and the diversity of views presented by culturally and linguistically different patient populations. MU3.2.1c Critically evaluate the role of the general practitioner in facilitating health access for people of culturally and backgrounds, in particular people of refugee MU3.2.2c Advocate for improved health access in the local community for people of cultural and MU3.2.3c Engage with the local community to enhance health access for people from diverse 8

9 Learning outcomes General practice lifelong learning MU3.3 Incorporate health promotion, screening and preventative care into care for people from culturally and MU3.3.1a Discuss the impact of cultural barriers on access to specific services. MU3.3.2a Describe the impact of linguistic barriers on access to specific services. MU3.3.1b Identify ways to access patient health information using a variety of media and in different languages, where appropriate. MU3.3.2b Apply strategies for effective and culturally appropriate health education and health promotion in local practices. MU3.3.1c Apply appropriate guidelines regarding preventative care and vaccinations. MU3.3.2c Develop strategies for effective and culturally appropriate health education and health promotion in local practices. MU3.3.3c Develop strategies for addressing hard-to-identify social health issues within specific culturally and communities. MU3.4 Identify and address the social determinants of health that impact on refugees, migrants and people from culturally and MU3.4.1aDiscuss the social determinants of health, articulating how social health issues intersect with health and health access. MU3.4.2a Explain Tudor Hart s Inverse Care Law and discuss how this is relevant to people from a culturally and MU3.4.3a Describe systemic factors that impact upon health disparities. MU3.4.1b Identify patients whose migration experience impacts upon the social determinants of health. MU3.4.2b Identify effective processes to reduce the impact of mobility and short-term housing upon general practice referrals to specialist services. MU3.4.3b Arrange follow up for health issues that are identified during health checks conducted on migrants prior to arrival in Australia. MU3.4.1c Advocate to address social health issues such as housing and social security. MU3.4.2c Engage with appropriate community health support services for the patient from a culturally and MU3.4.3c Advocate for health services relevant for the patient from a culturally and MU3.4.4a Describe the economic impact upon the community as a whole when social determinants of health are inadequately addressed. MU3.4.5aExplain the healthy migrant effect. MU3.4.6a Discuss the healthy migrant effect in the context of the refugee patient. MU3.4.4b Discuss how different visas can impact upon the care available to the individual migrant in the community. MU3.4.5b Document the patient s migration experience in a culturally sensitive manner. MU4.3.4c Coordinate referral agencies and resources that are able to work in the crosscultural space to assist in delivering health care or enhancing health literacy for patients from culturally and MU3.5 Deliver healthcare to refugees, migrants and people from culturally and MU3.5.1a Discuss the public health implications of Australian government policy MU3.5.1b Discuss the role of general practitioners in the provision of health care to asylum seekers in detention. MU3.5.1c Advocate for the health of vulnerable people from diverse cultural and linguistic backgrounds in the community. 9

10 Learning outcomes General practice lifelong learning backgrounds within the context of current government policies. on refugees and asylum seekers. MU3.5.2a Discuss the specific social, medical and mental health problems faced by asylum seekers, including children, placed in detention. MU3.5.2b Describe the restrictions on health care provision for asylum seekers in detention and the impact upon the health professional. MU3.5.2c Assess practice demographics and determine whether the needs of culturally and groups are met. 10

11 4 Professional and ethical role Learning outcomes General practice lifelong learning MU4.1 Practice within an ethical and culturally sensitive framework. MU4.1.1a Describe how the individual s own cultural background shapes his/her cultural lens. MU4.1.2a Outline how different cultural views can impact upon the perception of ethical aspects of healthcare and health services. MU4.1.3a Discuss how the application of the ethical principles of patient centred care can be affected by diversity. MU4.1.4a List the requirements of Good Medical Practice, Code of Conduct (Medical Board of Australia) for a culturally sensitive consultation. MU4.1.5a Discuss the potential confounders of the key principles underpinning free and voluntary informed consent for medical procedures and health research. MU4.1.1b Minimise the impact cultural bias or cultural lends on the healthcare delivered to patients from culturally and linguistically different communities. MU4.1.2b Use strategies that reduce the potential negative impact of a personal cultural lens on the consultation with patients from diverse MU4.1.3b Ensure the application of the ethical principle of patient centred care, in an appropriate and sensitive way, when the patient is from a culturally and MU4.1.4b Ensure issues of privacy and confidentiality are maintained, while recognising that legal right of the individual to privacy may not fit well with cultural expectations. MU4.1.5 b Reduce the confounders that may make consent invalid when the patient is from a culturally and background MU4.1.1c Develop strategies that can improve consultations with patients from culturally and linguistically different MU4.1.2c Critically evaluate the ethical and legal requirements to deliver high quality health care to all patients from culturally and MU4.1.3c Engage with local culturally and community leaders to support the development of processes that are respected by the community and aligned with professional practice. MU4.1.4c Ensure ethical concepts such as consent are protected for patients from diverse MU4.2 Practice collaborative and effective multidisciplinary care to culturally and communities. MU4.2.1a Identify and describe the role of each member of a multidisciplinary team. MU4.2.2a Identify services that can support people from diverse MU4.2.1b Appropriately use community services and resources for people from diverse MU4.2.2b Enhance the accessibility of the practice for the local communities. MU4.2.3b Identify community services including allied health services that are able to support the cross cultural health care delivered by the practice. MU4.2.1c Engage with individuals and organisations that could participate in multidisciplinary care. MU4.2.2c Actively coordinate and lead multidisciplinary teams. MU4.2.3c Provide support for health providers engaging with cross-cultural care. MU4.2.4c Identify and engage with specific cross-cultural training support within the local 11

12 Learning outcomes General practice lifelong learning area for staff, including administration staff. MU4.2.5c Revise strategies to improve follow up and recall of patients from culturally and 12

13 5 Organisational and legal dimensions Learning outcomes General practice lifelong learning MU5.1 Keep accurate and appropriate records for patients from culturally and MU5.1.1a Describe information that is important to capture that relates to people from culturally and MU5.1.2b Record necessary cultural information a culturally sensitive manner MU5.1.2b Ensure medical records capture important data for people from culturally and MU5.1.1c Review practice policies and procedures to ensure all legal requirements for documentation related to people from culturally and backgrounds is captured. MU5.2 Comply with legal requirements. MU5.2.1a Discuss the legal implications of some cultural practices. MU5.2.1b Report abusive cultural practices as required by law. MU5.2.1c Update knowledge and skills in the legal and regulatory requirements pertaining to people from diverse MU5.2.2c Support people from diverse background to navigate legal and legislative requirements pertaining to their health and care. 13

14 Requirements for competence This section needs filling with knowledge, skills and attitudes specific to working in the area of multicultural health. General practice lifelong learning Required knowledge Required skills Required attitudes Evidence required to demonstrate competence Methods of assessment Small group projects Literature review Supervisor report Observation Active learning modules as part of CPD Essays Simulations Role-play Third party reports Written and verbal questioning Clinical attachment Range statement Common communication challenges these can include language differences (verbal and nonverbal), nuance, idiom, jargon etc. Modify communication the patient may not be able to clearly communicate health issues and will depend on a different method of questioning or communicating to ensure meaning is understood. Interpreters can include interpreter services (telephone) as well as members of community organisations, volunteers and the patient s own family members. Cultural bias can create power imbalances in the doctor/patient relationship as well as bring up issues of class in some cultures. Patients may experience health issues differently because of their language, religious and cultural beliefs. 14

15 Examination practices may need to be modified to accommodate cultural issues around gender and chaperones. Global health issues can include maternal morbidity and perinatal mortality. Cultural expectations include gender issues and the need for gender-concordant care. Women s health issues include contraception, antenatal and obstetric care please see the Women s health curriculum. Health risks associated with immunocompromised refugees can relate to strongylodidiasis. Loss, torture and trauma can be compounded by the patient s pre-migration, migration and postmigration experiences. Faith in the benevolent nature of the health system can be impacted when political detainees have been tortured by health practitioners. Asylum Seeker - a person who is seeking asylum who has not yet had their application for asylum processed. This recognizes that the seeking of asylum can require refugees to breach immigration rules. Prohibited penalties might include being charged with immigration or criminal offences relating to the seeking of asylum, or being arbitrarily detained purely on the basis of seeking asylum. Importantly, the Convention contains various safeguards against the expulsion of refugees. The principle of nonrefoulement is so fundamental that no reservations or derogations may be made to it. It provides that no one shall expel or return ( refouler ) a refugee against his or her will, in any manner whatsoever, to a territory where he or she fears threats to life or freedom. Humanitarian Entrant this term is sometimes used to refer to a person who is settled in Australia under the Refugee and Special Humanitarian Program through the Department of Immigration and Border Protection. Information Available at: Specific services can include breast screening, PAP tests and colorectal screening. Systemic factors can include historical, political environmental and institutional. Different visas include refugee, asylum seeker, migrant worker etc. Reducing confounders in giving consent can be addressed by using an independent interpreter. Consent can also include iterative consent to the procedure or research participation on a number of occasions. It can also include family or community consent but must ensure confidentiality for the patient. Accessibility can be enhanced by the addition of adequate waiting room space for large families and culturally relevant posters or handouts in the waiting area. Important medical data can include the need for an interpreter, refugee status, torture survivor etc. Refugee a person owing to 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 or, owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable or, owing to such fear, is unwilling to return to it. In Australia, a refugee is re-settled under the refugee. From United Nations High Commissioner for Refugees - Convention and Protocol relating to the Status of Refugees and 1967 available at: 15

16 Resettlement the process of settling into the host country which involves learning new systems for government processes, health services, education services. It often involves learning a new language, learning a new trade or developing new skills for employment, managing new transport systems and engaging with a different finance system. The processes for accessing food, housing, social security and health care are often unfamiliar. The cultural, linguistic and religious context for the new processes can also be unfamiliar and complicate the difficulties engaging with the new processes. The adjustment can cause acculturative stress which may combine with other issues of loss and may compound mental health issues. The resettlement process takes many years and government support for this process varies depending upon the program and Visa under which the individual arrived. Many people experience the stigma of difference that may be accentuated by their cultural dress or religious beliefs. Social health issues Some health issues such as domestic violence, gambling problems may be difficult to identify in a people from different backgrounds and the general practitioner should be aware that these issues can exist in any community though there may be significant barriers identifying these serious issues in cross-cultural consultations.. Engagement with the hospital service For a patient to engage with a hospital service they are often sent out an appointment in English and if the patient does not speak English this can lead to a missed appointment unless there are other strategies put in place. Similarly, it is common for newly arrived refugees to move house regularly and they often fail to update their details with the local hospital service without assistance. Specific health issues in which consent can be especially sensitive in some communities may include contraception, termination. 16