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For me, health is a unique, dynamic balance of physical vitality, mental clarity, emotional well-being, and spiritual alignment. It means waking up energized, embracing life's challenges, and nurturing meaningful connections. It's the pursuit of happiness, resilience, and inner peace tailored to your aspirations and values, enabling a fulfilling life.

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The "meat pie" is a traditional dish in Australia. This mouthwatering pastry dish has a flaky crust filled with flavorful minced meat, frequently beef, and occasionally tomato sauce or gravy. A popular comfort dish, it can be found at sporting events, family get-togethers, and neighbourhood bakeries. The meat pie represents Australian cuisine, displaying the country's appreciation of filling, portable, and savoury meals that are suitable for any occasion.

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Kangaroo apple, emu bush, and tea tree oil are a few examples of native plants used in traditional Australian Indigenous medicine. Indigenous societies have employed these cures for generations due to their ability to treat a wide range of illnesses. Their expertise is essential to Australia's cultural heritage and advances our understanding of herbal treatment (M. Kamenev, 2011).

https://www.australiangeographic.com.au/topics/history-culture/2011/02/top-10-aboriginal-bush-medicines/

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I feel that competency standard 12.1 sits close to me as I have a deep understanding of how fortunate I am to be in the position I am and the privilege I am In as a member of Australian society—having aspirations of going into healthcare as a lifetime career and accepting that I will be coming across an extremely diverse range of people from all kinds of backgrounds with different stories. learning that all cultures have their own views and ways of life allows me to learn and understand why different cultures are the way they are. I have learned some of these differences and how to deal with them, although I am fully aware that you can never learn too much and stop learning about these cultures. I feel that I am capable of learning and have the heart to feel empathy and understand a wide range of views without being close-minded. I feel that all members of healthcare should learn to be empathetic and have a deep understanding so we can grow together as one and learn from one another. fortunate for myself being in Australia I am lucky to have this opportunity and I will make sure I continue to keep my head high so that patients can get the best experience and leave a positive impact on one another so we can grow for the better.

Migrant & Refugee Health Partnership. (2019). Culturally Responsive Clinical Practice: Working with People from Migrant and Refugee Backgrounds. Competency standards framework for clinicians. January 2019. Migrant & Refugee Health Partnership.

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Australia's religious diversity, shaped by a multiethnic society, encompasses various Christian denominations, notably Catholicism and Protestantism at 52%. Islam's rapid rise to 2.6% stems from recent immigration, introducing religious diversity. Meanwhile, Buddhism and Hinduism have grown to 2.4%, and 1.9%, and Indigenous spirituality remains crucial for Aboriginal and Torres Strait Islander communities, connecting them to their ancestral heritage. This diversity, with Christianity at 52% and other faiths, enriches Australia, promoting tolerance, interfaith dialogue, and cultural-spiritual celebration, highlighting Australia's commitment to respecting diverse beliefs and practices.

https://www.abs.gov.au/articles/religious-affiliation-australia

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Over the past 50 years, there has been a steady decline in the proportion of Australians who reported an affiliation with Christianity. The same period has seen a consistent rise in Other religions and No religion, particularly in the last 20 years.

Australia's religious profile has been shaped by waves of migration. In the late 18th Century, Christianity was introduced by the British. Other migration to Australia that has likely impacted the religious landscape includes:

1800s and early 1900s: British and Irish free settlers

1940s and 1950s: Post World War II migrants from Europe

1960s: Refugees from the Middle East

1970s: Refugees from Southeast Asia

2000s: Humanitarian entrants from Africa and Middle East; skilled migrants from North-east and Southern Asia(1).

The trend of an increase in Other religions and No religion in Australia is reflected in the religious affiliation of migrants who arrived since the last Census.

The religion with the highest proportional growth since the last Census was Yezidi.

Yezidis (or Yazidis) are an ancient religious minority, who are mostly from Northern Iraq. Many Yezidis fled their country in the past decade due to religious persecution.

The number of Yezidis in Australia increased from 63 people in 2016 to 4,123 in 2021 (an increase of 6,444%). Most of this group arrived in Australia in 2018 and 2017. This was a result of Australia's Humanitarian Program that specifically focussed on resettling Yezidi women, children and families from Iraq and Syria(2).

In 2021, Yezidis were mainly located in regional locations in Queensland and NSW. These areas are designated regional refugee settlement locations as part of the Humanitarian Settlement Program(3).

Christian affiliation of people in Australia varied across generations. Generally, older generations were more likely to be affiliated with Christianity and younger generations were more likely to have no religious affiliation.

For example, more than two-thirds (69.4%) of the Interwar generation were affiliated with Christianity and were the least likely to have No religion (18.6%).

Millennials had the highest proportion of No religion (46.5%) and Other religions (14.9%). This reflects the age profiles of these religions. For example, the median ages for Hinduism was 31 years, Sikhism was 30 years and Islam was 28 years.

The religious affiliation of Generation X closely aligned with the proportions of the Australian population overall.

The number of people affiliated with Christianity in Australia decreased from 12.2 million (52.1%) in 2016 to 11.1 million (43.9%) in 2021. This decrease occurred across most ages, with the largest decrease for young adults (18-25 years).

Anglican and Catholicism have been, and are, the largest Christian denominations in Australia. In 2021, the number of people reporting each of these denominations has dropped and make up most (78%) of the decrease in an affiliation with Christianity.

In 2021, Catholicism decreased to 20% (from 22.6% in 2016). While this number has been falling over time, the decrease has been slowed by immigration from regions with high numbers of followers of Catholicism, such as Southeast Asia and South America.

Of all migrants who came to Australia between 2016 and 2021, almost 200 thousand (191,000) reported an affiliation with Catholicism in the 2021 Census, over one-quarter of which were born in the Philippines.

The Anglican Church (named the Church of England until 1981) was the main religious denomination in Australia throughout the 19th and 20th Centuries. At the 1911 Census 38.4% of the population reported an affiliation with the Church of England. This proportion remained steady throughout the first half of the 20th Century, driven by the continued British migration to Australia. The 1954 Census reported 37.9% of Australians were affiliated with the Church of England.

In the past 50 years this proportion has been steadily declining. In 1986, the proportion of Anglican affiliation (23.9%) dropped below Catholic affiliation (26.1%). In 2006, Anglican affiliation (18.7%) was surpassed by those reporting to have No religion (19.4%).

From 2016 to 2021, Anglican affiliation had the largest drop in number of all religious denominations - from 3.1 million to 2.5 million people. This was a decrease of nearly one in five Anglicans (19.5%), from 13.3% to 9.8% of the population.

The average age of people with an Anglican affiliation in 2021 was 56 years, compared with 47 years for Christians overall.

Not all Christian denominations are declining. From 2016 to 2021, the highest increase was in responses coded to the supplementary category, Christianity nfd (not further defined). Christianity nfd includes responses containing enough information to be coded to Christianity but not to a specific denomination. In 2021, most of this group were people who answered "Christian" or "Christianity" to the religion question.

In 2021, there were nearly 700 thousand people in the Christianity nfd category (688,400), an increase of 75 thousand since 2016 (76,100). They represented 2.7% of Australians - the same as the proportion affiliated with Hinduism.

Christianity nfd was first included as a group in the 1996 Census when the Australian Standard Classification of Religious Groups (ASCRG) was developed. Since then, the number of responses in this category has grown from 181,900 (1.0% of Australians) in 1996.

An increase in this group may indicate a growing trend of people affiliating more broadly with Christianity rather than specific Christian denominations.

From 2016 to 2021 other Christian denominations that increased included Orthodox denominations. These denominations grew in Australia in the second half of the 20th Century due to post-World War II migration from Eastern Europe. They are common to people with Greek, Lebanese and Serbian ancestries. The largest of these denominations, Greek Orthodox, accounted for 1.5% of Australians in 2021.

In 2021, over 2.5 million people reported an affiliation with Other religions. This was an increase of over 600 thousand (617,800) since 2016.

In the past 25 years the proportion of people reporting an affiliation with Other religions has increased from 3.5% in 1996 to 10% of the population in 2021. This growth has particularly accelerated since 2006.

These increases reflect Australia's migration trends. In 2021, 93.8% of people affiliated with Other religions were either born overseas or had at least one parent born overseas.

In 2021, the main religions in Other Religion in Australia were Islam, Hinduism, and Buddhism.

In the 1981 Census, data on Buddhism was released for the first time in response to the arrival of large numbers of Buddhists as Vietnamese refugees in the 1970s. A steady increase since then has largely been maintained by migration from Southeast Asia, China and Sri Lanka.

While the numbers of Buddhists continue to increase, in 2021 the main contributors to the increase in Other religions were:

These increases were largely a result of recent migration from Southern and Central Asia.

Of migrants who arrived in Australia between 2016 and 2021, there were 210,500 who were affiliated with Hinduism. Most of these migrants (91.9%) were born in India and Nepal.

Similarly, nearly 60 thousand (57,300) recent migrants were affiliated with Sikhism, and almost all (95.9%) were born in India. Sikhism has grown in Australia particularly over the past ten years. The number of people who affiliate with Sikhism has almost tripled since the 2011 Census. In 2021, they accounted for 0.8% of the population (210,400 people).

The increase of Islamic affiliation can also be largely attributed to recent migration. Almost 126,000 people who arrived in Australia between 2016 and 2021 affiliated with Islam. Their main countries of birth were Pakistan, Afghanistan, India and Bangladesh.

While NSW and Victoria had higher proportions of religious affiliation with Islam and Hinduism than other states and territories in 2021, the state with the highest growth rate in these religions since 2016 was Tasmania.
Hinduism
From 2016 to 2021, the proportion of people who affiliated with Hinduism in Tasmania increased from 0.5% to 1.7% of the population. This was an increase from 2,550 to 9,720 people. Most were Nepalese and Indian migrants.

Of those who reported Hinduism:

5,088 born were born in Nepal

2,802 were born in India

898 were Australian-born children of migrants (aged under 15 with one or both parents born overseas).

Islam
The proportion of the population affiliating with Islam in Tasmania increased from 0.5% to 0.9%. The number almost doubled, from 2,498 to 4,947.

Of those who reported Islam:

1,385 were born in Pakistan

534 were born in Bangladesh.

661 were Australian-born children of migrants (aged under 15 with one or both parents born overseas).

Religious freedom is an important value in Australian society. People are free to choose, express and practice their religious beliefs in different ways. This includes the right not to profess a religion or belief.

In every Census since 1911, a proportion of people have responded that they did not have a religious affiliation. The 1911 Census form asked each person to state their religion. People could respond that they did not have a religion if they were "a free thinker, or if no denomination or religion". Over ten thousand people stated they had no religion in 1911. This was 0.2% of the population.

Over time, we have changed how we present the No religion option on the religion question. Amendments have been made to reflect changes in Australia's religious profile as well as in response to public consultation. These include:

1971: The first Census with instructions on the form "If no religion write none".

1991: The first Census with a check box list of religions, an option for free text and a check box for No religion at the bottom of list.

2016: The No religion response option was moved from the last to the first response option on the Census form.

These changes may have affected the number of No religion responses. For example, the proportion of the population who reported they had no religion increased from 0.8% in 1966 to 6.7% in 1971 when instructions were added to the religion question.

No religion in 2021

From 1971 to 2021, the proportion of people reporting to have no religion in Australia steadily increased.

In 2021, the proportion was 38.9%, an increase from 30.1% in 2016, representing an increase of more than 2.8 million people. This increase indicates a shift away from religious and spiritual viewpoints, by either expressing their beliefs outside of traditional religious institutional settings or not holding a religious or spiritual viewpoint to express.

Most of the responses in the broad category, Secular Beliefs and Other Spiritual Beliefs and No Religious Affiliation, were in the sub-category No religion, so described. The remaining subcategories account for only 1.2% of responses.

No religion by state and territory

The proportions of people reporting to have no religion varied across states and territories. In 2021, Tasmania had the highest proportion with half (50%) of the population reporting to have no religion. The lowest was NSW with almost one-third (33.2%) of the population.

From 2016 to 2021, the highest growth in the number of people reporting to have no religion was in Queensland and Tasmania.

No religion by age

An increase in people reporting to have No religion in 2021 indicates that some people have changed from being affiliated with a religion since the last Census in 2016.

An increase in people reporting to have No religion between 2016 and 2021 was highest for young adults, particularly those aged in their twenties. In general, the likelihood of people becoming unaffiliated with a religion decreased with age.

People reporting to have No religion were younger than people affiliated with Christianity. In 2021 almost half (48.4%) of people aged 25-34 years reported to have No religion. Since 2016 however, the median age of this group increased from 31 years to 33 years.

In 2021, while the proportion of people reporting to have No religion increased for all age groups, the highest proportional increase was people aged 65 years and over. This was an increase from nearly 600 thousand (592,000) to just over 1 million people. Despite this shift, in 2021, almost two-thirds (64.2%) of people in this age group were affiliated with Christianity.

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Exploration of the changes in reported religion in the 2021 Census

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Education, early childhood development and social inclusion and non-discrimination are three World Health Organisation social determinants that have an effect on migrant and refugee health (WHO, 2023).

For Australian refugees to successfully integrate and succeed, education is essential. But they frequently deal with trauma, language problems, and a lack of support. While having access to a good education can give them more power, overcoming these obstacles is essential for their relocation and forging a better future (RCOA, 2023).

Australian refugees' early childhood development is frequently hampered by culture shock, stress, and dislocation. Their social and cognitive development may be hampered by obstacles including limited availability to high-quality preschools and language challenges. It is crucial to offer helpful programmes and resources in their new surroundings to aid in their success (NAEYC, 2017).

For Australian refugees, social integration and non-discrimination are essential, yet they frequently encounter obstacles. They may become isolated due to barriers to language and culture, which will make it more difficult for them to integrate. Their difficulties may be made worse by discrimination, which may limit their access to social services, work opportunities, and education. Fostering a more inclusive culture for refugees in Australia requires actions to encourage diversity, offer cultural sensitivity training, and guarantee equal opportunity (BMC health, 2022).

https://www.naeyc.org/resources/pubs/tyc/aug2017/welcoming-refugee-children-into-classrooms

https://www.aph.gov.au/about_parliament/parliamentary_departments/parliamentary_library/pubs/rp/rp1617/refugeeresettlement

https://www.refugeecouncil.org.au/education-info/

https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-019-8068-3

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In Mr. Allen's pre-K class, the children greet their classmates in each other's home language. Seth turns to Maryam and greets her in Arabic, "Assalamu Aliakum." Maryam very softly says back, "Hello," in English. Tarek says, "Buenos días," and Isabella responds, "Günaydın," in Turkish.

Refugee families are a part of many communities, and they bring rich cultural experiences to early learning programs. Because of the social and emotional impact that being a refugee has on young children and their families, it is important that early childhood educators create inclusive and nurturing classroom environments.

Most children who are refugees have experienced hardship and trauma, so it's vital that they feel welcomed by teachers and peers in their new classrooms. Here are some ideas to get you started.

Prepare to greet the children

Work with the class to be ready to greet their new classmate in a warm and cheerful manner and to show appreciation for the child's culture. The children can learn the new child's name and how to say a few words in his or her language. They can create welcome cards and pictures for their new classmate.

Create play experiences that do not require English

All children need opportunities to play in the classroom. If new arrivals do not speak English, it will take them some time to learn the language. In the meantime, ensure that there are games and activities available that don't require much language. Offer board games and art experiences that need little instruction (simple games, such as Candyland, and open-ended art materials). Plan activities in which children engage in creative and imaginative play using music and movement.

Here are some play-based activities for dual language learners:

Photograph all the children in the classroom. Make a copy of each photo, and play a matching game. Write the children's names at the bottom of their photos to help them recognize their own and each other's names.

Children can create their own musical instruments and form bands. Make maracas by filling plastic bottles with beans, create string instruments by wrapping large rubber bands around open shoe boxes, and use a comb and tissue paper to make a kazoo. Children can compose music together and invite their families to a gig.

Play-based activities help create an environment where children can work together without the need for frequent teacher mediation. This environment offers opportunities for children to connect and helps new classmates adjust to the classroom.

Familiarize families with classrooms

Many families-whether refugees or immigrants-come from countries where school experiences are very different from those in the United States. All parents want to be involved and support their children in their new school. But sometimes it's hard for families with little or no prior school experience within early childhood settings to understand how to begin. And it can be especially confusing for families from different cultural backgrounds, who speak another language. Consider using visuals to introduce culturally and linguistically diverse families to the school environment. (See "A Picture's Worth a Thousand Words.")

If an interpreter is available or you can communicate verbally, talk with the parents and other caregivers about what to expect. Explain classroom routines, such as arrival and departure and the daily schedule. Talk about classroom rules. Many children who are refugees have spent unstructured time in camps or other transitional settings. Help them become part of the structured classroom routine as soon as possible.

Once they spend time in the classroom and observe their children's daily activities, families will feel more at ease and will be able to reinforce those routines at home. Inviting families and caregivers into the classroom helps build home-school relationships and encourages them to be active partners in their children's education.

Connect with related community cultural groups

Many children and teachers may not have interacted with diverse cultural groups from other countries-and particularly from countries suffering through war, famine, and other crises. It's difficult to understand the experiences of children who are refugees without first understanding their home cultures. And it also helps to be aware that there are different cultural groups within every country. One resource may be individuals who work closely with refugee families in the United States. They can offer information about particular cultures and help teachers better understand the experiences of children who are refugees.

Families who have escaped horrific conditions are not always comfortable talking about political situations in their home countries. Refugee families are trying to create a new sense of peace and calm in the lives of their children. They want to preserve their children's childhood and create new memories and positive beginnings.

Meeting emotional needs

Many parents and preschools try to shield children from harmful images and experiences so as not to overburden them emotionally. However, children who have lived in war zones and other fraught settings have experienced trauma beyond their years and may become overwhelmed and emotionally vulnerable in certain situations.

With preschoolers, typical conflicts arise while sharing materials or taking turns. They may use inappropriate language when trying to resolve these conflicts. It should come as no surprise that children who have experienced trauma may have an extra-difficult time working through common classroom conflicts. It's important to guide them in successful problem solving so they learn that they will not be punished when they make a mistake or have an outburst. It also helps all children if there is a quiet space to go to calm down, like the classroom library beanbag chair.

Establish one-on-one time with children who are refugees

It's not uncommon for young children to feel lost in the classroom and to miss their families. This can be exceptionally hard for children who are refugees, because they tend to have strong attachments to their families and may have shared traumatic experiences together. One of the biggest fears many children have is losing their parents-and some may actually have lost a parent or a loved one. A few times a day, reassure children that they are safe and that their parents or caregivers will return at the end of the day. Establishing trust and maintaining a strong bond with them is key to settling refugee children in your classroom. Build with blocks or draw together during centers time. You don't need to talk much if language is a barrier.

Create opportunities for refugee parents to share their traditions

As refugee families adjust to school and their children become comfortable with their peers, you might invite the parents or caregivers to share some of their traditions, such as celebrations, music, food, native clothing, and folktales. Offer activities like creating ornaments or other arts and crafts from their home countries. Support families by gathering materials in advance, making sure that participating doesn't cause a financial burden. Celebrate all the different cultures represented in the classroom so refugee families don't feel singled out.

Final thought

You will find that refugee families are grateful and appreciate your support. They are eager to cooperate and collaborate to ensure that their children fit into the classroom and maintain their connections to their rich cultures.

Resources to Help Teachers Welcome Refugee Children and Families

There are numerous resources that teachers can use to learn about the refugee crisis, in general, and strategies that they can use in their classrooms. Those below are a starting point in understanding the needs of families who are refugees.

Association for Childhood Education International
www.acei.org

"Collaborating with Refugee Resettlement Organizations: Providing a Head Start to Young Refugees," by Lyn Morland and Tarima Levine. Young Children, September 2016, pp. 69-75.

"How to Support Refugee Students in the ELL Classroom," by Kristina Robertson and Lydia Breiseth. Colorín Colorado
www.colorincolorado.org/article/how-support-refugee-students-ell-classroom

"Teaching Refugees with Limited Formal Schooling: Classroom Supports." Calgary Board of Education, Government of Alberta, Canada
http://teachingrefugees.com/socio-emotional-supports/classroom-strategies

Visit Raising Young Children in a New Country: Supporting Early Learning and Healthy Development https://eclkc.ohs.acf.hhs.gov/hslc/tta-system/cultural-linguistic/fcp/do..., to help you talk to families about child development, health, school readiness, and more.

A Picture's Worth a Thousand Words

Create a visual schedule of daily activities to help children and families understand what happens in a typical day in your classroom. Use photographs of circle time, read-aloud, snack, center time, and so on. Or you can print out pictures from the Internet or cut out pictures from magazines.

Discuss healthy eating and classroom routines and rules, such as hand washing before eating to keep everyone healthy. Use visuals with photographs. Or make short videos of routines such as snack time-children setting up the food, serving themselves, and clearing eating areas when they've finished.

Use visuals to explain rules about expectations for classroom behavior, such as lining up for transitions, sitting on individual carpet squares, and putting away blocks in the block area.

Photos courtesy of the author and © NAEYC/iStock

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Welcoming Refugee Children into Early Childhood Classrooms

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Refugee families are part of many communities, and they bring rich cultural experiences to early learning programs.

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Aboriginal music in Australia is diverse, reflecting Indigenous spirituality and the land. It includes genres like didgeridoo rhythms and clapstick patterns, serving ceremonial and social purposes. Songlines convey oral history. This music preserves culture and community bonds, reflecting Australia's First Nations heritage (Wattakara, 2021).

https://www.watarrkafoundation.org.au/blog/the-tradition-of-aboriginal-music#:~:text=Traditionally%20Aboriginal%20music%20is%20primarily,and%20of%20course%20the%20didgeridoo.

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The didgeridoo, a key instrument in Indigenous Australian cultures, is typically a hollowed eucalyptus branch, producing a distinct, resonant drone. It holds great cultural significance, used in ceremonies and stories for over 2,000 years. Performers breathe in a circular motion, inhaling through their nose and blowing repeatedly. Beyond its traditional role, it's embraced in various musical genres, conveying tales and cultural motifs, adorned with Aboriginal art. This iconic instrument represents Australia's cultural diversity and Indigenous heritage, demanding respect for its history when played (AAC, 2022).

https://www.aboriginalart.com.au/didgeridoo/

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Australia Day, observed on January 26th, commemorates the arrival of the First Fleet in 1788, signifying the nation's culture and history. It's a national holiday, celebrated with various events and festivities, yet it remains a subject of debate and reflection due to its complex historical context (AD, 2023).

https://www.australiaday.org.au/

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Principal health issues that refugees face

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Principal health issues that refugees face

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Malaria:
Since individuals were exposed to the disease in Afghanistan, malaria is a serious health risk for Afghan migrants. It is an infection spread by mosquitoes that results in fever, chills, and weariness. In refugee camps, prevention measures including insecticide-treated bed netts and antimalarial drugs are essential. To tackle this condition, early diagnosis and quick administration of antimalarial medications, such as combination therapy based on artemisinin, are crucial.

Mental health:
Afghan refugees frequently encounter severe mental health problems as a result of traumatic events. There is a high prevalence of ailments like post-traumatic stress disorder (PTSD), depression, and anxiety. Therapy, counselling, and medication, when appropriate, are all part of treating mental health disorders. For this population to receive the specialised care they require and to speed up their recovery, it is critical to offer culturally sensitive mental health services.

Sexually transmitted infections:
STIs, which are sexually transmitted infections, can be harmful to Afghan refugees' health. Chlamydia, gonorrhoea, and syphilis are common STIs. Education and safe sex practices are examples of preventive approaches. Antibiotics must be administered promptly to those who are infected to avoid problems and further spread of the infection. To manage STIs among immigrant populations, regular screening and access to healthcare services are crucial.

https://refugeehealthguide.org.au/sexually-transmissible-infections-stis/

https://refugeehealthguide.org.au/mental-health/

https://refugeehealthguide.org.au/malaria/

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Written by on . Posted in Communicable diseases and immunisation, General population

Aesen Thambiran, Mitchell Smith, Vanessa Clifford

Recommendations

A sexual health history should be completed sensitively, with awareness of gender issues, and with reassurance and careful explanations.

Offer an STI screen to people with a risk factor for acquiring an STI or on request (see text). Universal post-arrival screening for STIs for people from refugee-like backgrounds is not supported by current available evidence.

Syphilis serology should be offered to unaccompanied and separated children <15 years.

Children <15 years should be offered screening for other STIs including HIV and syphilis if there are clinical concerns (see text for details).

A complete STI screen includes a self-collected swab or first pass urine Nucleic Acid Amplification Test (NAAT) and consideration of throat and rectal swabs for chlamydia and gonorrhoea, and serology for syphilis, HIV and hepatitis B.

Asymptomatic patients with positive syphilis serology should be treated, unless there is documented prior treatment of treponemal infection. Treat syphilis with parenteral penicillin in consultation with a sexual health or ID unit.

Specimens for Neisseria gonorrhoea microscopy and culture should be taken before treatment is instituted. Treat gonorrhoea with ceftriaxone 500mg in 2mL of 1% lignocaine IMI, plus azithromycin 1g orally. Repeat NAAT and culture for test of cure of gonorrhoea two weeks after treatment.

Treat chlamydia with azithromycin 1g orally as a single dose, or, alternatively, doxycycline 100mg orally 12 hourly for 7 days.

Treat anorectal chlamydia with doxycycline 100mg orally 12 hourly for 7 days or azithromycin 1g orally as a single dose with a repeat dose a week later.

Offer women a pregnancy test and contraception, as appropriate (see Women's Health).

An STI screen provides an opportunity for education about safer sex and condom use.

* Chlamydia testing is consistent with the current National STI Strategy and Australasian Sexual Health Alliance (ASHA) guidelines.

[accordion tag=h3 clicktoclose=true autoclose=false][accordion-item title="+ Overview" state=closed]

The potential health impacts of STIs include multi-organ damage and congenital effects from syphilis, while chlamydia and gonorrhoea can cause infertility and a risk of ectopic pregnancy. Maternal gonorrhoea and chlamydia can lead to severe neonatal conjunctivitis. There are personal health and public health reasons to detect these infections in individuals regardless of background and to limit their transmission in the community.

Gender-based violence is common in women and girls in conflict zones and refugee camps, although men may also experience sexual violence, and also face barriers to disclosing this information. Once settled in Australia women may be at increased risk of sexual violence and sexual assaults have been reported in both onshore and offshore immigration detention centres.

People may not be aware of STIs or their partners' STI status or may be unable to negotiate a monogamous relationship with their partner and may be unaware of their risk of acquiring STIs. This can occur in any relationship, including new or longstanding relationships, where people have returned from overseas having married a new partner, and in adolescents. It is important to be aware of situations that may have led to an STI acquisition, such as sexual assault, and that these circumstances may not be disclosed. In addition, due to limited access to health education, both adolescents and adults may have poor understanding of sexual health and limited knowledge of contraception or safe sex practices.

The previous ASID guidelines recommended universal screening in adults for chlamydia and gonorrhoea; however, since this time, there have been more published data on STI prevalence in resettled refugee populations. Despite the apparent risks, there is a low reported prevalence of chlamydia (0.8-2.0%)43,48,159,211 and gonorrhoea (0%)43,48,159,211 infections in newly arrived refugees settling in Australia and in other developed countries.48,159,211-214 Therefore, the current available evidence does not support universal screening of newly arrived people from refugee-like backgrounds for chlamydia and gonorrhoea, and favours a risk-based approach to screening. a

Syphilis infection has a higher incidence in many parts of Africa and Asia and has been diagnosed in refugees settling in Australia (prevalence 1.5-8%). Until 2014, only a proportion of refugee applicants had syphilis screening overseas as part of their visa medical examination, which was recommended for those living in 'camp-like conditions.' Routine syphilis screening is now part of the Australian immigration medical examination for humanitarian entrants aged 15 years and over. Additionally, asylum seekers aged 15 years and older are screened and treated for syphilis in immigration detention facilities after arrival.

a. Some members of the EAG recommended offering universal STI screening in adolescents and adult because of the sensitivities of obtaining a sexual history in people from refugee-like backgrounds, particularly at an initial visit, and the difficulties in ensuring that previous syphilis has been adequately screened and treated. However, given available prevalence data, the panel did not consider that this was indicated. Furthermore, STI testing should be performed with informed consent, and hence universal screening does not obviate the need to discuss STI risks with the patient. [/accordion-item]

[accordion-item title="+ History and Examination" state=closed]

Discussion of sexual health and STIs can be challenging where there is low English proficiency and low health literacy. Furthermore in some cultures, open discussions about sexuality and sexual health are discouraged and there are demarcations between men's and women's issues. Individuals may feel deeply embarrassed to discuss sexual health with a health practitioner. Feelings of shame, guilt and fear may decrease the likelihood of patients asking for STI testing. People who identify as lesbian, gay, bisexual, transgender or intersex (LGBTI) may be reluctant to disclose/discuss this with health providers, especially if they experienced persecution in their country of origin.

Questions about sexual health should be asked sensitively, and reassuring the patient that health professionals understand these questions may be culturally unfamiliar can be helpful. It is important to explain need for screening, obtain informed consent, clarify that results will have no impact on residency status, and that confidential treatment, care and counselling is available if needed. Recognise the potential sensitivities around gender differences between doctor and patient - the best advice is to ask the patient about what is acceptable to them. Pelvic examination in women should be undertaken only if clinically necessary, ensuring that the woman feels comfortable with the provider and that time has been taken to build rapport and trust. Offer a chaperone and to also consider the gender of the interpreter whether onsite or via telephone.

STIs are often asymptomatic. Women may have local symptoms such as dysuria, urethritis, vaginal discharge, pelvic pain, dyspareunia, inter-menstrual or post-coital bleeding, or they may present with sequelae such as complaints of infertility. Men may have dysuria, urethral discharge or testicular pain. Anorectal symptoms include discharge, irritation, painful defecation and disturbed bowel function. Gonorrhoea or chlamydia can also present with purulent conjunctivitis.

Syphilis is usually asymptomatic; however, symptoms can range from the chancre of primary infection, to the generalised rash of secondary syphilis, to signs of tertiary disease such as aortic pathology and neurological manifestations.

Taking a sexual history from a person from a refugee-like background is an opportunity to build trust and create a safe environment in which the person may disclose an experience of sexual violence. However, most patients will not volunteer violence, in particular if family members or friends are accompanying clients. The patient needs not only to feel assured that what will be shared will remain confidential, but also that in risking the discussion about violence, there will be resources and opportunities to obtain help for this. Interpreter confidentiality and privacy is a further issue to consider, and offering a telephone interpreter is useful to preserve anonymity.

There may be cultural pressures affecting disclosure of family violence, and additional vulnerabilities related to migration status. Asylum seekers on bridging visas and those in community detention sign a code of conduct, potentially acting as a powerful negative disincentive to disclose family violence. Consider intimate partner violence in all relationships, including for those who identify as LGBTI. [/accordion-item]

[accordion-item title="+ Investigation" state=closed]

People from refugee-like backgrounds should be offered individualised STI screening which takes into account past screening and risk assessment.

Offer STI testing to:

Anyone with symptoms or a recent history of STI symptoms.

Individuals who have had more than one recent partner or who have recently changed partners (this may not always be volunteered).

Pregnant women.

People living with HIV.

People who inject drugs.

Sex workers, and people who are clients of sex workers.

Men who have sex with men (MSM) and those who identify as LGBTI.

Adults and adolescents with a history of being incarcerated, including in immigration detention centres.

Anyone who is interested in, or who would like an STI screen.

Woman who present opportunistically for a well women's check or PAP smear.

Anyone disclosing a history of sexual assault or gender-based violence.

In addition any sexually active person aged 15-29 years should be offered chlamydia screening in accordance with the National STI Strategy.

The most significant risk factor for HIV and syphilis infection in minors is maternal infection. Therefore unaccompanied or separated children should be tested for HIV and syphilis.

Tests to offer in an STI screen:

First pass urine for Chlamydia trachomatis and Neisseria gonorrhoea nucleic acid amplification test (NAAT). This is non-invasive and highly sensitive.

Self-obtained Lower Vaginal Swabs (SOLVS) is the optimal sampling method in women for Chlamydia trachomatis and Neisseria gonorrhoea. While it should be offered, this method may not be culturally acceptable to women from refugee-like backgrounds and first void urine should be offered if patient declines SOLVS. See link below for instructions on how client can self-obtain samples.

Rectal and throat swab for NAAT if at risk of infection at those sites. Offer test to all MSM, following sexual assault (at those sites) or to anyone with symptoms suggestive of infection. Gonococcal throat infections can occur in the setting of unprotected oral sex and patients may be unaware of this risk.

Swab for microscopy, culture and sensitivity for Neisseria gonorrhoea from any site with pus.

Syphilis serology

Consider offering tests for other sexually transmissible infections including: hepatitis B, HIV, hepatitis C. [/accordion-item]

[accordion-item title="+ Management and Referral" state=closed]

Syphilis

Venereal syphilis, when found through screening of asymptomatic recent arrivals, is usually late latent disease of low infectivity. Ask if there is a history of previous treatment with parenteral penicillin.

Interpretation of serological tests for treponemal infection can be quite complex. Seek advice from a sexual health or ID physician whenever there is any concern or doubt. Infection with various subspecies of Treponema can also cause yaws, bejel or pinta. As it is rarely possible to determine with certainty which type of treponemal infection has resulted in positive serology in an asymptomatic patient, such patients should always be treated, unless there is documented prior treatment of treponemal infection. Treatment is with parenteral penicillin (pregnancy category A) and is usually best done in the context of a specialised sexual health or ID unit. The sexual health service will monitor treatment response with the RPR serological test at 3, 6 and (if necessary) at 12 months. Note that the specific treponemal tests (e.g. TPHA) tend to remain positive lifelong, even after successful treatment.

Gonorrhoea

Wherever possible, patients with a positive NAAT test for N. gonorrhoea should have microscopy and culture of genital (cervical, vaginal, urethral) and/or throat swabs if discharge is present, and/or first pass urine, before treatment is instituted.

Treatment is generally with ceftriaxone 500mg in 2mL of 1% lignocaine IMI, plus azithromycin 1g orally as a single dose. For pharyngeal, anal or cervical infection, test of cure (NAAT) should be performed two weeks after treatment is completed. Microscopy and culture should also be repeated to assess for antibiotic resistance. These samples can be collected at the time of NAAT test of cure sample collection to save the patient having to return again.

Chlamydia

Current treatment is with azithromycin 1g orally as a single dose, or doxycycline 100mg orally 12 hourly for 7 days. Treat anorectal chlamydia with doxycycline 100mg orally 12 hourly for 7 days or azithromycin 1g orally as a single dose with a repeat dose a week later.

Test of cure is not routinely recommended, except for pregnant women or those with rectal chlamydia. In these situations, NAAT should be done at least four weeks after treatment.

Other STIs

Detailed guidance on the conditions above and on other STIs is available from the Australasian STI Management Guidelines for Use in Primary Care and the Australian Therapeutic Guidelines. Advice can also be sought from a sexual health service or physician.

Contact tracing of sexual partners (and children in the case of syphilis), where relevant and appropriate, should be discussed with the patient and attempted by the treating clinician. Seek specialist advice if unsure or in complex cases e.g. new HIV diagnosis. The Australasian Contact Tracing Manual offers comprehensive assistance. If working with a telephone interpreter, offer to keep your patient's name confidential.

HIV testing should be performed in all people diagnosed with an STI ( see HIV).

Regular review during therapy provides an opportunity to confirm adherence with treatment, to review contact history and to give further sexual health education. If indicated, further testing may need to be undertaken for HIV after the three-month window period ( see HIV) and for other STIs at the three-month visit if not undertaken at first presentation.

Consider offering immunisation for human papilloma virus for women, girls and boys in appropriate age or risk groups ( see immunisation).

Consider offering cervical cancer screening, pregnancy testing and assess for contraceptive needs ( see Women's Health).

Consider referral for follow up of trauma associated with a history of sexual assault or gender- based violence.
An STI screen provides an opportunity for education about safer sex and condom use. It is important to inform individuals that an STI screen is not comprehensive, infections such as herpes simplex and HPV are not routinely screened for and thus the need for barrier contraception should be emphasised to minimise future risk. Gonorrhoea, chlamydia and syphilis are notifiable diseases. [/accordion-item]
[accordion-item title="+ Considerations in Pregnancy and Breastfeeding" state=closed]

Doxycycline (Pregnancy category D) should not be used in pregnancy or during breastfeeding. Azithromycin (Pregnancy category B1) can be used for treatment of chlamydia and gonorrhoea.

Syphilis detected during antenatal screening should always be managed by a specialist; treatment is with penicillin (Pregnancy category A). Infants should be referred to a paediatrician for testing and follow-up. [/accordion-item]

[accordion-item title="+ Considerations for Children and Adolescents" state=closed]

Although children and adolescents from refugee-like backgrounds are at risk of having experienced sexual abuse and/or assault, families rarely volunteer this information. However, if such information is disclosed, or if an STI is suspected for other reasons, e.g. vaginal discharge, genital ulcers or undiagnosed chronic lower abdominal pain, seek advice from a service experienced in managing child sexual abuse, and consider mandatory reporting obligations. Other non-STI causes of genital symptoms in girls need to be considered, including pinworm infection and, occasionally, female genital mutilation/cutting (FGM/C, see Women's health).

Unlike adults, children under 15 years are not routinely tested for HIV as part of the pre-migration or detention screen unless they are unaccompanied or separated minors; and they are not tested for syphilis.

Adolescent sexual health is frequently missed, but should be included in a post-arrival assessment. Adolescents should be seen alone for part of the consultation once rapport is established. Explaining this is routine in the Australian healthcare system and seeking permission from both the adolescent and their parent/carers is helpful in facilitating this process. Adolescent sexual health is often approached using the HEADDS framework; and adolescents frequently value the opportunity to ask questions of health providers. This form of consultation is also an opportunity for health promotion and to improve sexual health literacy.

Most adolescents can be treated for common STIs using standard adult doses. Seek specialist advice (including for assessment of child protection issues for younger children). Child and adolescent refugees who have a positive treponemal serology result should be discussed with or referred to a paediatric ID physician. If the patient is a child and the biological mother's treponemal test is negative, congenital syphilis can usually be excluded.

Doxycycline should not be used in children less than 8 years of age. Seek specialist advice. [/accordion-item]

[accordion-item title="+ Links" state=closed]
http://www.stipu.nsw.gov.au/wp-content/uploads/SELF_TESTING_CARD.pdf http://www.mcwh.com.au/downloads/publications/MCWH_CommonThreads_ BestPracticeGuide_WEB.pdf Sexual assault hotline (interpreters available)Easidose, a visual prescribing aid
Australasian Contact Tracing Manual [/accordion-item][/accordion]

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Written by on . Posted in Communicable diseases and immunisation, General population Aesen Thambiran, Mitchell Smith, Vanessa Clifford A sexual health history should be completed sensitively, with awareness of gender issues, and with reassurance and careful explanations. Offer an STI screen to people with a risk factor for acquiring an STI or on request (see text).