1Kadir A, et al. BMJ Paediatrics Open 2019;3:e000364. doi:10.1136/bmjpo-2018-000364
Open access
Children on the move in Europe: a narrative review of the evidence on the health risks, health needs and health policy for asylum seeking, refugee and undocumented children
Ayesha Kadir, 1 Anna Battersby,2 Nick Spencer,3 Anders Hjern 4
To cite: Kadir A, Battersby A, Spencer N, et al. Children on the move in Europe: a narrative review of the evidence on the health risks, health needs and health policy for asylum seeking, refugee and undocumented children. BMJ Paediatrics Open 2019;3:e000364. doi:10.1136/bmjpo-2018-000364
Received 24 August 2018Revised 2 January 2019Accepted 3 January 2019
1Institute for Studies of Migration, Diversity and Welfare, Malmo Hogskola, Malmo, Sweden2Kaleidoscope Centre for Children and Young People, London, UK3Division of Mental Health and Wellbeing, Warwick Medical School, University of Warwick, Coventry, UK4Clinical Epidemiology, Department of Medicine, Karolinska Institutet and Centre for Health Equity Studies (CHESS), Karolinska Institutet/Stockholm University, Stockholm, Sweden
Correspondence toDr Ayesha Kadir; kadira@ gmail. com
Original article
© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
AbstrACtbackground Europe has experienced a marked increase in the number of children on the move. The evidence on the health risks and needs of migrant children is primarily from North America and Australia.Objective To summarise the literature and identify the major knowledge gaps on the health risks and needs of asylum seeking, refugee and undocumented children in Europe in the early period after arrival, and the ways in which European health policies respond to these risks and needs.Design Literature searches were undertaken in PubMed and EMBASE for studies on migrant child health in Europe from 1 January 2007 to 8 August 2017. The database searches were complemented by hand searches for peer-reviewed papers and grey literature reports.results The health needs of children on the move in Europe are highly heterogeneous and depend on the conditions before travel, during the journey and after arrival in the country of destination. Although the bulk of the recent evidence from Europe is on communicable diseases, the major health risks for this group are in the domain of mental health, where evidence regarding effective interventions is scarce. Health policies across EU and EES member states vary widely, and children on the move in Europe continue to face structural, financial, language and cultural barriers in access to care that affect child healthcare and outcomes.Conclusions Asylum seeking, refugee and undocumented children in Europe have significant health risks and needs that differ from children in the local population. Major knowledge gaps were identified regarding interventions and policies to treat and to promote the health and well-being of children on the move.
IntrODuCtIOnForced displacement is a major child health issue worldwide. More than 13 million chil-dren live as refugees or asylum seekers outside their country of birth.2 Conservative estimates suggest that nearly 1 80 000 children on the move are unaccompanied or sepa-rated from their caregivers.2 The majority of
these children live in Asia, the Middle East and Africa.3
Europe has experienced a marked increase in the number of irregular migrants since 2011, with a peak in arrivals during 2015.4 Children have accounted for a large proportion of people making the journey, either with family or on their own, in search of safety, stability and a better future. Between 2015 and 2017, more than 1 million asylum applications were made for children in Europe.4 The majority of these children originated from
What is already known on this topic?
► Europe has experienced a significant increase in mi-gration of displaced people escaping humanitarian crises.
► Displaced children are known to be vulnerable to violence, violation of their rights and discrimination.
► The existing literature on the health of children on the move in Europe is largely focused on infectious disorders.
► The Convention on the Rights of the Child provides children on the move with the right to the conditions that promote optimal health and well-being and with access to healthcare without discrimination.
What this study hopes to add?
► Indicates that the main challenges for child health services lie in the domain of mental health and well-being.
► Indicates that many children on the move in Europe are insufficiently vaccinated.
► Identifies significant gaps in knowledge, particularly with regard to policies and interventions to promote child health and well-being.
► Identifies research priorities to promote effective, ethical care and support health policy.
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Syria, Iraq and Afghanistan.3 In 2017, 70% of the 210 000 asylum claims made for children in Europe were filed in Germany, France, Greece and Italy.5
The phenomenon of migration to Europe has been characterised by continual evolution, with frequent changes in the most common migration routes, modes of travel and the length of stay in transit coun-tries. Children making these dangerous and often prolonged journeys are exposed to considerable health risks. The health of children on the move is related to their health status before the journey, conditions in transit and after arrival and is influ-enced by experience of trauma, the health of their caregivers and their ability to access healthcare.6
Much of the literature on the health of children on the move comes from North America and Australia. In light of the marked increase in the number of children arriving in Europe and the need for improved understanding of the situation for these children in the European context, this paper reviews the health risks and needs of children on the move in Europe and how European health poli-cies respond to these risks and needs. It is important to note that children may live for months or years in one or several countries before settling, being repatriated or going underground. In the longer term, factors such as the social determinants of health, ethnicity and issues relating to legal status and prolonged periods of transit begin to take precedence.
The Convention on the Rights of the Child (CRC) affords all children with the right to healthcare without discrimination.7 Articles 2, 9, 20, 22, 30 and 39 devote specific attention to the rights of displaced and unac-companied children.7 As such, the CRC provides a useful framework to address the health of children on the move.
Terms such as migrants, refugees and asylum seekers are often used interchangeably and may shift the focus away from people towards political discourse. In this paper, we focus on asylum seeking, refugee and undoc-umented children (table 1). Undocumented children are included because they are known to be a mobile and highly marginalised group, with particular barriers in access to services. We use the term ‘children on the move’
for these three groups of children in order to maintain a rights-based focus.
MethODsThe findings presented in this review are based on a comprehensive literature search of studies on the health of children on the move in Europe from 1 January 2007 to 8 August 2017. Searches were run in PubMed and EMBASE on 8 August 2017. Search terms included combinations of terms for children such as ‘child’, ‘youth’ and ‘adolescent’ with terms for migrant, such as ‘migrant’, ‘asylum seeker’, ‘refugee’ and ‘undocumented migrant’ and with terms for countries in the European Union as well as five coun-tries that are major origin and transit countries for children travelling to Europe, including Afghanistan, Jordan, Lebanon, Syria and Turkey. The database searches were limited to papers providing data on children (birth–18 years) in the English language. Papers were included if they addressed physical and mental health of children on the move, health exam-inations of these children, the effect of caregiver mental health, access to care or disparities in care between children on the move and the local popula-tion. Multiregional reviews that provided data on chil-dren in Europe were also included. Papers on adult populations (defined as a study population ≥18 years) that did not provide disaggregated data on children were excluded. However, papers including UASC with a stated age ≤19 years were included, as well as longi-tudinal cohort studies that followed migrant chil-dren into early adulthood (<24 years old). Additional exclusion criteria included special populations, small single-facility studies, lack of migrant and/or health focus, intervention studies that did not provide data on child health outcomes and papers from non-Euro-pean host countries. Commentaries and conference abstracts were excluded. For further information on specific child health and policy topics, hand searches were also undertaken to identify relevant peer-re-viewed papers and grey literature reports.
Table 1 Definitions
Child Person under the age of 18 years.7
Asylum seeker Persons or children of such persons who are in the process of applying for refugee status under the 1951 Geneva Refugee Convention.57
Refugee A person, who ‘owing to well-founded fear of persecution for reasons of race, religion, nationality, membership of a particular social group or political opinions, 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’.1
Undocumented children
Children who live without a residence permit, have overstayed visas or have refused immigration applications and who have not left the territory of the destination country subsequent to receipt of an expulsion order or children passing through or residing temporarily in a country without seeking asylum.57
Unaccompanied minors
Children who have been separated from both parents and other relatives and are not being cared for by any adult.1
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Patient and public involvementNo patients were involved in this study.
resultsThe searches identified 1634 records. After removing 117 duplicates, 1517 titles were screened. A total of 149 papers were reviewed in full text review, of which 118 papers were excluded. Our final sample included 31 papers. An additional 23 articles and reports were identified by the hand searches (figure 1: Flow diagram). Tables 2 and 3 provide an overview of the 45 original research studies and review papers that are included in this review.
Overall, the papers indicate that the health needs of children on the move are highly heterogeneous, depending on the conditions in the country of origin, during the journey and after arrival in the countries of destination. Children separated or travelling unaccom-panied (UASC) are particularly vulnerable to various forms of exploitation at all phases of their journey and after arrival. Structural, financial, language and cultural barriers in access to healthcare affect care-seeking behaviours as well as diagnostic evaluation, treatment and health outcomes (table 4).6 8 9
Communicable diseasesDuring travel and after arrival in Europe, children may be housed in overcrowded facilities with inadequate hygiene and sanitation conditions that place them at risk of communicable diseases. The most common infection sites include the respiratory tract, gastrointestinal tract
and skin, with a concerning prevalence of parasitic and wound infections.10–13
Children originating from low-income and middle-in-come countries may have been exposed to infec-tious agents that are rare in high income countries in Europe.14–16 Furthermore, exposure to armed conflict may increase their risk of exposure to infections.17 Notable infections among populations on the move include latent or active tuberculosis (TB),15 18 malaria,17 Hepatitis B and C,15 17 Syphilis,15 Human T-lympho-tropic virus type 1 or 2,15 louse-born relapsing fever,17 19 shigella17 and leishmaniasis.17 There is a notable lack of studies with age-disaggregated data on HIV prevalence among migrant children in Europe. A Spanish study which screened 358 children did not find any cases.15 While children on the move are at risk for a number of different infections, the prevalence of communicable diseases varies markedly between groups and is thought to be heavily related to the conditions during travel and after migration.17
The treatment of children on the move with infec-tious diseases may require different regimens than those recommended by national protocols, as these children may be at higher risk of colonisation and infection with drug-resistant organisms. In Germany, routine screening practices at hospital admission have found that children on the move have higher rates of multiple drug-resis-tant (MDR) bacterial strains than the local population.20 MDR Infections may be more difficult to treat and carry higher morbidity and mortality risks.
Figure 1 Flow diagram.
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Tab
le 2
O
rigin
al r
esea
rch
artic
les
Firs
t au
tho
r an
d y
ear
Co
untr
yS
tud
y p
op
ulat
ion
Stu
dy
des
ign
Sam
ple
siz
e (c
hild
ren
onl
y)S
umm
ary
of
find
ing
s
Hue
mer
et
al41
(201
1)A
ustr
iaA
fric
an U
AS
C 1
5–18
yea
rs
old
Ob
serv
atio
nal
coho
rt41
56%
of A
fric
an U
AS
C h
ad a
t le
ast
one
men
tal h
ealth
dia
gnos
is b
y st
ruct
ured
clin
ical
in
terv
iew
. The
mos
t co
mm
on d
iagn
oses
wer
e ad
just
men
t d
isor
der
, PTS
D a
nd d
ysth
ymia
.
Der
luyn
et
al42
(200
7)B
elgi
umU
AS
C*
Cro
ss-s
ectio
nal
surv
ey14
2B
etw
een
37%
and
47%
of t
he u
nacc
omp
anie
d r
efug
ee y
outh
s ha
d s
ever
e or
ver
y se
vere
sy
mp
tom
s of
anx
iety
, dep
ress
ion
and
pos
t-tr
aum
atic
str
ess
whe
n sc
reen
ed w
ith t
he
Hop
kins
Sym
pto
ms
Che
cklis
t 37
A. G
irls
and
tho
se h
avin
g ex
per
ienc
ed m
any
trau
mat
ic
even
ts a
re a
t ev
en h
ighe
r ris
k fo
r th
e d
evel
opm
ent
of t
hese
em
otio
nal p
rob
lem
s.
Der
luyn
43
(200
8)B
elgi
umM
igra
nt a
nd n
ativ
e ad
oles
cent
s 10
–21
year
sC
ross
-sec
tiona
l su
rvey
1249
mig
rant
/602
na
tive
Mig
rant
ad
oles
cent
s ex
per
ienc
ed m
ore
trau
mat
ic e
vent
s th
an t
heir
Bel
gian
pee
rs
and
sho
wed
hig
her
leve
ls o
f pee
r p
rob
lem
s an
d a
void
ance
sym
pto
ms.
Non
-mig
rant
ad
oles
cent
s d
emon
stra
ted
mor
e sy
mp
tom
s of
anx
iety
, ext
erna
lisin
g p
rob
lem
s an
d
hyp
erac
tivity
. Fac
tors
influ
enci
ng t
he p
reva
lenc
e of
em
otio
nal a
nd b
ehav
iour
al p
rob
lem
s w
ere
the
num
ber
of t
raum
atic
eve
nts
exp
erie
nced
, gen
der
and
the
livi
ng s
ituat
ion.
Van
Ber
laer
et
al10
(201
6)
Bel
gium
Asy
lum
see
kers
Sin
gle
faci
lity
cros
s-se
ctio
nal s
tud
y39
1P
rimar
ily r
epor
ted
out
com
es in
ad
ults
. Nea
rly h
alf o
f asy
lum
see
kers
and
tw
o-th
irds
of
child
ren<
5 ye
ars
suffe
red
from
infe
ctio
ns. A
mon
g ch
ildre
n<5
year
s, 5
0% h
ad r
esp
irato
ry
dis
ease
s (n
=76
), 20
% d
iges
tive
dis
ord
ers
(n=
30),
14%
ski
n d
isor
der
s (n
=21
) and
7%
su
ffere
d fr
om in
jurie
s (n
=10
).
Verv
liet
et a
l44
(201
4)B
elgi
umU
AS
C 1
4–17
yea
rs o
ldLo
ngitu
din
al c
ohor
t10
3U
AS
C r
epor
ted
an
aver
age
of 7
.5 t
raum
atic
exp
erie
nces
at
the
stud
y st
art.
The
mea
n nu
mb
er o
f rep
orte
d d
aily
str
esso
rs in
crea
sed
ove
r th
e st
udy
per
iod
. Par
ticip
ants
had
hig
h sc
ores
for
anxi
ety,
dep
ress
ion
and
inte
rnal
isin
g sy
mp
tom
s. T
here
wer
e no
sig
nific
ant
diff
eren
ces
in m
enta
l hea
lth s
core
s ov
er t
ime.
The
num
ber
of t
raum
atic
exp
erie
nces
and
th
e nu
mb
er o
f dai
ly s
tres
sors
wer
e as
soci
ated
with
sig
nific
antly
hig
her
sym
pto
m le
vels
of
dep
ress
ion
(dai
ly s
tres
sors
), an
xiet
y an
d P
TSD
(tra
umat
ic e
xper
ienc
es a
nd d
aily
str
esso
rs).
Hat
leb
erg
et a
l14
(201
4)D
enm
ark
Chi
ldre
n<15
yea
rs o
ld in
D
enm
ark
Ep
idem
iolo
gica
l su
rvei
llanc
e st
udy
323
323
TB c
ases
wer
e re
por
ted
in c
hild
ren
aged
<15
yea
rs in
Den
mar
k b
etw
een
2000
and
20
09. T
he in
cid
ence
of c
hild
hood
TB
dec
lined
from
4.1
per
100
000
to
1.9
per
100
000
d
urin
g th
e st
udy
per
iod
. Im
mig
rant
chi
ldre
n co
mp
rised
79.
6% o
f all
case
s. A
mon
g D
anis
h ch
ildre
n, t
he m
ajor
ity w
ere<
5 ye
ars
and
had
a k
now
n TB
exp
osur
e. P
ulm
onar
y TB
was
the
m
ost
com
mon
pre
sent
atio
n.
Mon
tgom
ery38
(200
8)D
enm
ark
Ref
ugee
s 11
–23
year
s ol
dLo
ngitu
din
al c
ohor
t13
1Fo
llow
-up
stu
dy
in r
efug
ee c
hild
ren
afte
r 9
year
s. P
artic
ipan
ts r
epor
ted
a m
ean
of
1.8
exp
erie
nces
of d
iscr
imin
atio
n. A
n as
soci
atio
n w
as fo
und
bet
wee
n d
iscr
imin
atio
n,
psy
chol
ogic
al p
rob
lem
s an
d s
ocia
l ad
apta
tion.
Per
ceiv
ed d
iscr
imin
atio
n p
red
icte
d
inte
rnal
isin
g b
ehav
iour
s. S
ocia
l ad
apta
tion
was
pro
tect
ive,
cor
rela
ting
nega
tivel
y w
ith
dis
crim
inat
ion
as w
ell a
s ex
tern
alis
ing
and
inte
rnal
isin
g b
ehav
iour
s.
Mon
tgom
ery37
(201
0)D
enm
ark
Ref
ugee
s 11
–23
year
s ol
dLo
ngitu
din
al c
ohor
t13
1S
ame
pop
ulat
ion
as M
ontg
omer
y (2
008)
. On
arriv
al, t
he c
hild
ren
exp
erie
nced
hig
h ra
tes
of
clin
ical
ly s
igni
fican
t p
sych
olog
ical
pro
ble
ms
whi
ch r
educ
ed m
arke
dly
at
9-ye
ar fo
llow
-up
. P
ersi
sten
t sy
mp
tom
s w
ere
asso
ciat
ed w
ith h
ighe
r nu
mb
er o
f typ
es o
f str
essf
ul e
vent
s af
ter
arriv
al, s
ugge
stin
g en
viro
nmen
tal f
acto
rs p
lay
an im
por
tant
rol
e in
res
ilien
ce a
nd r
ecov
ery
from
psy
chol
ogic
al t
raum
a.
Heu
dor
f et
al20
(2
016)
Ger
man
yU
AS
C<
18 y
ears
old
Ob
serv
atio
nal
coho
rt11
9U
AS
C a
rriv
ing
in F
rank
furt
dur
ing
Oct
ober
–Nov
emb
er 2
015
had
hig
h le
vels
of d
rug
resi
stan
t m
icro
bia
l flor
a. E
nter
obac
teria
ceae
with
ES
BL
wer
e d
etec
ted
in 4
2 of
119
(35%
) yo
uth.
Nin
e yo
uth
had
flor
a w
ith a
dd
ition
al r
esis
tanc
e to
fluo
roq
uino
lone
s (8
% o
f tot
al
scre
ened
).
Con
tinue
d
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Open access
Firs
t au
tho
r an
d y
ear
Co
untr
yS
tud
y p
op
ulat
ion
Stu
dy
des
ign
Sam
ple
siz
e (c
hild
ren
onl
y)S
umm
ary
of
find
ing
s
Kul
la e
t al
31
(201
6)G
erm
any
Ref
ugee
infa
nts
and
ch
ildre
n* r
escu
ed a
t se
aO
bse
rvat
iona
l co
hort
293
Am
ong
the
2656
ref
ugee
s re
scue
d b
y a
Ger
man
Nav
al F
orce
frig
ate
bet
wee
n M
ay a
nd
Sep
tem
ber
201
5, 1
9 (0
.7 %
) wer
e in
fant
s an
d 2
74 (1
0.3
%) w
ere
child
ren.
27%
of a
ll p
atie
nts
req
uire
d t
reat
men
t b
y a
phy
sici
an d
ue t
o in
jury
or
illne
ss a
nd w
ere
defi
ned
as
‘sic
k’. O
ne in
fant
(5.2
%) a
nd 3
8 ch
ildre
n (1
3.9%
) wer
e id
entifi
ed a
s si
ck. P
red
omin
ant
dia
gnos
es w
ere
der
mat
olog
ical
dis
ease
s, in
tern
al d
isea
ses
and
tra
uma.
Mar
qua
rdt
et
al11
(201
6)G
erm
any
UA
SC
12–
18 y
ears
old
Cro
ss-s
ectio
nal
surv
ey10
2P
ilot
stud
y th
at e
mp
loye
d p
urp
ose
sam
plin
g fo
r a
non-
rep
rese
ntat
ive
sub
set
of U
AS
C
in B
iele
feld
, Ger
man
y. 5
9% o
f the
you
th h
ad a
t le
ast
one
infe
ctio
n an
d 2
0% s
uffe
red
p
aras
itic
infe
ctio
ns. 1
3.7%
wer
e d
iagn
osed
with
men
tal i
llnes
s. 1
7.6%
wer
e fo
und
to
have
iro
n d
efici
ency
ana
emia
. Ove
rall,
the
you
th h
ad a
low
pre
vale
nce
of n
on-c
omm
unic
able
d
isea
ses
(<2.
0%).
Mic
hael
is e
t al
23
(201
7)G
erm
any
Asy
lum
see
kers
with
H
epat
itis
AE
pid
emio
logi
cal
surv
eilla
nce
stud
y23
1A
sylu
m s
eeki
ng c
hild
ren
5–9
year
s ol
d a
ccou
nted
for
97 o
f 278
(35%
) rep
orte
d H
AV
ca
ses
amon
g as
ylum
see
kers
dur
ing
Sep
tem
ber
201
5 to
Mar
ch 2
016.
The
pre
dom
inan
t su
bge
noty
pe
was
1B
, a s
trai
n p
revi
ousl
y re
por
ted
in t
he M
idd
le E
ast,
Tur
key,
Pak
ista
n an
d
Eas
t A
fric
a. T
here
was
one
cas
e of
tra
nsm
issi
on fr
om a
n as
ymp
tom
atic
chi
ld t
o a
nurs
ery
nurs
e w
orki
ng in
a m
ass
acco
mm
odat
ion
cent
re.
Mel
lou
et a
l24
(201
7)G
reec
eR
efug
ees,
asy
lum
see
kers
an
d m
igra
nts†
livi
ng in
ho
stin
g fa
cilit
ies
in G
reec
e
Ob
serv
atio
nal s
tud
y15
2R
epor
t on
HA
V in
fect
ion
amon
g re
fuge
es in
hos
ting
faci
litie
s in
Gre
ece
Ap
ril–D
ecem
ber
20
16. A
tot
al o
f 177
cas
es w
ere
foun
d, o
f whi
ch 1
52 w
ere
in c
hild
ren<
15 y
ears
old
.
Pav
lop
oulo
u
et a
l33 (2
017)
Gre
ece
Mig
rant
and
ref
ugee
‡ ch
ildre
n 1–
14 y
ears
old
Sin
gle
faci
lity
pro
spec
tive
cros
s-se
ctio
nal s
tud
y
300
Sur
vey
of im
mig
rant
and
ref
ugee
chi
ldre
n p
rese
ntin
g fo
r he
alth
exa
min
atio
n w
ithin
3
mon
ths
of t
heir
arriv
al, M
ay 2
010
and
Mar
ch 2
013.
The
mai
n he
alth
pro
ble
ms
foun
d
incl
uded
unk
now
n va
ccin
atio
n st
atus
(79.
3%),
elev
ated
blo
od le
ad le
vels
(30.
6%),
den
tal
pro
ble
ms
(21.
3%),
eosi
nop
hilia
(22.
7%) a
nd a
naem
ia (1
3.7%
). E
ight
chi
ldre
n (2
.7%
) wer
e d
iagn
osed
with
late
nt t
uber
culo
sis
bas
ed o
n M
anto
ux a
nd c
hest
X-r
ay a
nd t
wo
case
s w
ere
confi
rmed
with
Qua
ntiF
ER
ON
-TB
Gol
d t
estin
g.
Cie
rvo
et a
l19
(201
6)Ita
lyA
sylu
m s
eeki
ng
adol
esce
nts<
18 y
ears
Cas
e se
ries
3D
escr
iptio
n of
Lou
se-b
orne
rel
apsi
ng fe
ver
in t
hree
Som
ali a
dol
esce
nts
who
wer
e se
ekin
g as
ylum
.
Bea
n et
al45
(2
007)
The
Net
herla
nds
UA
SC
<18
yea
rs o
ldP
rosp
ectiv
e co
hort
st
udy
582
The
self-
rep
orte
d p
sych
olog
ical
dis
tres
s of
ref
ugee
min
ors
was
foun
d t
o b
e se
vere
(50%
) an
d o
f a c
hron
ic n
atur
e (s
tab
le fo
r 1
year
) and
was
con
firm
ed b
y re
por
ts fr
om t
he g
uard
ians
(3
3%) a
nd t
each
ers
(36%
). Th
e nu
mb
er o
f sel
f-re
por
ted
ad
vers
e lif
e ev
ents
was
str
ongl
y re
late
d t
o th
e se
verit
y of
psy
chol
ogic
al d
istr
ess.
Seg
lem
et
al46
(2
011)
Nor
way
UA
SC
Cro
ss-s
ectio
nal
surv
ey41
4S
urve
yed
of U
AS
C w
ho w
ere
gran
ted
a r
esid
ence
per
mit
in N
orw
ay fr
om 2
000
to 2
009.
Th
e yo
uth
rang
ed fr
om 1
1 to
27
year
s at
the
tim
e of
the
sur
vey.
The
stu
dy
foun
d t
hat
UA
SC
ar
e a
high
-ris
k gr
oup
for
men
tal h
ealth
pro
ble
ms
also
aft
er r
eset
tlem
ent
in a
new
cou
ntry
, w
ith h
igh
pre
vale
nce
of d
epre
ssio
n an
d P
TSD
.
Bel
hass
en-
Gar
cia
et a
l15
(201
5)
Sp
ain
Imm
igra
nt c
hild
ren
and
yo
ung
peo
ple
†<18
yea
rs
old
Ob
serv
atio
nal
coho
rt37
3Im
mig
rant
s<18
yea
rs o
f age
com
ing
from
Sub
-Sah
aran
Afr
ica,
Nor
th A
fric
a an
d L
atin
A
mer
ica
wer
e p
rosp
ectiv
ely
scre
ened
bet
wee
n Ja
nuar
y 20
07 a
nd D
ecem
ber
201
1. L
aten
t tu
ber
culo
sis
was
foun
d in
12.
7% (3
6/28
5), A
ctiv
e TB
infe
ctio
n in
1%
(3/2
85),
HB
V in
4.3
%
(15/
350)
and
HC
V in
2.3
5% (8
/346
). N
one
(0/3
58) w
ere
HIV
pos
itive
.
Ben
net16
(201
7)S
wed
enU
AS
C<
18 y
ears
old
Ob
serv
atio
nal
coho
rt24
2224
22 U
AS
C w
ere
scre
ened
for
tub
ercu
losi
s w
ith a
Man
toux
tub
ercu
lin s
kin
test
or
a Q
uant
iFE
RO
N-T
B G
old
. 349
had
a p
ositi
ve t
est,
of w
hich
16
had
TB
dis
ease
and
278
la
tent
tub
ercu
losi
s in
fect
ions
(LTB
I). C
hild
ren
orig
inat
ing
from
the
hor
n of
Afr
ica
had
hig
h p
reva
lenc
e of
late
nt T
B a
nd T
B d
isea
se.
Tab
le 2
C
ontin
ued
Con
tinue
d
on May 14, 2020 by guest. P
rotected by copyright.http://bm
jpaedsopen.bmj.com
/bm
jpo: first published as 10.1136/bmjpo-2018-000364 on 31 January 2019. D
ownloaded from
6 Kadir A, et al. BMJ Paediatrics Open 2019;3:e000364. doi:10.1136/bmjpo-2018-000364
Open access
Firs
t au
tho
r an
d y
ear
Co
untr
yS
tud
y p
op
ulat
ion
Stu
dy
des
ign
Sam
ple
siz
e (c
hild
ren
onl
y)S
umm
ary
of
find
ing
s
Hje
rn e
t al
39
(201
3)S
wed
enM
igra
nt a
nd n
ativ
e 15
ye
ar-
old
sC
ross
-sec
tiona
l su
rvey
76 2
29In
a n
atio
nal s
urve
y us
ing
the
KID
SC
RE
EN
inst
rum
ent,
the
psy
chol
ogic
al w
ell-
bei
ng in
fo
reig
n-b
orn
child
ren
from
Afr
ica
and
Asi
a w
as fo
und
to
be
muc
h lo
wer
(−0.
8 in
Z-s
core
s)
com
par
ed w
ith t
he m
ajor
ity p
opul
atio
n if
the
stud
ent
bod
y co
nsis
ted
mai
nly
of n
ativ
e st
uden
ts fr
om t
he m
ajor
ity p
opul
atio
n. S
core
s w
ere
very
sim
ilar
to t
he m
ajor
ity p
opul
atio
n in
sch
ools
whe
re a
t le
ast
50%
had
tw
o fo
reig
n-b
orn
par
ents
. Bul
lyin
g ex
pla
ined
muc
h of
th
is d
iffer
ence
.
Rid
del
59 (2
016)
Sw
eden
UA
SC
9–1
8 ye
ars
old
Qua
litat
ive
inte
rvie
ws
53Th
e yo
uth
des
crib
ed e
xper
ienc
e of
ext
rem
e vi
olen
ce a
nd e
xplo
itatio
n as
wel
l as
lack
of
acce
ss t
o p
hysi
cal a
nd m
enta
l hea
lthca
re. T
hey
des
crib
e le
ngth
y as
ylum
pro
ced
ures
, d
elay
s in
rec
eivi
ng a
gua
rdia
n, la
ck o
f acc
ess
to in
terp
rete
rs a
nd in
exp
erie
nced
and
in
adeq
uate
ly t
rain
ed s
taff
amon
g gu
ard
ians
in t
he a
ccom
mod
atio
n ce
ntre
s. G
irls
and
yo
unge
r ch
ildre
n re
por
ted
bei
ng h
ouse
d w
ith o
lder
boy
s an
d e
xper
ienc
ing
bul
lyin
g an
d
hara
ssm
ent
in t
heir
acco
mm
odat
ion
faci
litie
s.
Alk
ahta
ni e
t al
8 (2
014)
Eng
land
Ref
ugee
chi
ldre
n in
the
E
ast
Mid
land
s co
mp
ared
w
ith n
ativ
e co
ntro
ls
Cas
e-co
ntro
l11
7 m
igra
nt/9
9 na
tive
Com
par
ison
mad
e b
etw
een
the
child
ren
of 5
0 re
fuge
e p
aren
ts (n
=11
7 ch
ildre
n) w
ith
child
ren
of 5
0 E
nglis
h p
aren
ts (n
=99
chi
ldr e
n), w
ith m
edia
n ag
es 5
and
4 y
ears
, res
pec
tivel
y.
Ref
ugee
chi
ldre
n w
ere
mor
e lik
ely
to r
ecei
ve p
resc
ribed
med
icin
es d
urin
g th
e p
revi
ous
mon
th (p
=0.
008)
and
6 m
onth
s (p
<0.
001)
tha
n E
nglis
h ch
ildre
n an
d w
ere
less
like
ly t
o re
ceiv
e ov
er t
he c
ount
er (O
TC) m
edic
ines
in t
he p
ast
6 m
onth
s (p
=0.
009)
. The
find
ings
su
gges
t fin
anci
al b
arrie
r in
acc
ess
to m
edic
atio
n.
Bro
nste
in47
(2
012)
UK
Afg
han
UA
SC
13–
18 y
ears
Cro
ss-s
ectio
nal
surv
ey22
2O
ne t
hird
of y
outh
wer
e fo
und
to
scor
e ab
ove
the
cut-
off o
n a
valid
ated
PTS
D-s
cree
ning
in
stru
men
t.
Bro
nste
in48
(2
013)
UK
Afg
han
UA
SC
13–
18 y
ears
Cro
ss-s
ectio
nal
surv
ey22
2In
a s
urve
y us
ing
the
Hop
kins
Sym
pto
ms
Che
cklis
t 37
A, 3
1.4%
sco
red
ab
ove
cut-
offs
for
emot
iona
l and
beh
avio
ural
pro
ble
ms,
34.
6% fo
r an
xiet
y an
d 2
3.4%
for
dep
ress
ion.
Sco
res
incr
ease
d w
ith t
ime
afte
r ar
rival
in t
he U
K a
nd lo
ad o
f pre
mig
ratio
n tr
aum
atic
eve
nts.
Hod
es e
t al
49
(200
8)U
KU
AS
C (1
3–18
yea
rs o
ld)
and
acc
omp
anie
d r
efug
ee
child
ren
(13–
19 y
ears
old
)
Cro
ss-s
ectio
nal
surv
ey78
UA
SC
and
35
acco
mp
anie
dU
AS
C h
ad e
xper
ienc
ed h
igh
leve
ls o
f tra
umat
ic e
vent
s (m
ean
of 6
.8 e
vent
s, r
ange
0–1
6)
and
rep
orte
d h
igh
leve
ls o
f pos
t-tr
aum
atic
str
ess
sym
pto
ms
com
par
ed w
ith a
ccom
pan
ied
ch
ildre
n. P
red
icto
rs o
f hig
h p
ostt
raum
atic
sym
pto
ms
incl
uded
low
-sup
por
t liv
ing
arra
ngem
ents
, fem
ale
gend
er a
nd e
xper
ienc
e of
tra
uma.
Am
ong
UA
SC
, pos
t-tr
aum
atic
sy
mp
tom
s in
crea
sed
with
age
. Hig
h d
epre
ssiv
e sc
ores
wer
e as
soci
ated
with
fem
ale
gend
er a
nd r
egio
n of
orig
in in
UA
SC
.
Bai
llot
et a
l32
(201
8)M
ultip
leA
sylu
m s
eeke
rsLi
tera
ture
rev
iew
, in
-dep
th in
terv
iew
s w
ith e
xper
ts in
E
U-b
ased
FG
M
inte
rven
tions
N/A
FGM
is a
n im
por
tant
bas
is fo
r as
ylum
cla
ims
girls
and
wom
en in
Eur
ope.
Mon
itorin
g an
d
inte
rven
tions
var
y b
etw
een
coun
trie
s. T
here
are
no
poo
led
dat
a, h
owev
er, a
s va
riatio
ns
in r
epor
ting
pra
ctic
es b
etw
een
coun
trie
s p
recl
ude
the
eval
uatio
n or
mon
itorin
g of
FG
M-
bas
ed a
sylu
m c
laim
s in
the
EU
.
Od
one
et a
l18
(201
5)M
ultip
leM
igra
nts
to t
he E
U†
Lite
ratu
re
revi
ew, a
naly
sis
of E
urop
ean
Sur
veill
ance
S
yste
m d
ata
and
in
form
atio
n fr
om
exp
erts
N/A
Prim
arily
rep
orte
d o
utco
mes
in a
dul
ts. F
rom
200
0 to
200
9, 1
5.3%
of r
epor
ted
pae
dia
tric
TB
cas
es in
the
EU
/EE
A w
ere
of fo
reig
n or
igin
. Thi
s fig
ure
is lo
wer
tha
n th
e p
rop
ortio
n of
fore
ign-
bor
n re
por
ted
TB
cas
es in
the
ove
rall
pop
ulat
ion
(26%
). N
orw
ay, S
wed
en a
nd
Aus
tria
rep
orte
d a
hig
her
num
ber
of f
orei
gn-o
rigin
TB
cas
es t
han
nativ
e-or
igin
TB
cas
es
amon
g ch
ildre
n<15
yea
rs. R
isk-
bas
ed a
naly
sis
is li
mite
d b
ecau
se s
urve
illan
ce d
ata
in m
ost
EU
/EE
A c
ount
ries
do
not
dis
tingu
ish
bet
wee
n ch
ildre
n b
orn
in t
he h
ost
coun
try
to fo
reig
n-b
orn
par
ents
from
tho
se b
orn
to n
ativ
e p
aren
ts.
Tab
le 2
C
ontin
ued
Con
tinue
d
on May 14, 2020 by guest. P
rotected by copyright.http://bm
jpaedsopen.bmj.com
/bm
jpo: first published as 10.1136/bmjpo-2018-000364 on 31 January 2019. D
ownloaded from
7Kadir A, et al. BMJ Paediatrics Open 2019;3:e000364. doi:10.1136/bmjpo-2018-000364
Open access
Firs
t au
tho
r an
d y
ear
Co
untr
yS
tud
y p
op
ulat
ion
Stu
dy
des
ign
Sam
ple
siz
e (c
hild
ren
onl
y)S
umm
ary
of
find
ing
s
Stu
bb
e Ø
ster
gaar
d
et a
l57 (2
017)
Mul
tiple
Asy
lum
see
kers
and
un
doc
umen
ted
mig
rant
ch
ildre
n<18
yea
rs
Sur
vey
and
des
k re
view
N/A
Sur
veye
d c
hild
hea
lth p
rofe
ssio
nals
, NG
Os
and
Eur
opea
n O
mb
udsp
erso
ns fo
r C
hild
ren
in 3
0 E
U/E
EA
cou
ntrie
s an
d A
ustr
alia
and
rev
iew
ed o
ffici
al d
ocum
ents
. Ent
itlem
ents
for
asyl
um s
eeki
ng, r
efug
ee a
nd ir
regu
lar
mig
rant
s in
the
EU
are
var
iab
le; h
owev
er, o
nly
five
coun
trie
s (F
ranc
e, It
aly,
Nor
way
, Por
tuga
l and
Sp
ain)
exp
licitl
y en
title
all
mig
rant
chi
ldre
n,
irres
pec
tive
of le
gal s
tatu
s, t
o re
ceiv
e eq
ual h
ealth
care
to
that
of i
ts n
atio
nals
. The
nee
ds
of ir
regu
lar
mig
rant
s fr
om o
ther
EU
cou
ntrie
s ar
e of
ten
over
look
ed in
Eur
opea
n he
alth
care
p
olic
y.
Vill
adse
n et
al30
(2
010)
Mul
tiple
Stil
lbirt
hs a
nd n
eona
tal
dea
ths
of in
fant
s b
orn
to
mot
hers
of T
urki
sh o
rigin
Ret
rosp
ectiv
e p
reva
lenc
e st
udy
239
387
Incl
udes
dat
a fr
om n
ine
EU
cou
ntrie
s. T
he s
tillb
irth
rate
s w
ere
high
er in
infa
nts
bor
n to
Tu
rkis
h m
othe
rs t
han
in t
he n
ativ
e p
opul
atio
n in
all
coun
trie
s. T
he n
eona
tal m
orta
lity
was
va
riab
le, w
ith e
leva
ted
ris
ks fo
r in
fant
s of
Tur
kish
mot
hers
in D
enm
ark,
Sw
itzer
land
, Aus
tria
an
d G
erm
any,
and
low
er r
ates
in N
ethe
rland
s, t
he U
K a
nd N
orw
ay w
hen
com
par
ed w
ith
the
nativ
e p
opul
atio
ns.
Will
iam
s et
al22
(2
016)
Mul
tiple
Mig
rant
s§Li
tera
ture
rev
iew
, su
rvey
of 3
0 co
untr
ies,
and
in
form
atio
n fr
om
exp
erts
N/A
Nat
iona
l sur
veill
ance
sys
tem
s d
o no
t sy
stem
atic
ally
rec
ord
mig
ratio
n-sp
ecifi
c in
form
atio
n.
Exp
erts
att
ribut
ed m
easl
es o
utb
reak
s to
low
vac
cina
tion
cove
rage
or
par
ticul
ar h
ealth
or
rel
igio
us b
elie
fs a
nd c
onsi
der
ed o
utb
reak
s re
late
d t
o m
igra
tion
to b
e in
freq
uent
. The
lit
erat
ure
revi
ew a
nd c
ount
ry s
urve
y su
gges
ted
tha
t so
me
mea
sles
out
bre
aks
in t
he E
U/
EE
A w
ere
due
to
sub
optim
al v
acci
natio
n co
vera
ge in
mig
rant
pop
ulat
ions
.
Hje
rn e
t al
60
(201
7)E
U27
Mig
rant
chi
ldre
n<18
yea
rsC
ross
-sec
tiona
l su
rvey
to
clin
icia
ns,
natio
nal c
hild
om
bud
smen
and
N
GO
s
N/A
Sev
en E
U c
ount
ries
(Bel
gium
, Fra
nce,
Ital
y, N
orw
ay, P
ortu
gal a
nd S
pai
n an
d S
wed
en)
exp
licitl
y en
title
all
non-
EU
mig
rant
chi
ldre
n, ir
resp
ectiv
e of
lega
l sta
tus,
to
rece
ive
equa
l he
alth
care
to
that
of i
ts n
atio
nals
. Tw
elve
Eur
opea
n co
untr
ies
have
lim
ited
ent
itlem
ents
to
heal
thca
re fo
r as
ylum
see
king
chi
ldre
n, in
clud
ing
Ger
man
y th
at s
tand
s ou
t as
the
cou
ntry
w
ith t
he m
ost
rest
rictiv
e he
alth
care
pol
icy
for
mig
rant
chi
ldre
n. T
he n
eed
s of
irre
gula
r m
igra
nts
from
oth
er E
U c
ount
ries
are
ofte
n ov
erlo
oked
in E
urop
ean
heal
thca
re p
olic
y.
*Age
gro
ups
not
clea
rly d
efine
d.
†Mig
rant
sta
tus
not
clea
rly d
efine
d.
‡Im
mig
rant
s w
ere
defi
ned
as
the
child
ren
of p
aren
ts w
ith lo
ng-
term
res
iden
ce p
erm
it w
ho e
nter
ed G
reec
e fo
r fa
mily
reu
nific
atio
n. T
he r
emai
ning
chi
ldre
n, in
clud
ing
refu
gees
, asy
lum
see
kers
or
irre
gula
r m
igra
nts
wer
e d
efine
d a
s ‘r
efug
ees’
.§V
aria
ble
defi
nitio
ns o
f mig
rant
s b
etw
een
coun
trie
s an
d b
etw
een
stud
ies.
ES
BL,
ext
end
ed s
pec
trum
bet
a-la
ctam
ases
; HA
V, H
epat
itis
A V
irus;
LTB
I, la
tent
tub
ercu
losi
s in
fect
ions
; OTC
, ove
r th
e co
unte
r; P
TSD
, pos
t-tr
aum
atic
str
ess
dis
ord
er; T
B, t
uber
culo
sis.
Tab
le 2
C
ontin
ued
on May 14, 2020 by guest. P
rotected by copyright.http://bm
jpaedsopen.bmj.com
/bm
jpo: first published as 10.1136/bmjpo-2018-000364 on 31 January 2019. D
ownloaded from
8 Kadir A, et al. BMJ Paediatrics Open 2019;3:e000364. doi:10.1136/bmjpo-2018-000364
Open access
Tab
le 3
R
evie
w a
rtic
les
Firs
t au
tho
r an
d
year
Stu
dy
po
pul
atio
nS
tud
y d
esig
nS
amp
le s
ize
(chi
ldre
n o
nly)
Sum
mar
y o
f fi
ndin
gs
Ayn
sley
-Gre
en
et a
l53 (2
012)
Ref
ugee
and
as
ylum
-see
king
ch
ildre
n an
d y
oung
p
eop
le
Rev
iew
with
out
info
rmat
ion
on
sear
ch s
trat
egy
or
incl
usio
n cr
iteria
N/A
Evi
den
ce t
hat
X-r
ay e
xam
inat
ion
of b
ones
and
tee
th is
imp
reci
se a
nd u
neth
ical
and
sho
uld
no
t b
e us
ed. F
urth
er r
esea
rch
need
ed o
n a
holis
tic m
ultid
isci
plin
ary
app
roac
h to
age
as
sess
men
t.
Bol
lini e
t al
29
(200
9)Im
mig
rant
w
omen
(a) w
ho
del
iver
ed a
n in
fant
E
urop
e
Sys
tem
atic
rev
iew
an
d m
eta-
anal
ysis
18 3
22 9
78
pre
gnan
cies
in
65 s
tud
ies
61 s
tud
ies
wer
e cr
oss-
sect
iona
l des
ign
and
27
wer
e fr
om s
ingl
e fa
cilit
ies.
Com
par
ed d
ata
on 1
.6 m
illio
n in
imm
igra
nt w
omen
with
16.
7 m
illio
n na
tive
wom
en. I
mm
igra
nt w
omen
had
43
% h
ighe
r ris
k of
low
birt
h w
eigh
t, 2
4% o
f pre
term
del
iver
y, 5
0% o
f per
inat
al m
orta
lity
and
61%
of c
onge
nita
l mal
form
atio
ns c
omp
ared
with
nat
ive
Eur
opea
n w
omen
.
Col
e54 (2
015)
UA
SC
Rev
iew
art
icle
of
met
hod
s fo
r ag
e as
sess
men
t
N/A
Mos
t in
div
idua
ls a
re m
atur
e b
efor
e ag
e 18
in h
and
-wris
t X
-ray
s. O
n M
RI o
f the
wris
t an
d o
rtho
pan
tom
ogra
m o
f the
thi
rd m
olar
, the
mea
n ag
e of
att
ainm
ent
is o
ver
19 y
ears
; ho
wev
er, i
f the
re is
imm
atur
e ap
pea
ranc
e, t
hese
met
hod
s ar
e un
info
rmat
ive
abou
t lik
ely
age;
as
such
, the
MR
I and
thi
rd m
olar
s ha
ve h
igh
spec
ifici
ty b
ut lo
w s
ensi
tivity
.
Der
luyn
et
al43
(2
008)
UA
SC
Rev
iew
with
out
info
rmat
ion
on
sear
ch s
trat
egy
or
incl
usio
n cr
iteria
N/A
UA
SC
are
a v
ulne
rab
le p
opul
atio
n w
ith c
onsi
der
able
nee
d fo
r p
sych
olog
ical
sup
por
t an
d t
here
fore
nee
d a
str
ong
and
sta
ble
rec
eptio
n sy
stem
. The
cre
atio
n of
suc
h a
syst
em
wou
ld b
e gr
eatly
faci
litat
ed if
the
lega
l sys
tem
con
sid
ered
the
m c
hild
ren
first
and
ref
ugee
s/m
igra
nts
seco
nd.
Dev
i12 (2
016)
UA
SC
Op
inio
n p
iece
N/A
Sum
mar
ises
find
ings
on
infe
ctio
us d
isea
ses
affe
ctin
g un
acco
mp
anie
d m
inor
s b
ased
on
two
Uni
cef a
nd o
ne H
uman
Rig
hts
Wat
ch r
epor
ts.
Eis
et17
(201
7)R
efug
ees
and
as
ylum
see
kers
- a
ll ag
es
Nar
rativ
e re
view
Not
sp
ecifi
ed51
stu
die
s of
infe
ctio
us c
ond
ition
s in
ref
ugee
s an
d a
sylu
m s
eeke
rs in
clud
ing
child
ren
and
ad
ults
. Fin
din
gs r
elat
ed t
o ch
ildre
n: li
mite
d e
vid
ence
on
infe
ctio
us d
isea
ses
amon
g re
fuge
e an
d a
sylu
m-s
eeki
ng c
hild
ren;
rel
ativ
ely
low
vac
cina
tion
rate
s w
ith o
ne s
tud
y sh
owin
g 52
.5%
of m
igra
nt c
hild
ren
need
ing
trip
le v
acci
ne a
nd 1
3.2%
nee
din
g M
MR
and
a fu
rthe
r st
udy
show
ing
low
leve
ls o
f rub
ella
imm
unity
am
ong
refu
gee
child
ren.
The
rev
iew
rep
orts
on
rat
es o
f TB
, HIV
, hep
atiti
s B
and
C, m
alar
ia a
nd le
ss c
omm
on in
fect
ions
; how
ever
, rat
es
are
not
rep
orte
d b
y ag
e gr
oup
.
Faze
l et
al35
(201
2)R
efug
ee c
hild
ren
and
you
ng p
eop
leS
yste
mat
ic r
evie
w57
76 c
hild
ren
and
you
th in
44
stud
ies
Exp
osur
e to
vio
lenc
e, b
oth
dire
ct a
nd in
dire
ct (t
hrou
gh p
aren
ts),
are
imp
orta
nt r
isk
fact
ors
for
adve
rse
men
tal h
ealth
out
com
es in
ref
ugee
chi
ldre
n an
d a
dol
esce
nts.
Pro
tect
ive
fact
ors
incl
ude
bei
ng a
ccom
pan
ied
by
an a
dul
t ca
regi
ver,
exp
erie
ncin
g st
able
set
tlem
ent
and
soc
ial s
upp
ort
in t
he h
ost
coun
try.
Hje
rn55
(in
pre
ss)
UA
SC
Nar
rativ
e re
view
N/A
Man
y U
AS
C c
ome
from
‘fai
led
sta
tes’
like
Som
alia
and
Afg
hani
stan
whe
re o
ffici
al
doc
umen
ts w
ith e
xact
birt
h d
ates
are
rar
ely
issu
ed. N
o cu
rren
tly a
vaila
ble
med
ical
met
hod
ha
s th
e ac
cura
cy n
eed
ed t
o re
pla
ce s
uch
doc
umen
ts. U
ncle
ar g
uid
elin
es a
nd a
rbitr
ary
pra
ctic
es m
ay le
ad t
o al
arm
ing
shor
tcom
ings
in t
he p
rote
ctio
n of
thi
s hi
gh-r
isk
grou
p o
f ch
ildre
n an
d a
dol
esce
nts
in E
urop
e. M
edic
al p
artic
ipat
ion,
as
wel
l as
non-
par
ticip
atio
n, in
th
ese
dub
ious
dec
isio
ns r
aise
s a
num
ber
of e
thic
al q
uest
ions
.
Con
tinue
d
on May 14, 2020 by guest. P
rotected by copyright.http://bm
jpaedsopen.bmj.com
/bm
jpo: first published as 10.1136/bmjpo-2018-000364 on 31 January 2019. D
ownloaded from
9Kadir A, et al. BMJ Paediatrics Open 2019;3:e000364. doi:10.1136/bmjpo-2018-000364
Open access
Firs
t au
tho
r an
d
year
Stu
dy
po
pul
atio
nS
tud
y d
esig
nS
amp
le s
ize
(chi
ldre
n o
nly)
Sum
mar
y o
f fi
ndin
gs
ISS
OP
Mig
ratio
n W
orki
ng G
roup
6 (2
017)
Mig
rant
chi
ldre
n in
E
urop
eN
arra
tive
revi
ew
and
pos
ition
st
atem
ent
N/A
Bas
ed o
n a
com
pre
hens
ive
liter
atur
e se
arch
and
a r
ight
s-b
ased
ap
pro
ach,
pol
icy
stat
emen
t id
entifi
es m
agni
tud
e of
sp
ecifi
c he
alth
and
soc
ial p
rob
lem
s af
fect
ing
mig
rant
ch
ildre
n in
Eur
ope
and
rec
omm
end
s ac
tion
by
gove
rnm
ent
and
pro
fess
iona
ls t
o he
lp
ever
y m
igra
nt c
hild
to
achi
eve
thei
r p
oten
tial t
o liv
e a
hap
py
and
hea
lthy
life,
by
pre
vent
ing
dis
ease
, pro
vid
ing
app
rop
riate
med
ical
tre
atm
ent
and
sup
por
ting
soci
al r
ehab
ilita
tion.
Mar
kkul
a et
al9
(201
8)Fi
rst
and
sec
ond
ge
nera
tion
mig
rant
ch
ildre
n co
mp
ared
w
ith n
on-m
igra
nt
child
ren
Sys
tem
atic
rev
iew
10 0
30 3
11
child
ren
in 9
3 st
udie
s
57%
of i
nclu
ded
stu
die
s w
ere
from
Eur
ope
and
36%
from
Nor
th A
mer
ica.
Use
of n
on-
emer
genc
y he
alth
care
ser
vice
s w
as le
ss c
omm
on a
mon
g m
igra
nt c
omp
ared
with
non
-m
igra
nt c
hild
ren:
in 1
9/27
stu
die
s re
por
ting
on g
ener
al a
cces
s to
car
e, 9
/19
rep
ortin
g on
va
ccin
e up
take
, 9/1
6 re
por
ting
on m
enta
l hea
lth s
ervi
ce u
se, 9
/14
rep
ortin
g on
ora
l hea
lth
serv
ice
use,
10/
14 r
epor
ting
on p
rimar
y ca
re a
nd o
ther
ser
vice
use
. Mig
rant
chi
ldre
n w
ere
rep
orte
d t
o b
e m
ore
likel
y to
use
Em
erge
ncy
and
Hos
pita
l ser
vice
s in
9/1
5 st
udie
s.
Mip
atrin
i et
al21
(2
017)
Mig
rant
s an
d
refu
gees
Sys
tem
atic
rev
iew
N/A
The
stud
y re
por
ts p
rimar
ily o
n d
ata
in a
dul
ts o
r w
here
age
cla
ssifi
catio
n is
not
sp
ecifi
ed.
Ove
rall,
mig
rant
s an
d r
efug
ees
wer
e fo
und
to
have
low
er im
mun
isat
ion
rate
s co
mp
ared
w
ith E
urop
ean-
bor
n in
div
idua
ls. S
tud
ies
in m
igra
nt c
hild
ren
foun
d lo
wer
rat
es o
f MM
R,
Pol
io a
nd t
etan
us v
acci
natio
n. R
easo
ns c
ited
incl
ude
low
vac
cina
tion
cove
rage
in t
he
coun
try
of o
rigin
and
bar
riers
in a
cces
s to
car
e in
Eur
ope.
Sau
er e
t al
56
(201
6)U
AS
CE
dito
rial/P
ositi
on
stat
emen
tN
/AP
ositi
on s
tate
men
t b
y th
e E
urop
ean
Aca
dem
y of
Pae
dia
tric
s ou
tlini
ng m
edic
al, e
thic
al
and
lega
l rea
sons
for
reco
mm
end
ing
that
phy
sici
ans
shou
ld n
ot p
artic
ipat
e in
age
d
eter
min
atio
n of
una
ccom
pan
ied
and
sep
arat
ed c
hild
ren
seek
ing
asyl
um.
Slo
ne36
(201
6)C
hild
ren
aged
0–
6 ye
ars
exp
osed
to
war
, ter
roris
m o
r ar
med
con
flict
Sys
tem
atic
rev
iew
4365
chi
ldre
n in
35
stu
die
sYo
ung
child
ren
suffe
r fr
om s
ubst
antia
l dis
tres
s in
clud
ing
elev
ated
Ris
k fo
r P
TSD
or
PTS
sy
mp
tom
s, n
on-s
pec
ific
beh
avio
ural
and
em
otio
nal r
eact
ions
and
dis
turb
ance
of s
leep
and
p
lay
ritua
ls. P
aren
tal a
nd c
hild
ren’
s p
sych
opat
holo
gy c
orre
late
d a
nd fa
mily
env
ironm
ent
and
par
enta
l fun
ctio
ning
mod
erat
es e
xpos
ure–
outc
ome
asso
ciat
ion
for
child
ren.
The
au
thor
s co
nclu
de
that
long
itud
inal
stu
die
s ar
e ne
eded
to
des
crib
e th
e d
evel
opm
enta
l tr
ajec
torie
s of
exp
osed
chi
ldre
n.
Will
iam
s et
al34
(2
016)
Ref
ugee
chi
ldre
n in
E
urop
eR
evie
w w
ithou
t in
form
atio
n on
se
arch
str
ateg
y or
in
clus
ion
crite
ria
N/A
Incr
ease
d r
ates
of d
epre
ssio
n, a
nxie
ty d
isor
der
s an
d P
TSD
am
ong
refu
gee
child
ren,
as
wel
l as
high
leve
ls o
f den
tal d
ecay
and
low
imm
unis
atio
n co
vera
ge.
PTS
D, p
ost-
trau
mat
ic s
tres
s d
isor
der
; TB
, tub
ercu
losi
s; U
AS
C, u
nacc
omp
anie
d a
nd s
epar
ated
chi
ldre
n; F
GM
, fem
ale
geni
tal m
utila
tion;
NG
O, n
ongo
vern
men
tal o
rgan
isat
ion;
MM
R, M
easl
es,
mum
ps
and
rub
ella
vac
cina
tion.
Tab
le 3
C
ontin
ued
on May 14, 2020 by guest. P
rotected by copyright.http://bm
jpaedsopen.bmj.com
/bm
jpo: first published as 10.1136/bmjpo-2018-000364 on 31 January 2019. D
ownloaded from
10 Kadir A, et al. BMJ Paediatrics Open 2019;3:e000364. doi:10.1136/bmjpo-2018-000364
Open access
Children on the move may need catch-up immunisa-tions to match the vaccination schedule of the country of destination.17 Several studies of children on the move in Europe have identified low vaccination coverage against hepatitis B, measles, mumps, rubella and varicella and low immunity to vaccine preventable diseases including tetanus and diphtheria: this is coupled with a higher prevalence of previous exposure to vaccine-preventable diseases.21 Since 2015, cases of cutaneous diphtheria17 and outbreaks of measles in the EU22 have been attributed to insufficient vaccination coverage in migrant popu-lations. Further, Hepatitis A cases have been reported in children living in camps and centres in Greece and Germany, with particularly high rates among children under 15 years.23 24 There is no evidence of increased transmission of communicable diseases from migrants to host populations.25
non-communicable diseases and injuriesDisplacement places children at risk for a broad variety of non-communicable diseases and injuries that may be exacerbated by limited and irregular access to paedi-atric and neonatal healthcare. Paediatric groups that are particularly vulnerable include unaccompanied minors, pregnant adolescents and infants.
In 2017, more than half of the children arriving in Europe were registered in Greece, and the largest age group were infants and small children (0–4 years old).26 Infants born during the journey may be born without adequate access to prenatal, intrapartum or postnatal care, resulting in increased birth complications, stillbirth and infant mortality.27 Further, these newborns may have lacked access to screening for congenital disorders that is routinely offered in European countries. Infant nutrition
may suffer, particularly as breastfeeding is a challenge for mothers during their journey.28 The evidence regarding the risk of birth complications in children born to mothers after arrival in the destination country is mixed. Some studies in Europe have shown that these infants have higher rates of birth complications, including hypo-thermia, infections, low birth weight, preterm birth and perinatal mortality when compared with the native popu-lation,13 29 while other studies have found that outcomes in certain countries are similar to the national popula-tions.30 These patterns suggest that the cause of altered risks may be related to society-specific factors such as integration policies, socioeconomic disadvantage among different migrant groups and barriers in access to care.30
Traumatic events such as torture, sexual violence or kidnapping may have long‐lasting physical and psycho-logical effects on a child. Physical trauma related to the journey and attempts at illegal border crossings may include skin lacerations, tendon lacerations, fractures and muscle contusions. If left untreated and/or in unhy-gienic conditions, injuries may become infected, with severe and potentially life-threatening consequences.12 People arriving by sea are particularly susceptible to injury and illness; a recent survey of rescue ships found that dehydration and dermatological conditions asso-ciated with poor hygiene and crowded conditions were common, as well as new and old traumatic injuries from both violence and accidents.31 The risk of female genital mutilation is high in girls from certain regions and is a recognised reason for seeking asylum.32
Nutritional deficiencies and dental problems are more common in children on the move, with reported prev-alence of iron deficiency anaemia ranging from 4% to
Table 4 Barriers in access to care for children on the move
Information Patients and families Unfamiliar health system, lack of knowledge about where and how to seek care
Variable education and literacy, with variable knowledge about health
Lack of awareness about health rights
Health professionals Variable understanding of and experience with treating children on the move
Limited epidemiological data on the health status and context-specific risks of children on the move
Lack of clear and readily available national guidance on the legal and practical aspects of healthcare for migrants
Culture and language differences Language barriers, with limited or lack of access to medical interpreters
Differing cultural and health beliefs
Expectations for healthcare encounter may differ between the health professional and patient /family
Financial Costs associated with care may include transport to health facility, treatment, medications and medical supplies
Other barriers Distance to health facility, transportation needed to access care
Insufficient time allotted to appointments
Fear, including the fear that accessing care may affect asylum decision
Breakdown in trust between patients and health workers
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18% among children living in Germany and Greece.11 33 Dental problems are perhaps the most prevalent health issue in children on the move, and indeed caries preva-lence has been reported as high as 65% among migrant and refugee children in the UK.34
While the prevalence of non-communicable chronic diseases in children on the move in the EU is not thought to differ significantly from host populations, there is little evidence to support this thinking. Further, the barriers in access to care and different health beliefs pose challenges to diagnosing and managing children on the move with chronic diseases (tables 2 and 3).
Psychosocial and mental health issuesChildren on the move are at high risk for psychosocial and mental health problems, with separated and unac-companied children at highest risk. Direct and indi-rect exposure to traumatic events are associated with post-traumatic stress disorder (PTSD), anxiety, depres-sion, sleep disturbances and a broad range of internal-ising and externalising behaviours in refugee children.35
The mental health of caregivers, especially mothers, plays an important role in their children’s mental and physical health. Maternal PTSD and depression are correlated with increased risk of PTSD, PTS symptoms, behavioural problems and somatic complaints in their children.36 Conversely, good caregiver mental health is a protective factor for the mental and behavioural health of refugee children.35
Transit and host country reception policies also impact the mental health outcomes of children on the move. Numerous studies have documented that postmigra-tion detention increases psychological symptoms and the prevalence of psychiatric illness in children on the move.35 Detention, multiple relocations, prolonged asylum processes and lack of child-friendly immigra-tion procedures are associated with poor mental health outcomes in refugee children and have been described in some studies as having placed the children in greater adverse situations than those which the children endured before migration.35 A longitudinal study of refugee chil-dren from the Middle East living in Denmark found that psychological symptoms improved over time, with risk factors related to war and persecution being important during the early years after arrival in Denmark.37 In the longer term, social factors in the country of resettlement were more important predictors of mental health.37
Racism and xenophobia play an important role in the psychological health and well-being of children on the move. Studies in Sweden and Denmark have found that the experience of discrimination is common among youth on the move and is associated with lower rates of social acceptance, poorer peer relations and mental health problems.38 39 In a national survey of Swedish 9th graders, rates of bullying experienced by children on the move were associated with migrant density in schools, whereby children attending schools with low migrant density
reported three times the rate of bullying compared with those attending schools with high migrant density.39
unaccompanied minorsThe numbers of unaccompanied and separated children seeking asylum in Europe have increased in recent years. During 2015, 95 205, and in 2016, 63 245 UASC applied for asylum in the 28 EU member states, with Germany receiving about a third of these children.40
The mental health of unaccompanied refugee adoles-cents during the first years of exile has been studied in several European epidemiological studies in recent years.41–50 In the largest of these studies, a comparison was made between three groups2: (1) newly arrived, unaccom-panied children aged 12–18 years in the Netherlands,3 (2) young refugees of the same age who had arrived with their parents and4 (3) an age-matched Dutch group.45 The unaccompanied youths had much higher levels of depressive symptoms than the accompanied refugee chil-dren (47% vs 27%), and this was partly explained by a higher burden of traumatic stress. Follow-up interviews 12 months later showed no indication of improvement. The level of externalising symptoms and behaviour prob-lems were, however, lower among the unaccompanied refugees than in the Dutch comparison population. A similar picture of high levels of traumatic stress and introverted symptoms was noted in a Norwegian study of 414 unaccompanied youth; of note, this study was carried out at an average of 3.5 years after their arrival in the country.46
Age assessmentHaving an assumed chronological age above or below 18 years determines the support provided for young asylum seekers in most European countries, despite the fact that many lack documents with an exact birth date.6 This has led to the use of many different methods to assess age in Europe. In the UK, social workers independent of the migration authorities undertake age assessment inter-views which consider any documents or evidence indi-cating likely age, along with an assessment of appearance and demeanour.51 Many other European countries rely on medical examinations, primarily in the form of radi-ographs of the hand/wrist (23 countries), collar bone (15 countries) and/or teeth (17 countries).52 The indi-vidual variation in age-specific maturity in the later teens with these methods, and the unknown variation between high-income and low-income countries, make them unsuitable for assessing whether a young person is below or above 18 years of age.53 54
The use of these imprecise methods raise serious ethical and human rights concerns and is often experienced as unfair and stressful by the young asylum seekers.55 The European Academy of Paediatrics and several national medical associations have therefore recommended their members not to participate in age assessment procedures of asylum applicants on behalf of the state.56
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health policies and child rightsIdentification of the health needs of an individual child on the move, and subsequent timely investigation and management may be suboptimal in the arrival countries for a plethora of reasons associated with legal status, healthcare system efficiencies and individual factors. A recent survey identified 12 EU/EEA countries with significant inequities in healthcare entitlements for children on the move (compared with locally born chil-dren) according to their legal status.57 In a number of countries, undocumented children only have access to emergency healthcare services.58 Worryingly, in Sweden, a recent Human Rights Watch report found that children spend months without receiving health screening.59
In an analysis of healthcare policies for children on the move, Hjern et al60 compared entitlements for asylum seeking and undocumented children in 31 EU member and EES states in 2016 with those of resident children. Only seven countries (Belgium, France, Italy, Norway, Portugal, Spain and Sweden) have met the obligations of non-discrimination in the CRC and entitled both these categories of migrants, irrespective of legal status, to receive equal healthcare to that of its nationals. Twelve European countries have limited entitlements to health-care for asylum seeking children. Germany and Slovakia stand out as the EU countries with the most restrictive healthcare policies for refugee children.
In all but four countries in the EU/EEA, there are systematic health examinations of newly settled migrants of some kind.58 In most eastern European countries and Germany, this health examination is mandatory, while in the rest of western and northern Europe it is voluntary. All countries that have a policy of health examination aim to identify communicable diseases, so as to protect the host population. Almost all countries with a voluntary policy also aim to identify the child’s individual health-care needs, but this is rarely the case in countries that have a mandatory policy.
DIsCussIOnOur review of the available evidence indicates that chil-dren on the move in Europe have particular health risks and needs that differ from both the local population as well as between migrant groups. The body of evidence from Europe remains limited; however, as it is based primarily on observational studies from individual coun-tries, with few multicountry or intervention studies. It is important to note that our searches were limited to studies published in English and listed in the PubMed and EMBASE databases. As such, our searches may have missed relevant studies published in other languages, in the grey literature and studies listed in other databases.
A large body of evidence exists on the health needs and risks of children on the move outside of Europe, most notably in North America and Australia.34 61–64 The evidence from these areas indicates that the health deter-minants and patterns of risk are similar across settings;
the specific health risks and needs of children are heavily dependent on the conditions before and during travel and after arrival. There are also patterns that are shared across high-income, middle-income and low-income settings, such as children’s risk of exposure to violence, risk of exploitation and a high risk of mental health prob-lems related to these two factors.65 The similarities across regions suggest that, although context plays an important role for the individual child, there are certain health risks and needs shared by children on the move across the globe.
In light of these similarities, findings from the litera-ture in other parts of the world may help to fill in some of the existing gaps in the evidence in Europe. For example, there is little good quality evidence from Europe on the risk of injury during the early period after arrival to the country of destination. However, a large Canadian study found that refugee children have an increased risk of injury after resettlement. The study reported a 20% higher rate of unintentional injury in refugee youth compared with non-refugee immigrant youth for most causes of injury, with notably higher rates of motor vehicle inju-ries, poisonings, suffocation and scald burns.66 However, to our knowledge, there are no studies that provide data on the prevalence of disability or its effect on the health and development of children on the move.
There are important contextual factors that are likely to affect the health of children on the move differently across the world. Basic needs such as clean water, sanita-tion and food security may more profoundly influence child health and well-being in refugee camps in devel-oping countries as compared with Europe. Other contex-tual factors may include the nature of rights violations, such as the large-scale detention and separation of chil-dren on the move from their caregivers in the USA.67 68 Studies in Finnish children separated from their parents for a period during World War II found that these chil-dren exhibited altered stress physiology, earlier menarche and lower scores on intelligence testing.69–71 The deten-tion of children together with their families was demon-strated to cause significant, quantifiable harm to children in a comparison study from Australia.72 The interplay between common or widespread health risks, contextual factors, access to care and health promotion activities is likely to play a major role in the ultimate health outcomes of children on the move in a given geographical area.
Newly settled children have greater health needs than the average European child; however, access to health-care remains a major obstacle for them. Although there have been very few studies assessing access to healthcare by migrant families, it has been proposed that unfamiliar healthcare systems and financial costs of over the counter medications pose specific challenges to the migrant family.8 In the UK, UASC have their specific health needs identified as part of statutory health assessments, where the state has assumed the role of the corporate parent and undertakes the responsibility for the needs of the child. However, accompanied children (those children
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who arrive with and remain in the care of their migrant, refugee or asylum-seeking parent/s), depend on their newly arrived parent(s) to negotiate unfamiliar health-care systems.
Other important barriers to care in Europe are similar to those found in other settings, including language barriers, lack of professional medical inter-preters and variable cultural competence of health personnel. Health workers may lack knowledge or experience in caring for children on the move, may be unaware of their health rights and may lack guidance on the health needs and risks of the newly arrived population. The International Society for Social Pedi-atrics and Child Health released a position paper characterising these barriers and providing recom-mendations for health policy, healthcare, research and advocacy.6 These recommendations are grounded in child rights and can serve as a guide for individ-uals, groups and organisations seeking to improve the health and well-being of children on the move.
The main health risks and the main challenge for health services for children on the move in Europe are in the domain of mental health. A small prospective longi-tudinal study from Australia identified modifiable protec-tive factors for refugee children’s social and emotional well-being that related to resettlement practices, family factors and community support.73 This review highlights an important knowledge gap in the evidence in Europe for programmes and policies that address early recogni-tion and intervention, access to care and the development of effective preventive services for mental health. There is an urgent need for research on the effect of interven-tions and policies intended to promote and protect the health, well-being and positive development of children on the move in Europe.
The remarkable resilience observed among displaced children has been a topic of significant discourse and study.6 Healthy and positive adaptive processes have been associated with social inclusion, supportive family environments, good caregiver mental health and posi-tive school experiences.35 74 Although the evidence base for interventions remains limited, research and experi-ence suggest that the most effective way to protect and promote refugee child mental health is through compre-hensive psychosocial interventions that address psycho-logical suffering in the context of the child’s family and environment; such interventions necessarily include family, education and community needs and caregiver mental health.75
COnClusIOnAsylum seeking, refugee and undocumented children in Europe have significant health risks and needs that differ between groups and from children in the local population. Health policies across EU and EES member states vary widely, and children on the move in Europe face a broad range of barriers in access to care. The
CRC provides children with the right to access to health-care without discrimination and to the conditions that promote optimal health and well-being. With children increasingly on the move, it is imperative that individuals and sectors that meet and work with these children are aware of their health risks and needs and are equipped to respond to them.
Acknowledgements The authors would like to thank the ISSOP Migration Working Group, whose work inspired this review paper.
Contributors The authors collectively identified the need for the paper. AK designed and carried out the database searches. NS, AH and AK screened titles and abstracts, and all authors screened full text papers. AK, AB and AH wrote sections of the first draft. AK led development and compilation of the first draft and carried out subsequent revisions. All authors contributed to critical review of the drafts and to the development of the supporting tables and figures.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent Not required.
Provenance and peer review Commissioned; externally peer reviewed.
Open access This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http:// creativecommons. org/ licenses/ by- nc/ 4. 0/.
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